WBR0657: Difference between revisions

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(Created page with "{{WBRQuestion |QuestionAuthor={{Rim}} |ExamType=USMLE Step 1 |MainCategory=Pathophysiology |SubCategory=Gastrointestinal |MainCategory=Pathophysiology |SubCategory=Gastrointes...")
 
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|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Gastrointestinal
|SubCategory=Gastrointestinal
|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?
|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.
|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.  


[[File:Pneumobilia-101.jpg|400px]]


Learning objective: Large biliary stones can create a fistula between the gallbladder and duodenum and block the ileocecal valve leading to gallstone ileus.
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.


Reference:
|References=Le T, Bhushan V. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014.  
 
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.
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|RightAnswer=C
|RightAnswer=C
|WBRKeyword=Gallstone ileus, Cholelithiasis, Cholecystitis
|WBRKeyword=Gallstone ileus, Cholelithiasis, Cholecystitis
|Approved=No
'''|Approved=Not at all'''
}}
}}

Revision as of 18:56, 3 July 2014
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 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.

Which of the following symptoms is most likely to occur in this patient?]]

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'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.

Educational Objective: 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.]]

Approved Approved::Not at all'''
Keyword WBRKeyword::Gallstone ileus, WBRKeyword::Cholelithiasis, [[WBRKeyword::Cholecystitis

]]

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