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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor= {{SSK}} (Reviewed by Serge Korjian)
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
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|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|SubCategory=Gastrointestinal
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
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|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|SubCategory=Gastrointestinal
|Prompt=A 32-year-old female presents to the ER with severe right upper quadrant abdominal pain. The patient reports that her discomfort started shortly after eating lunch. Upon physical examination, when the patient is asked to breath in while her liver is being palpated she cuts her breath short because of the severity of her pain. The abdominal CT scan is displayed below.
|Prompt=A 32-year-old woman presents to the emergency department for 3 hours of severe right upper quadrant abdominal pain. The patient reports that her crisis started shortly after a lunch of chicken nuggets and french fries. On physical examination, you note marked tenderness to palpation, and a sudden interruption of her breathing when the liver is palpated. Abdominal ultrasound is unremarkable. Magnetic resonance cholangiogram reveals air in the biliary tree but no evidence of stone. What would you expect the patient to complain of other than her pain?
 
|Explanation=The patient has the typical presentation of a biliary colic with physical exam suggestive of cholecystitis (Murphy's sign is positive). Murphy's sign is assessed by asking the patient to inhale deeply while the approximate location of the gallbladder is palpated (right upper quadrant, midclavicular line). As the patient inhales and pushed the bowel contents down, the pressure exerted on the inflamed gallbladder causes the patient to stop breathing suddenly. The air that was observed in the biliary tree on cholangiogram is indicative that a large gallbladder stone has likely created a fistula between the gallbladder and the small intestine allowing it to escape. Classically, if the stone is large enough, it would obstruct the narrowest part of the intestinal lumen, usually the ileocecal valve. Obstruction would cause a syndrome of ileus with bloating, nausea and vomiting, and obstipation known as gallstone ileus. Treatment is usually surgical. Despite treatment, mortality can be as high as 30% of patients affected.
[[File:Pneumobilia-101.jpg|400px]]
 
Which of the following symptoms is most likely to occur in this patient?
|Explanation=The patient's presentation and physical findings are suggestive of a [[biliary colic]] secondary to [[cholecystitis]] (Murphy's sign is positive). The presence of air in the biliary tree (pneumobilia) is most commonly observed in patients following a sphincterotomy or biliary-enteric anastomosis. Nonsurgical causes of pneumobilia are relatively uncommon and are usually indicative of serious disease including infection, neoplasm, biliary-enteric fistula, emphysematous cholecystitis, and incompetence of the sphincter of Oddi.
 
|EducationalObjectives= Large biliary stones can create a fistula between the gallbladder and duodenum and block the ileocecal valve leading to gallstone ileus.
 
|References=Le T, Bhushan V. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014.  
|AnswerA=Bloody diarrhea
|AnswerA=Bloody diarrhea
|AnswerAExp=Bloddy diarrhea is not usually seen with gallstones that perforate.
|AnswerAExp=Bloddy diarrhea is not usually seen with gallstones that perforate.
|AnswerB=Fever, chills and abdominal rigidity
|AnswerB=Fever, chills and abdominal rigidity
|AnswerBExp=Fever, chills and abdominal rigidity can sometimes be seen in severe ascending cholangitis with continued obstruction.  
|AnswerBExp=Fever, chills and abdominal rigidity can sometimes be seen in severe ascending cholangitis with continued obstruction.
|AnswerC=Bloating, vomiting, and obstipation
|AnswerC=Bloating, vomiting, and obstipation
|AnswerCExp=Bloating, vomiting, and obstipation are characteristic of gallstone ileus.
|AnswerCExp=Bloating, vomiting, and obstipation are characteristic of ileus.
|AnswerD=Jaundice and icterus
|AnswerD=Jaundice and icterus
|AnswerDExp=Jaundice and icterus are seen in active biliary tract obstruction absent in this patient.
|AnswerDExp=Jaundice and icterus are seen in active biliary tract obstruction absent in this patient.
|AnswerE=Shortness of breath
|AnswerE=Shortness of breath
|AnswerEExp=Shortness of breath is not typical of large perforating stones.
|AnswerEExp=Shortness of breath is not typical of large perforating stones.
|EducationalObjectives=Large biliary stones can create a fistula between the gallbladder and duodenum and block the ileocecal valve leading to gallstone ileus.
|References=Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60(6):441-6.
|RightAnswer=C
|RightAnswer=C
|WBRKeyword=Gallstone ileus, Cholelithiasis, Cholecystitis
|WBRKeyword=Gallstone ileus, Cholelithiasis, Cholecystitis
'''|Approved=Not at all'''
|Approved=Yes
}}
}}

Latest revision as of 01:20, 28 October 2020
Author [[PageAuthor::Serge Korjian M.D. (Reviewed by Serge Korjian)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathophysiology
Sub Category SubCategory::Gastrointestinal
Prompt [[Prompt::A 32-year-old woman presents to the emergency department for 3 hours of severe right upper quadrant abdominal pain. The patient reports that her crisis started shortly after a lunch of chicken nuggets and french fries. On physical examination, you note marked tenderness to palpation, and a sudden interruption of her breathing when the liver is palpated. Abdominal ultrasound is unremarkable. Magnetic resonance cholangiogram reveals air in the biliary tree but no evidence of stone. What would you expect the patient to complain of other than her pain?]]
Answer A AnswerA::Bloody diarrhea
Answer A Explanation AnswerAExp::Bloddy diarrhea is not usually seen with gallstones that perforate.
Answer B AnswerB::Fever, chills and abdominal rigidity
Answer B Explanation AnswerBExp::Fever, chills and abdominal rigidity can sometimes be seen in severe ascending cholangitis with continued obstruction.
Answer C AnswerC::Bloating, vomiting, and obstipation
Answer C Explanation AnswerCExp::Bloating, vomiting, and obstipation are characteristic of ileus.
Answer D AnswerD::Jaundice and icterus
Answer D Explanation AnswerDExp::Jaundice and icterus are seen in active biliary tract obstruction absent in this patient.
Answer E AnswerE::Shortness of breath
Answer E Explanation AnswerEExp::Shortness of breath is not typical of large perforating stones.
Right Answer RightAnswer::C
Explanation [[Explanation::The patient has the typical presentation of a biliary colic with physical exam suggestive of cholecystitis (Murphy's sign is positive). Murphy's sign is assessed by asking the patient to inhale deeply while the approximate location of the gallbladder is palpated (right upper quadrant, midclavicular line). As the patient inhales and pushed the bowel contents down, the pressure exerted on the inflamed gallbladder causes the patient to stop breathing suddenly. The air that was observed in the biliary tree on cholangiogram is indicative that a large gallbladder stone has likely created a fistula between the gallbladder and the small intestine allowing it to escape. Classically, if the stone is large enough, it would obstruct the narrowest part of the intestinal lumen, usually the ileocecal valve. Obstruction would cause a syndrome of ileus with bloating, nausea and vomiting, and obstipation known as gallstone ileus. Treatment is usually surgical. Despite treatment, mortality can be as high as 30% of patients affected.

Educational Objective: Large biliary stones can create a fistula between the gallbladder and duodenum and block the ileocecal valve leading to gallstone ileus.
References: Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60(6):441-6.]]

Approved Approved::Yes
Keyword WBRKeyword::Gallstone ileus, WBRKeyword::Cholelithiasis, WBRKeyword::Cholecystitis
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