Acute cholecystitis differential diagnosis: Difference between revisions

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==Overview==
==Overview==
Acute cholecystitis must be differentiated from other diseases that cause right upper quadrant pain and nausea/vomiting such as biliary colic, acute cholangitis, and viral hepatitis.
Acute cholecystitis must be differentiated from other diseases that cause [[Abdominal pain|right upper quadrant abdominal pain]] and [[Nausea and vomiting|nausea/vomiting]] such as [[biliary colic]], [[acute cholangitis]], and [[viral hepatitis]].


==Differentiating Acute cholecystitis from other Diseases==
==Differentiating Acute cholecystitis from other Diseases==
Acute cholecystitis must be differentiated from other diseases that cause right upper quadrant pain and nausea/vomiting such as:<ref name="BluthBenson2008">{{cite journal|last1=Bluth|first1=Edward I.|last2=Benson|first2=Carol B.|last3=Ralls|first3=Philip W.|last4=Siegel|first4=Marilyn J.|title=1: Right Upper Quadrant Pain|year=2008|doi=10.1055/b-0034-71418|url=https://www.thieme-connect.de/products/ebooks/lookinside/10.1055/b-0034-71418}}</ref><ref name="urlAcute cholecystitis | The BMJ">{{cite web |url=http://www.bmj.com/content/325/7365/639 |title=Acute cholecystitis &#124; The BMJ |format= |work= |accessdate=}}</ref><ref name="pmid24679431">{{cite journal |vauthors=Knab LM, Boller AM, Mahvi DM |title=Cholecystitis |journal=Surg. Clin. North Am. |volume=94 |issue=2 |pages=455–70 |year=2014 |pmid=24679431 |doi=10.1016/j.suc.2014.01.005 |url=}}</ref>
Acute cholecystitis must be differentiated from other diseases that cause right upper quadrant pain and nausea/vomiting such as:<ref name="BluthBenson2008">{{cite journal|last1=Bluth|first1=Edward I.|last2=Benson|first2=Carol B.|last3=Ralls|first3=Philip W.|last4=Siegel|first4=Marilyn J.|title=1: Right Upper Quadrant Pain|year=2008|doi=10.1055/b-0034-71418|url=https://www.thieme-connect.de/products/ebooks/lookinside/10.1055/b-0034-71418}}</ref><ref name="urlAcute cholecystitis | The BMJ">{{cite web |url=http://www.bmj.com/content/325/7365/639 |title=Acute cholecystitis &#124; The BMJ |format= |work= |accessdate=}}</ref><ref name="pmid24679431">{{cite journal |vauthors=Knab LM, Boller AM, Mahvi DM |title=Cholecystitis |journal=Surg. Clin. North Am. |volume=94 |issue=2 |pages=455–70 |year=2014 |pmid=24679431 |doi=10.1016/j.suc.2014.01.005 |url=}}</ref>
*Biliary colic
*[[Biliary colic]]
*Acute cholangitis
*[[Acute cholangitis]]
*Viral hepatitis
*[[Viral hepatitis]]
*Alcoholic hepatitis
*[[Alcoholic hepatitis]]
*Acute pancreatitis
*[[Acute pancreatitis]]
*Acute appendicitis
*[[Acute appendicitis]]
*Irritable bowel syndrome
*[[Irritable bowel syndrome]]




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! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Extra-abdominal causes
! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Extra-abdominal causes
| colspan="2" rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pulmonary causes
| colspan="2" rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" align="center" |Pulmonary causes
| " style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Pulmonary embolism]]
| style="padding: 5px 5px; background: #DCDCDC;" align="center" " |[[Pulmonary embolism]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ/LUQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |RUQ/LUQ
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
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{|
{|
|-
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| [[Image:Right_upper_quadrant.PNG|link=Right upper quadrant abdominal pain resident survival guide]]||[[Image:Epigastric_quadrant_pain.PNG|link=Epigastric pain resident survival guide]]||[[Image:Left_upper_quadrant.PNG|link=Left upper quadrant abdominal pain resident survival guide]]  
| <figure-inline class="mw-default-size">[[Image:Right_upper_quadrant.PNG|link=Right upper quadrant abdominal pain resident survival guide|339x339px]]</figure-inline>||<figure-inline class="mw-default-size">[[Image:Epigastric_quadrant_pain.PNG|link=Epigastric pain resident survival guide|179x179px]]</figure-inline>||<figure-inline class="mw-default-size">[[Image:Left_upper_quadrant.PNG|link=Left upper quadrant abdominal pain resident survival guide|329x329px]]</figure-inline>
|-
|-
| [[Image:Right_flank_quadrant.PNG|link=Right flank pain resident survival guide]]||[[Image:Umbilical_pain.PNG|link=Umbilical region pain resident survival guide]]||[[Image:Left_flank_quadrant.PNG|link=Left flank quadrant abdominal pain resident survival guide]]
| <figure-inline class="mw-default-size">[[Image:Right_flank_quadrant.PNG|link=Right flank pain resident survival guide|338x338px]]</figure-inline>||<figure-inline class="mw-default-size">[[Image:Umbilical_pain.PNG|link=Umbilical region pain resident survival guide|165x165px]]</figure-inline>||<figure-inline class="mw-default-size">[[Image:Left_flank_quadrant.PNG|link=Left flank quadrant abdominal pain resident survival guide|335x335px]]</figure-inline>
|-
|-
| [[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide]]||[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide]]||[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide]]
| <figure-inline class="mw-default-size">[[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide|338x338px]]</figure-inline>||<figure-inline class="mw-default-size">[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide|199x199px]]</figure-inline>||<figure-inline class="mw-default-size">[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide|335x335px]]</figure-inline>
|}
|}



Revision as of 15:54, 15 December 2017

Acute cholecystitis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Furqan M M. M.B.B.S[2]

Overview

Acute cholecystitis must be differentiated from other diseases that cause right upper quadrant abdominal pain and nausea/vomiting such as biliary colic, acute cholangitis, and viral hepatitis.

Differentiating Acute cholecystitis from other Diseases

Acute cholecystitis must be differentiated from other diseases that cause right upper quadrant pain and nausea/vomiting such as:[1][2][3]


Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram, US = Ultrasound

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute cholecystitis RUQ + + + Hypoactive Ultrasound shows:
  • Gallstone
  • Inflammation
Acute suppurative cholangitis RUQ + + + + + + + N
  • Abnormal LFT
  • WBC >10,000
  • Ultrasound shows biliary dilatation/stents/tumor
  • Septic shock occurs with features of SIRS
Acute cholangitis RUQ + + N
  • Ultrasound shows biliary dilatation/stents/tumor
  • Biliary drainage (ERCP) + IV antibiotics
Cholelithiasis RUQ/Epigastric ± ± ± Normal to hyperactive for dislodged stone
  • Fatty food intolerance
Acute pancreatitis Epigastric + + ± + ± N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
  • Pain radiation to back
Primary biliary cirrhosis RUQ/Epigastric + N
  • Increased AMA level, abnormal LFTs
  • ERCP
  • Pruritis
Primary sclerosing cholangitis RUQ + + N ERCP and MRCP shows
  • Multiple segmental strictures
  • Mural irregularities
  • Biliary dilatation and diverticula
  • Distortion of biliary tree
  • The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Hepatic causes Viral hepatitis RUQ + + + Positive in Hep A and E + Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + ± + + + ± Normal or hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + + +
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Budd-Chiari syndrome RUQ ± ± Positive in liver failure leading to varices N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Hemochromatosis RUQ Positive in cirrhotic patients N
  • >60% TS
  • >240 μg/L SF
  • Raised LFT
    Hyperglycemia
  • Ultrasound shows evidence of cirrhosis
Extra intestinal findings:
  • Hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Cirrhosis RUQ + + + + N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Intestinal causes Acute appendicitis Starts in epigastrium, migrates to RLQ + Positive in pyogenic appendicitis + ± Positive in perforated appendicitis + + Hypoactive
  • Ct scan
  • Ultrasound
  • Positive Rovsing sign
  • Positive Obturator sign
  • Positive Iliopsoas sign
Irritable bowel syndrome Diffuse ± ± + N Normal Normal Symptomatic treatment
Hollow Viscous Obstruction Biliary colic RUQ + + N
  • Ultrasound
Extra-abdominal causes Pulmonary causes Pulmonary embolism RUQ/LUQ ± ± N
  • ABGs
  • D-dimer
  • Dyspnea
  • Tachycardia
  • Pleuretic chest pain
Pneumonia RUQ/LUQ + + + ± + Normal or hypoactive
  • ABGs
  • Leukocytosis
  • Pancytopenia
  • CXR
  • CT chest
  • Bronchoscopy
  • Shortness of breath
  • Cough

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References

  1. Bluth, Edward I.; Benson, Carol B.; Ralls, Philip W.; Siegel, Marilyn J. (2008). "1: Right Upper Quadrant Pain". doi:10.1055/b-0034-71418.
  2. "Acute cholecystitis | The BMJ".
  3. Knab LM, Boller AM, Mahvi DM (2014). "Cholecystitis". Surg. Clin. North Am. 94 (2): 455–70. doi:10.1016/j.suc.2014.01.005. PMID 24679431.


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