Case history
Case history
A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the right upper quadrant (RUQ) that radiates through to her back. This pain began after eating dinner, gradually increased, and has remained constant over the last few hours. She has experienced previous episodes of similar pain for which she did not seek medical advice. Her vital signs are normal. The pertinent findings on physical exam are tenderness to palpation in the RUQ without guarding or rebound.
Other presentations
Biliary colic is characterized by steady, severe pain (intensity >5 on a scale of 1-10) in the RUQ of the abdomen lasting more than 15-30 minutes.[1] Simple biliary colic commonly requires an analgesic but should resolve within 5 hours.[8]
Acute cholecystitis presents with biliary pain lasting more than 5 hours, accompanied by inflammatory features such as fever, marked RUQ tenderness (Murphy's sign), and leukocytosis.[1] This can lead to sepsis.[9] See Acute cholecystitis.
Choledocholithiasis occurs when gallstones move into the bile ducts where they can cause obstruction. This results in biliary-type pain, often accompanied by cholestasis, which manifests as jaundice.
More sinister is acute cholangitis, a medical emergency, characterized by the Charcot triad of biliary pain, jaundice, and fever.[1] See Acute cholangitis.
Acute pancreatitis can occur when a stone that has passed distally to the ampulla then blocks the main pancreatic duct.[1] It presents with severe sudden-onset mid-epigastric or left upper quadrant abdominal pain (which often radiates into the back), nausea, and vomiting, accompanied by elevated pancreatic enzymes (lipase or amylase).[1] See Acute pancreatitis.
On rare occasions, a stone can perforate the gallbladder, leading to intestinal obstruction (gallstone ileus). Mirizzi syndrome is a rare complication in which the gallstone becomes impacted in the cystic duct or neck of the gallbladder, compressing the adjacent common hepatic duct, and resulting in biliary obstruction and jaundice.
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