The printable version is no longer supported and may have rendering errors. Please update your browser bookmarks and please use the default browser print function instead.
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 , viral hepatitis , alcoholic hepatitis , acute pancreatitis , acute appendicitis , and irritable bowel syndrome .
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:
Acute suppurative cholangitis
RUQ
+
+
+
+
−
−
−
−
+
+
+
N
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
Acute pancreatitis
Epigastric
+
−
+
±
−
−
+
−
±
−
−
N
Ultrasound shows evidence of inflammation
CT scan shows severity of pancreatitis
Primary biliary cirrhosis
RUQ /Epigastric
−
−
−
+
−
−
−
−
−
−
−
N
Increased AMA level, abnormal LFTs
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
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
Hepatocellular carcinoma /Metastasis
RUQ
+
−
−
+
−
−
+
−
−
−
−
Normal
Hyperactive if obstruction present
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
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
Extra-abdominal causes
Pulmonary causes
Pulmonary embolism
RUQ/LUQ
±
−
−
−
−
−
−
−
±
−
−
N
Dyspnea
Tachycardia
Pleuretic chest pain
Pneumonia
RUQ/LUQ
+
+
+
−
−
±
−
−
+
−
−
Normal or hypoactive
ABGs
Leukocytosis
Pancytopenia
CXR
CT chest
Bronchoscopy
Shortness of breath
Cough
<figure-inline> </figure-inline>|<figure-inline> </figure-inline>|<figure-inline> </figure-inline>
<figure-inline> </figure-inline>|<figure-inline> </figure-inline>|<figure-inline> </figure-inline>
<figure-inline> </figure-inline>|<figure-inline> </figure-inline>|<figure-inline> </figure-inline>
References
Template:WikiDoc Sources