الاثنين، 22 أبريل 2013

MCQs In Hepatobiliary Diseases

Q 1:

A 13-year-old girl presents with a 4-month history of right upper quadrant abdominal pain. The
pain occurs at different times, but seems to strike primarily after meals, more frequently after
she eats fatty foods. In your office, she complains of intermittent pain to deep palpation of the
right upper quadrant. Complete blood count, alanine aminotransferase, alkaline phosphatase,
serum bilirubin, amylase, and lipase findings are normal. Abdominal ultrasonography shows no
evidence of stones or gallbladder thickening. Upper endoscopy and biopsy results are normal,
with no evidence of ulcers or gastritis.
Of the following, the MOST appropriate next step is

A. abdominal computed tomography scan
B. endoscopic retrograde cholangiopancreatography (ERCP)
C. nuclear medicine gallbladder emptying scan with fatty meal
D. psychiatric consultation to rule out depression or anxiety
E. referral to an acupuncturist for chronic pain management

Answer

C


The colicky abdominal pain in the right upper quadrant after the ingestion of fatty foods
described for the patient in the vignette is strongly suggestive of gallbladder disease. However,
results of laboratory studies and abdominal ultrasonography are within normal limits. Because of
the symptom profile, the possibility of chronic acalculous cholecystitis with gallbladder dysmotility
should be considered, and the test of choice to evaluate for this condition is a radionuclide
gallbladder emptying scan. If the patient has markedly delayed gallbladder motility, consideration
should be given to performing a cholecystectomy.

Classically, cholecystitis occurs when the gallbladder is inflamed and irritated by gallstones.
Such gallstones typically are classified as cholesterol stones and pigment (bilirubin) stones. Risk
factors for cholesterol stones include older age, female sex, pregnancy, and overweight. Risk
factors for pigment stones include parenteral nutrition and hemolysis (as seen in children who
have sickle cell disease). For patients who have stones, cholecystitis commonly presents with
pain in the right upper quadrant, epigastrium, and back. Fever, jaundice, and abnormal liver
enzyme values also may be present, especially if a gallstone is in the biliary tree
(choledocholithiasis).

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