Triage: upper abd pain, nausea since 0300 am. hx. of recent Pneumonia, Afib, Htn Diabetes

History of Present Illness: A man in his mid-70’s presents to the hospital abdominal pain upper abdomen since around 3 in the morning. No diarrhea vomiting fever chills or other complaints.

Vital Signs: T: 36.6 °C – HR: 55 – RR: 16 – BP: 179/71 – SpO2: 97%

Physical Exam: ABDOMEN: Soft, epigastric and right upper quadrant-tenderness with guarding. No rebound

Initial Diagnostic Testing:

  • CBC: White count elevated at 13 with left shift but CRP normal at 0.7
  • Chem-7: Metabolic panel and LFTs essentially normal. Troponin normal
  • UA: normal
  • Imaging: see cut of CT scan below

What is the most likely diagnosis?

  • A) kidney stone
  • B) cholecystitis
  • C) gastritis
  • D) pancreatitis

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What is the most likely diagnosis?

  • A) kidney stone
  • B) cholecystitis
  • C) gastritis
  • D) pancreatitis

1-Minute Consult on this topic: Click HERE and scroll

CASE CONCLUSION: CT scan of the abdomen which was chosen to rule out mesenteric ischemia given history of A-fib read by radiologist as showing evidence of cholecystitis with a thick gallbladder wall.   An ultrasound recommended by radiologist was ordered along with repeat repeat LFTs.   The ultrasound showed gallstones but no cholecystitis.  Repeat LFT’s remained normal without even a trend of change.  Patient sent home but returned 2 days later with WBC count of 22, CRP of 25 and lactic acid of 3.8, normal LFTs (even lower than during the prior visit) and an ultrasound showing clear cholecystitis.

Case Lessons:

  1. RUQ pain lasting more than 6 hours with gallstones is likely to be cholecystitis even if the LFT’s are stone cold normal and the ultrasound shows a normal gallbladder wall.  If a patient like this is sent home recommend a 12-24 hour recheck
  2. CT is almost as good as US for cholecystitis and in some cases is better