WBR0657

Author	[[PageAuthor::Rim Halaby, M.D. [1]]]
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 exam, you note marked tenderness to palpation, and when the patient is asked to breath in while her liver is being palpated she cuts her breath short because of her pain. 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 gallstone 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). The air seen in the biliary tree is indicative that a large gallbladder stone has probably 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. Learning objective: Large biliary stones can create a fistula between the gallbladder and duodenum and block the ileocecal valve leading to gallstone ileus. Reference: Le T, Bhushan V. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014. Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::Gallstone ileus, WBRKeyword::Cholelithiasis, WBRKeyword::Cholecystitis
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::