Morning Report April 1, 2013

Holly Shillington, MD, PGY-3

The Case
18 year old Hispanic female in continuity clinic with abdominal pain.

She has had intermittent abdominal pain since September, but was started on omeprazole in January for heartburn and that pain has since resolved.

This pain episode seems different from her prior episodes of pain (specifically - different location and duration).

 Pain

started last night after dinner and has continued on and off for the past 20 hours. Location: RUQ, sometimes moves up and down. 7/10 pain, squeezing. Worse with eating and deep breathing. No change with activity, bowel movements, or copious amounts of pepto bismol. Associated nausea and vomiting (NBNB).

Stooling: Usually stools daily (sometimes hard, sometimes soft), but had loose stools yesterday.

Diet: Eats a lot of fast food.

ROS
Negative except for abdominal pain, diarrhea, rhinorrhea, sore throat.
No fever!

PMH: PCOS, acne, obesity, heartburn Meds: omeprazole, OCP, Retin A NKDA IMMS: UTD Family Hx: no gallstones or kidney stones Social: Lives with Mom, Moms fianc, and brother. Planning on graduating high school this May and starting at a local university in the Fall.

Teen Only Interview

Never

been sexually active. LMP one week ago. Denies verbal, physical, sexual abuse. Denies drug use. No other concerns from patient.

Physical Exam

Completely normal vitals and exam except:

Obesity
Black

tongue Mild RUQ tenderness to palpation

Pepto Bismol!

DDX of Acute Abdominal Pain

GI

Appendicitis Peptic Ulcer Disease Constipation Gastroenteritis

Renal Renal stone UTI

*More specific to the RUQ* Gallstones/Biliary Colic Cholecystitis Hepatitis Pancreatitis

GYN Pregnancy PID Ruptured ovarian cyst Ovarian Torsion

Follow up

Friday:
Alk

phos: 112 (nl) GGT 594 (abnl) (nl 21-101) Ordered hepatitis panel, AST 217 (abnl) (nl 12-32) CMV, EBV, total/direct bili ALT 224 (abnl) (nl 5-32) Ordered U/S Amylase 33 (nl) Monday: Lipase 33 (nl)
U/S:

Sunday: continued pain

Cholelithiasis w/o evidence of cholecystitis.

No Murphys Sign

Risk Factors for Gallstones

4 Fs: female, > 40, fat, fertile*

*Estrogen increases cholesterol secretion and progesterone reduces bile acid secretion leading to supersaturation of the bile with cholesterol which promotes stone formation. Progesterone also slows gallbladder emptying leading to bile stasis.

Risk Factors for Gallstones

Estrogen replacement therapy in post-menopausal women OCPs slight increased risk of gallstone formation (which appears to be transient). Especially with high-dose estrogen (> 50 mcg) Family History and Genetics Obesity Rapid weight loss Diabetes

Elevated triglycerides Cirrhosis Gallbladder stasis (spinal cord injuries, prolonged fasting, TPN) Drugs: estrogen, OCPs, octreotide, clofibrate*, ceftriaxone** Decreased physical activity Crohns Disease Hemolysis

Biliary Colic
Intense,

dull RUQ discomfort that may radiate to the back (often right shoulder blade) lasting 30 minutes to hours. Associated with nausea and vomiting. Often post-prandial, but may be nocturnal. Not exacerbated with movement and not relieved by squatting, passing gas, or having a bowel movement. Pain is due to increased intra-gallbladder pressure that occurs when gallbladder contractions force a stone against the gallbladder outlet.

Uncomplicated Gallstone Disease

Labs should be normal!

If labs are abnormal (leukocytosis, elevated liver or pancreatic enzymes), this suggests the development of a complication (acute cholecystitis, cholangitis, pancreatitis).

Biliary Colic Treatment. When Stones are Present!

Pain Relief

NSAIDS (or opioids) If severe vomiting. 92% curative 600 mg daily Reduces need for cholecystectomy by 30%

Hydration

Cholecystectomy

Ursodiol

Extracorporeal shock-wave lithotripsy therapy

Cholecystectomy Complications and Side Effects

2.6% risk of major complications in lap chole:

Bleeding,

abscess formation, biliary injury, bowel injury of patients (but often improves)

Diarrhea (due to lack of gallbladder)

5-12%

Incidental Gallstones
The majority of patients with gallstones are asymptomatic. Only 20% of patients with asymptomatic gallstones will develop symptoms over a 15-year follow up period.

References
Approach to the patient with abnormal liver biochemical and function tests. Up To Date. 30 March 2013. Dissolution therapy for the treatment of gallstones. Up To Date. 30 March 2013. Epidemiology of and risk factors for gallstones. Up To Date. 30 March 2013. Uncomplicated gallstone disease in adults. Up To Date. 30 March 2013.