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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor=Gerald {{Alison}}
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
Line 20: Line 20:
|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=An obese 48-year-old, multiparous female, presents to the physician's office with nonradiating right upper quadrant pain, nausea, bloating, and vomiting that becomes worse after the consumption of fries and a hamburger. Ultrasonography displays hyperechogenic foci within the right upper quadrant. Laboratory testing reveals a WBC count of 16,000/mm<sup>3</sup> and a serum amylase level of 70 U/L. Which of the following substances results in her right upper quadrant pain?


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


Which of the following symptoms is most likely to occur in this patient?
|Explanation= The patient in this scenario demonstrates symptoms, as well as laboratory and imaging results, which are suggestive of gallstone cholecystitis. Gallstone cholecystitis is typically presented in patients who fit the profile of the “4F’s”: Female, Fat, Fertile, and Forty. The right upper-quadrant pain that results from gallbladder contraction, is induced by cholecystokinin (CCK), which secretes in response to the presence of peptides, amino acids, and fatty acids in the duodenum.
|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.
'''ADD TABLE'''


|EducationalObjectives= Large biliary stones can create a fistula between the gallbladder and duodenum and block the ileocecal valve leading to gallstone ileus.


gallbladder contraction, which produces right upper quadrant pain in an obese, middle-aged, multiparous women with ultrasonographic findings consistent with gallstones is a classic presentation of acute calculous cholecystitis. Acute calculous cholecystitis is an acute mechanical inflammation of the gallbladder commonly resulting from a gallbladder stone obstructing the gallbladder neck or cystic duct, chemical inflammation, and/or bacterial inflammation.
|EducationalObjectives= Gallstone cholecystitis, induced by cholecystokinin, is typically presented in patients who fit the profile of the “4F’s”: Female, Fat, Fertile, and Forty.
|References=Le T, Bhushan V. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014.  
|References=Le T, Bhushan V. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014.  
|AnswerA=Bloody diarrhea
|AnswerA=Cholecystokinin
|AnswerAExp=Bloddy diarrhea is not usually seen with gallstones that perforate.
|AnswerAExp= See overall explanation
|AnswerB=Fever, chills and abdominal rigidity
|AnswerB=Gastrin
|AnswerBExp=Fever, chills and abdominal rigidity can sometimes be seen in severe ascending cholangitis with continued obstruction.
|AnswerBExp=
|AnswerC=Bloating, vomiting, and obstipation
|AnswerC= Pepsin
|AnswerCExp=Bloating, vomiting, and obstipation are characteristic of gallstone ileus.
|AnswerCExp=
|AnswerD=Jaundice and icterus
|AnswerD= Secretin
|AnswerDExp=Jaundice and icterus are seen in active biliary tract obstruction absent in this patient.
|AnswerDExp=
|AnswerE=Shortness of breath
|AnswerE= Gastric inhibitory peptide
|AnswerEExp=Shortness of breath is not typical of large perforating stones.
|AnswerEExp=
|RightAnswer=C
|RightAnswer=A
|WBRKeyword=Gallstone ileus, Cholelithiasis, Cholecystitis
|WBRKeyword=Gallstone ileus, Cholelithiasis, Cholecystitis
'''|Approved=Not at all'''
|Approved=No
}}
}}

Revision as of 16:08, 7 July 2014
Author [[PageAuthor::Gerald (Reviewed by Alison Leibowitz)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathophysiology
Sub Category SubCategory::Gastrointestinal
Prompt [[Prompt::An obese 48-year-old, multiparous female, presents to the physician's office with nonradiating right upper quadrant pain, nausea, bloating, and vomiting that becomes worse after the consumption of fries and a hamburger. Ultrasonography displays hyperechogenic foci within the right upper quadrant. Laboratory testing reveals a WBC count of 16,000/mm3 and a serum amylase level of 70 U/L. Which of the following substances results in her right upper quadrant pain?]]
Answer A AnswerA::Cholecystokinin
Answer A Explanation AnswerAExp::See overall explanation
Answer B AnswerB::Gastrin
Answer B Explanation AnswerBExp::
Answer C AnswerC::Pepsin
Answer C Explanation AnswerCExp::
Answer D AnswerD::Secretin
Answer D Explanation AnswerDExp::
Answer E AnswerE::Gastric inhibitory peptide
Answer E Explanation AnswerEExp::
Right Answer RightAnswer::A
Explanation [[Explanation::The patient in this scenario demonstrates symptoms, as well as laboratory and imaging results, which are suggestive of gallstone cholecystitis. Gallstone cholecystitis is typically presented in patients who fit the profile of the “4F’s”: Female, Fat, Fertile, and Forty. The right upper-quadrant pain that results from gallbladder contraction, is induced by cholecystokinin (CCK), which secretes in response to the presence of peptides, amino acids, and fatty acids in the duodenum.

ADD TABLE 


gallbladder contraction, which produces right upper quadrant pain in an obese, middle-aged, multiparous women with ultrasonographic findings consistent with gallstones is a classic presentation of acute calculous cholecystitis. Acute calculous cholecystitis is an acute mechanical inflammation of the gallbladder commonly resulting from a gallbladder stone obstructing the gallbladder neck or cystic duct, chemical inflammation, and/or bacterial inflammation.

Educational Objective: Gallstone cholecystitis, induced by cholecystokinin, is typically presented in patients who fit the profile of the “4F’s”: Female, Fat, Fertile, and Forty.
References: Le T, Bhushan V. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014.]]

Approved Approved::No
Keyword WBRKeyword::Gallstone ileus, WBRKeyword::Cholelithiasis, WBRKeyword::Cholecystitis
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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