Differentials
Acute cholangitis
SIGNS / SYMPTOMS
Classic findings are fever and chills, jaundice, and abdominal pain (Charcot triad).[48]
INVESTIGATIONS
Magnetic resonance cholangiography or MRI findings: intraductal purulent material with low signal intensity on heavily T2-weighted images and/or intermediate signal intensity on fat-suppressed T1-weighted images.
Chronic cholecystitis
SIGNS / SYMPTOMS
Repeated bouts of mild attacks or chronic irritation by large gallstones.[2]
INVESTIGATIONS
No specific investigations.
Mucosal atrophy and fibrosis of the gallbladder wall in postoperative specimens.
Peptic ulcer disease
SIGNS / SYMPTOMS
Burning epigastric pain that occurs hours after meals or with hunger. Often wakes the patient at night. Pain improves with eating.
INVESTIGATIONS
Endoscopy may reveal a peptic ulcer.
Acute pancreatitis
SIGNS / SYMPTOMS
Epigastric or periumbilical abdominal pain that radiates to the back.
Ecchymosis in the periumbilical region (Cullen sign) or the flank (Grey Turner sign) may be present in severe pancreatitis.
INVESTIGATIONS
Tripling of serum amylase and lipase.
Pancreatic inflammation on CT abdomen.
Sickle cell crises
SIGNS / SYMPTOMS
Associated with gallstone disease.
Pain can occur anywhere in the body (including right upper quadrant), which may be unrelated to gallstone formation.
INVESTIGATIONS
Blood film may show sickle cells.
Hemoglobin electrophoresis shows the presence of hemoglobin S or C.
Appendicitis
SIGNS / SYMPTOMS
Pain is usually located in the right iliac fossa but may start in the periumbilical region.
INVESTIGATIONS
Abdominal CT scan: dilated appendix with thickened, hyperenhancing wall and mural stratification of appendix.
Right lower lobe pneumonia
SIGNS / SYMPTOMS
Productive cough with fever.
Exam may reveal bronchial breath sounds, crepitations, and dullness to percussion.
INVESTIGATIONS
Right lower lobe consolidation on chest x-ray.
Acute coronary syndrome
SIGNS / SYMPTOMS
Typically central chest pain, squeezing in nature, radiation to jaw or left arm. Pain may be felt in the epigastrium.
May be a history of angina and risk factors for coronary artery disease (e.g., smoking, hypertension, diabetes mellitus, obesity).
INVESTIGATIONS
Ischemic changes on ECG (ST elevation or depression, T-wave inversion, left bundle-branch block).
Elevated cardiac enzymes.
GERD
SIGNS / SYMPTOMS
Burning sensation in chest after meals, worse on bending over or lying down. May be acid reflux and dysphagia.
INVESTIGATIONS
Therapeutic trial with proton-pump inhibitors leads to symptom relief.
Esophagitis may be seen on endoscopy.
pH <4 for >4% of the time is typical.
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