A 36-year-old woman comes to the clinic due to intermittent abdominal pain. She has had 5 episodes of pain over the past several weeks. The pain is dull, is located in the right upper quadrant and epigastrium, and often radiates to the back. It occurs only after eating, lasts 30-60 minutes, and is not relieved by antacids. The pain is occasionally associated with nausea and vomiting, but the patient has no hematemesis, melena, or weight loss. The patient does not use nonsteroidal anti-inflammatory drugs, tobacco, or alcohol. Her father died of pancreatic cancer at age 64. Temperature is 37.5 C (99.5 F), blood pressure is 142/89 mm Hg, pulse is 67/min, and respirations are 12/min. BMI is 32 kg/m2. The abdomen is tender to palpation in the right upper quadrant and epigastrium but is nondistended and without rebound or guarding. Laboratory results are as follows:
| Complete blood count | |
| Hemoglobin | 14.4 g/dL |
| Platelets | 280,000/mm3 |
| Leukocytes | 7,500/mm3 |
| Liver function studies | |
| Total bilirubin | 0.2 mg/dL |
| Alkaline phosphatase | 73 U/L |
| Aspartate aminotransferase (SGOT) | 12 U/L |
| Alanine aminotransferase (SGPT) | 24 U/L |
Which of the following is the best next step in management of this patient?
Cholelithiasis (gallstones) | |
Risk |
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Clinical features |
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Diagnosis |
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Management |
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Complications |
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RUQ = right upper quadrant. | |
This patient's presentation suggests biliary colic, which occurs when the gallbladder contracts against a gallstone (or sludge) that temporarily blocks the cystic duct. Risk factors include female sex, age >40, hypertriglyceridemia, and obesity.
Patients classically develop dull postprandial right upper quadrant (RUQ) or epigastric pain that often radiates to the upper back or right shoulder. The pain rapidly increases in intensity over 30-60 minutes and subsides with gallbladder relaxation (typically within 6 hr). Nausea, vomiting, and diaphoresis may occur; however, temperature, leukocyte count, and liver function tests should remain normal.
RUQ abdominal ultrasonography is the preferred imaging modality for evaluating patients with biliary colic. It is the most sensitive test for detecting gallstones, is noninvasive, and is readily available without the need for contrast or radiation. Obesity may make visualization more difficult (although this is operator dependent) but is not a contraindication for ultrasonography.
(Choice B) Abdominal x-ray has limited usefulness in the evaluation of biliary colic. Only a small percentage of gallstones contain sufficient calcium to appear radiopaque on plain imaging.
(Choice C) CT scan is frequently performed to exclude other causes of abdominal pain (eg, pancreatitis, pancreatic cancer) but is less sensitive than ultrasonography for detecting gallstones (ie, lack of gallstones on CT would not reliably exclude their presence). Although pancreatitis can cause epigastric pain radiating to the back, the pain is typically persistent and progressive (vs intermittent and lasting 30-60 min). Despite this patient's family history, pancreatic cancer is exceedingly rare in young individuals and would more likely cause weight loss and progressive pain.
(Choice D) Testing for Helicobacter pylori is commonly performed for patients with dyspepsia. Although postprandial epigastric pain is common, it is usually described as burning (as opposed to dull) and relieved by antacids. Most important, dyspepsia is not associated with vomiting.
(Choice E) HIDA scan is used to diagnose acute cholecystitis in patients with equivocal abdominal ultrasonography. It is not indicated as first-line imaging. In addition, this patient has no signs of cholecystitis (eg, fever, leukocytosis).
(Choice F) Upper gastrointestinal endoscopy is useful for ruling out peptic ulcers, but the postprandial abdominal pain is often described as burning and relieved by antacids. Major risk factors are nonsteroidal anti-inflammatory drug use and H pylori infections.
Educational objective:
Biliary colic occurs when a gallstone intermittently obstructs the cystic duct. Classic symptoms include episodic, postprandial right upper quadrant or epigastric pain with nausea and vomiting; temperature, leukocyte count, and liver function studies remain normal. Abdominal ultrasonography can confirm the diagnosis.