Differentials
Acute cholecystitis
SIGNS / SYMPTOMS
Positive Murphy sign (inhibition of inspiration by pain on right upper quadrant [RUQ] palpation).
Murphy sign is most commonly associated with cholecystitis, which can occur alongside cholangitis but this rarely happens in clinical practice. People with cholangitis typically have diffuse RUQ pain and not classic Murphy sign.
INVESTIGATIONS
Transabdominal ultrasound: pericholecystic fluid and gallbladder wall thickening.
Abnormal hepatic imido-diacetic acid scan.
Peptic ulcer disease
SIGNS / SYMPTOMS
Symptoms often improve with food and antacids. Pain can last a few weeks and remit for a period of time.
INVESTIGATIONS
LFTs typically normal.
Acute pancreatitis
SIGNS / SYMPTOMS
History of alcohol consumption, or medication-induced or chronic pancreatitis.
Pain is often more severe than that experienced with cholangitis.
It is important to note that cholangitis can occur in the setting of acute or chronic pancreatitis but is less common.
INVESTIGATIONS
Amylase: greater elevation when compared with cholangitis.
Lipase: elevated levels are more specific to the pancreas than amylase levels.
CT scan: often shows stranding around the pancreas.
Hepatic abscess
SIGNS / SYMPTOMS
Hepatomegaly, acute abdomen.
It is important to note that acute cholangitis can cause hepatic abscesses, but in the case of hepatic abscess alone, bile ducts are much less likely to be dilated.
INVESTIGATIONS
Ultrasound, CT, or MRI will typically identify the abscess.
Acute pyelonephritis
SIGNS / SYMPTOMS
Flank pain, costovertebral angle tenderness.
INVESTIGATIONS
Urinalysis: pyuria, positive nitrites.
CT scan may show perinephric stranding.
Acute appendicitis
SIGNS / SYMPTOMS
McBurney point tenderness, Rovsing sign, obturator sign (pain with passive flexion and internal rotation of the right hip), acute abdomen on exam with rebound, guarding or rigidity.
INVESTIGATIONS
CT scan of the abdomen: fat stranding around the appendix, thickening of the appendix, periappendiceal fluid.
Right lower lobe pneumonia
SIGNS / SYMPTOMS
Positive history of cough, shortness of breath. Physical exam will have crackles on lung auscultation.
INVESTIGATIONS
CT scan of the abdomen usually images the lower lung lobes and will show a consolidation.
HELLP syndrome of preeclampsia
SIGNS / SYMPTOMS
Presence of hemolytic anemia, elevated liver enzymes, and low platelet count (HELLP syndrome). It typically occurs in the latter stages of pregnancy and is considered a form of preeclampsia. A small percentage of cases occur after delivery.
Elevated BP.
INVESTIGATIONS
Fibrin degradation products: elevated.
Lactate dehydrogenase: elevated (marker of hemolysis).
Urinalysis: proteinuria.
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