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Epigastric & Back Pain

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 52-year-old female with a history of DM presents to the ED for 12 hours of epigastric pain radiating to the back associated with non-bloody emesis.  She denies any fever, diarrhea or other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for mildly elevated blood pressure.  Physical exam is otherwise normal except for epigastric tenderness.

Initial Differential Diagnosis:

  • Gastritis
  • Bowel obstruction
  • Gallstones
  • AAA
  • Pancreatitis
  • CAD
  • Syphilis, the great imitator

Initial Diagnostic Testing:

  • EKG: none
  • Labs: CBC, BPM, lipase, troponin, and LFTs all normal
  • Imaging: see sonogram below

QUESTIONS:

  1. What does the case image show?  (click two times to enlarge)
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image shows .
  2. What should you do next?  Treat with.  Consult.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: The surgeon doubted cholecystitis because he had never seen a gallbladder wall that thick and suspected something else.  A DESIDA scan was negative, but the pain persisted so she was taken to the OR.  Postoperative Diagnoses were:

  • Cholelithiasis with Cholesterolosis of Gallbladder Mucosa
  • Acute on Chronic Cholecystitis
  • Short friable Cystic Duct
  • RUQ Inflammatory Adhesions

Cholesterolosis = hyperplastic changes in the gall bladder, mostly in 30-50 year old females and often asymptomatic.

CASE LESSONS: cholecystitis can present as epigastric pain and labs can all be normal.  Suspect it anytime pain lasts more than 6 hours.

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