A patient with right hypochondriac pain
If a patient presents with right hypochondriac pain, one should consider following differential diagnoses considering site such as
- Cholecystitis
- Pancreatitis
- Subdiaphragmatic abscess
- Hepatitis
- Liver abscess
- Pneumonia/empyema
- Pleurisy/pleurodynia
A patient with right hypochondriac pain and vomiting
A 30 years old lady presents with right hypochondriac pain and vomiting for 3 days. The pain initially was colicky and then became constant.
What are the diagnoses striking in your mind?
Acute cholecystitis
Billiary ascariasis
Choledocholithiasis (Billiary colic)
What key questions would you ask?
- Pain- right hypochondriac pain initially colicky, then became constant with radiation to right shoulder and tip of the scapula.
- severe colicky pain with no radiation, not relieved by change of posture, several bouts of pain during the whole period- billiary ascariasis (unless complicated by cholecystitis or pancreatitis.)
- Similar colicky pain but does not usually persist more than 6 hours in billiary colic (choledocholithiasis) unless complicated by cholecystitis or pancreatitis.
- Vomiting- content of vomitus
- Fever- rise of temperature but no rigor.
What will you examine?
General examination- distressed during pain. Fever is present.
Abdominal examination- right hypochondrial tenderness, rigidity worse on inspiration (Murphy’s sign +ve) and occasionally a gallbladder mass (30% of cases)- Acute cholecystitis.
No tenderness or any other abnormalities in billiary ascariasis.
Clinical diagnosis–
History of abdominal pain initially colicky and then constant with radiation to shoulder tip and Murphy’s sign positive suggest the diagnosis of acute cholecystitis.
Features suggesting cholecystitis include severe and prolonged pain, fever and leucocytosis.
Investigation-
USG of HBS- Ultrasonography detects gallstones and gallbladder thickening due to cholecystitis.
CBC- neutrophilic leucocytosis.
Treatment-
Medical-
- Bed rest
- Pain relief- Moderate pain can be treated with NSAID but more severe pain should be treated with pethidine
- Antibiotics- A cephalosporin (such as cefuroxime) is the antibiotic of choice, but metronidazole is usually added in severely ill patients.
- Maintenance of fluid balance- Fluid balance is maintained by intravenous therapy, and nasogastric aspiration is only needed for persistent vomiting.
Surgical-
- Emergency cholecystectomy–
Urgent surgery is the optimal treatment when cholecystitis progresses in spite of medical therapy and when complications such as empyema or perforation develop.
- Interval cholecystectomy- done after 6 weeks of recovery.