01
Nursing Note
Triage:
47-year-old woman with worsening upper abdominal pain since last night. Nauseated. Vomited once. Says the pain is “under my ribs.”
- HR
- 106
- BP
- 124/76
- RR
- 20
- Temp
- 38.1°C
- SpO₂
- 99% RA
01
Chief complaint?
Upper Abdominal Pain
- Always start with the chief complaint.
- Be as specific as the available information allows, but do not make a diagnosis yet.
02
Differential
02
Differential for upper abdominal pain by systems?
GI
- Gastritis
- Peptic ulcer disease
- Perforated ulcer
Hepatobiliary
- Biliary colic
- Acute cholecystitis
- Choledocholithiasis
- Cholangitis
- Hepatitis
Pancreatic
- Pancreatitis
Cardiac / Vascular
- ACS
- Aortic pathology
- Mesenteric ischemia
Pulmonary
- Lower-lobe pneumonia
- Pulmonary embolism
GU
- Pyelonephritis
- Renal/ureteral stone
Clinical Approach
- The pain location determines where you enter the algorithm.
- The history, examination, and testing narrow the differential.
03
Initial Assessment
You walk in and find her uncomfortable but awake, answering normally, and not diaphoretic. Her abdomen is not rigid.
03
Before you start sorting out the diagnosis, what are the first two things you need to decide in any abdominal-pain patient?
Initial Priorities
- Determine whether she is critically ill or unstable.
- Assess for peritoneal signs.
Current Assessment
- She has no evidence of shock or generalized peritonitis.
- If instability or peritoneal signs were present, prioritize ABCs, IV access, monitoring, resuscitation, and early surgical involvement.
Peritoneal Signs
- Involuntary guarding
- Rigidity
- Rebound
Core Reading
- Cope's Early Diagnosis of the Acute Abdomen explains how abdominal disease evolves, how peritoneal irritation changes the examination, and why serial examination matters. Cope's Early Diagnosis of the Acute Abdomen — Amazon
04
Critical Diagnosis Gate
04
She's stable. Before you decide this is stomach or gallbladder disease, what dangerous diagnoses still need to stay in your head?
Dangerous Diagnoses
- ACS
- Perforated viscus
- Mesenteric ischemia
- Aortic catastrophe
- Ectopic pregnancy in a patient who could be pregnant
Clinical Approach
- Consider causes outside the abdomen when evaluating abdominal pain.
What if?
4a
Epigastric pressure + diaphoresis + risk factors?
Diagnosis to Consider
- ACS.
4b
Sudden severe epigastric pain + rigid abdomen + free air?
Diagnosis to Consider
- Perforated viscus.
4c
AFib + severe pain out of proportion to exam?
Diagnosis to Consider
- Mesenteric ischemia.
05
History
“I've had this before. Usually after I eat, especially a heavy meal. It hurts for a couple of hours and then goes away. Last night it started about an hour after dinner, but this time it never stopped. It started in the upper middle and right side and now goes toward my right back and shoulder blade.”
She has nausea and no appetite.
05
What do the prior short postprandial episodes sound like? What's different about today's episode? What's happening physiologically?
Previous Episodes: Biliary Colic
- The prior short postprandial attacks are consistent with biliary colic.
- A gallstone transiently obstructs the cystic duct, and the gallbladder contracts against the obstruction, producing pain.
- When the stone moves and the obstruction resolves, the pain resolves.
- Despite the name, biliary colic is often steady pain, rather than rhythmic intestinal-type colic.
Current Episode: Acute Cholecystitis
- Persistent pain with fever and systemic inflammation is concerning for acute cholecystitis.
- The cystic duct remains obstructed, leading to gallbladder distention, chemical inflammation, edema, ischemia, and an inflammatory response.
- The earlier episodes resolved; today's episode persists and is accompanied by fever, tenderness, and leukocytosis.
06
Examination
You press under the right costal margin and ask her to take a deep breath. She inspires, suddenly stops, and grabs your hand because of the pain.
06
What's that called? What exactly are you doing physiologically when you elicit it? Does a positive sign make the diagnosis by itself?
Murphy Sign
- During inspiration, the diaphragm descends and the gallbladder moves downward toward the examining hand.
- If the gallbladder and surrounding peritoneum are inflamed, contact produces sharp pain and abrupt inspiratory arrest.
Diagnostic Value
- Murphy sign supports the diagnosis but does not diagnose cholecystitis by itself.
- No single history, physical-exam, or routine laboratory finding is strong enough to independently rule acute cholecystitis in or out. Trowbridge et al., JAMA 2003
07
Labs
| Test | Result |
|---|---|
| WBC | 14.3 K/µL |
| Neutrophils | 85% |
| AST | 34 U/L |
| ALT | 38 U/L |
| Alkaline phosphatase | 105 U/L |
| Total bilirubin | 0.8 mg/dL |
| Lipase | 31 U/L |
| Creatinine | 0.8 mg/dL |
| hCG | Negative |
07
What supports inflammation here? What argues against a common bile duct obstruction? What argues against pancreatitis?
Inflammation
- WBC 14.3 with neutrophilia supports an inflammatory process.
Common Bile Duct Obstruction
- Normal bilirubin and alkaline phosphatase make significant common bile duct obstruction less likely.
Pancreatitis
- Normal lipase argues strongly against acute pancreatitis in this clinical setting.
08
Imaging
08
First imaging study? What findings would support acute cholecystitis?
First Study: Right Upper Quadrant Ultrasound
- Obtain a right upper quadrant ultrasound as the initial study for suspected biliary disease. ACR Appropriateness Criteria — Right Upper Quadrant Pain
Supporting Findings
- Gallstones
- Gallbladder wall thickening
- Gallbladder distention
- Pericholecystic fluid
- Sonographic Murphy sign
Interpretation
- No single ultrasound finding is perfect; interpret the pattern together with the clinical picture.
What if?
8a
What if the ultrasound is nondiagnostic but your suspicion remains high? What is your next move?
HIDA Scan / Hepatobiliary Scintigraphy
- A HIDA scan is the classic next test when ultrasound is equivocal and suspicion remains high.
- Failure of the gallbladder to visualize supports cystic duct obstruction.
Other Imaging
- CT or MRI/MRCP may also be appropriate, depending on the diagnosis or complication being evaluated. ACR Appropriateness Criteria — Right Upper Quadrant Pain
Ultrasound Result
Multiple gallstones
Gallbladder wall 5 mm
Mild pericholecystic fluid
Positive sonographic Murphy sign
Common bile duct 4 mm
No intrahepatic ductal dilation
09
Diagnosis? Which ultrasound findings support it? What does the normal common bile duct tell you?
Acute Calculous Cholecystitis
- The ultrasound findings support acute calculous cholecystitis.
Supporting Findings
- Gallstones
- Gallbladder wall thickening
- Pericholecystic fluid
- Sonographic Murphy sign
Common Bile Duct
- The normal CBD diameter and normal bilirubin make an obstructing common bile duct stone less likely at this point.
09
Biliary Anatomy Side Quest
10
Where else can a gallstone lodge? What disease does each location produce?
Transient Cystic Duct Obstruction: Biliary Colic
- A stone temporarily obstructs the cystic duct and then moves, producing biliary colic.
Persistent Cystic Duct Obstruction: Acute Cholecystitis
- Persistent obstruction causes gallbladder inflammation and acute cholecystitis.
Common Bile Duct: Choledocholithiasis
- A stone in the common bile duct causes choledocholithiasis, preventing bile from draining normally from the liver.
- Associated findings include jaundice, elevated bilirubin, cholestatic liver enzymes, and a dilated CBD.
Infected Obstructed Common Bile Duct: Ascending Cholangitis
- The combination of obstruction and infection produces ascending cholangitis and can rapidly progress to sepsis.
Ampulla: Gallstone Pancreatitis
- A stone lodged near the ampulla can obstruct pancreatic drainage and cause gallstone pancreatitis.
- The location of the stone determines which disease develops.
10
Treatment
11
CT isn't needed to make the diagnosis. She's febrile, leukocytotic, ultrasound-positive. What do you do in the ED, and where is she ultimately headed?
ED Treatment
- Keep the patient NPO and establish IV access.
- Provide analgesia and an antiemetic.
- Give IV fluids if needed and start IV antibiotics.
- Consult surgery.
Antibiotic Selection
- Select antibiotics based on disease severity, allergy history, and local resistance patterns.
- Ceftriaxone ± metronidazole is a common ED approach, depending on the clinical situation and local protocol.
Definitive Treatment
- For a typical surgical candidate, definitive treatment is early laparoscopic cholecystectomy during the same hospitalization. Gallaher & Charles, JAMA 2022
11
The Surgeon Is on Speaker
They're between cases.
12
Present the Case. Twenty seconds. Go.
Twenty-Second Presentation
“Forty-seven-year-old woman with recurrent postprandial upper abdominal pain, now with persistent RUQ pain since last night, fever, nausea, and a positive Murphy sign. WBC is 14.3, and bilirubin and lipase are normal. Ultrasound shows gallstones, a 5-mm gallbladder wall, pericholecystic fluid, and a positive sonographic Murphy sign with a normal CBD. She's NPO, medicated, and on IV antibiotics; I need surgical management for acute calculous cholecystitis.”
12
What If?
She Turns Yellow
In this version of the case, she looks jaundiced. Her total bilirubin is 4.8 mg/dL and alkaline phosphatase is 330 U/L. Ultrasound shows a CBD measuring 10 mm.
13
What's changed? What diagnosis are you worried about now? What study or procedure becomes relevant?
Choledocholithiasis
- A stone is likely obstructing the common bile duct.
Further Evaluation
- Evaluation may include MRCP or EUS, depending on probability and clinical stability.
- Evidence of ascending cholangitis requires urgent biliary decompression, typically ERCP. Tokyo Guidelines 2018 — acute cholangitis
Fever + Jaundice
The same patient develops a temperature of 39.5°C, with RUQ pain and jaundice.
14
Name the triad.
Charcot Triad
- Fever
- RUQ pain
- Jaundice
What if?
14a
What if you add hypotension and confusion? What is the emergency treatment?
Reynolds Pentad
- Charcot triad plus hypotension and altered mental status constitutes Reynolds pentad.
- This pattern indicates ascending cholangitis with severe systemic illness.
Emergency Treatment
- Begin resuscitation and broad-spectrum antibiotics.
- Arrange urgent biliary drainage, usually ERCP. Tokyo Guidelines 2018 — biliary drainage
She's a Heavy Drinker
A different patient presents with severe epigastric pain radiating straight through to the back and vomiting. Her lipase is 1,200 U/L.
15
Diagnosis? What changed your differential?
Acute Pancreatitis
- Epigastric pain radiating to the back, vomiting, and lipase greater than three times the upper limit of normal support acute pancreatitis.
- Alcohol and gallstones are two major causes.
- Keep pancreatitis in the differential rather than anchoring on the gallbladder because the pain is upper abdominal.
The ICU Patient
A seventy-year-old patient who is intubated, septic, on vasopressors, and receiving TPN develops unexplained fever and RUQ tenderness. Ultrasound shows a distended, inflamed gallbladder with no gallstones.
16
What's the diagnosis? Why is this patient different?
Acalculous Cholecystitis
- Acalculous cholecystitis occurs without gallstones and is especially associated with critically ill patients.
Associated Conditions
- Critical illness
- Shock
- Prolonged fasting / TPN
- Major trauma
- Burns
- Severe systemic disease
Clinical Presentation
- These patients may not provide a classic history.
- Acalculous cholecystitis is an important cause of otherwise unexplained deterioration in critically ill patients. Gallaher & Charles, JAMA 2022
- The main clue may be an ICU patient whose condition is worsening without a clear explanation.
13
Four Hours Later
She's still in your ED because no OR bed is available. The nurse reports:
“She's shaking now. Her eyes look yellow and her pressure's dropping.”
- HR
- 132
- BP
- 84/48
- RR
- 26
- Temp
- 39.6°C
She's becoming confused, and repeat labs show a bilirubin of 5.1 mg/dL.
17
This was uncomplicated cholecystitis four hours ago. What are you worried happened now? What are the four shock types? Which one is she developing?
Ascending Cholangitis with Septic Shock
- Another stone may have migrated into the common bile duct, creating an infected, obstructed biliary system.
- Ascending cholangitis can progress to sepsis and shock.
Four Shock Categories
- Hypovolemic
- Cardiogenic
- Distributive
- Obstructive
Shock in This Patient
- She is developing primarily distributive septic shock.
18
What changes immediately? What treatment and source control does she need now?
Immediate Resuscitation
- Give IV fluids and broad-spectrum antibiotics.
- Check a lactate and obtain blood cultures if doing so will not delay antibiotics.
- Start norepinephrine if hypotension persists after appropriate fluid resuscitation.
Source Control
- Contact GI and surgery immediately.
- Arrange urgent biliary decompression, usually ERCP.
- Her deterioration from stable cholecystitis to septic cholangitis requires immediate source control.
14
Rapid Fire
R1
Recurrent postprandial RUQ pain that resolves?
Answer
- Biliary colic.
R2
Biliary colic is actually colicky?
Answer
- Biliary colic is usually steady pain, despite its name.
R3
Persistent cystic duct obstruction?
Answer
- Acute cholecystitis.
R4
Inspiratory arrest with RUQ palpation?
Answer
- Murphy sign.
R5
First imaging?
Answer
- Right upper quadrant ultrasound.
R6
Gallstones + thick wall + pericholecystic fluid?
Answer
- The findings form a cholecystitis pattern.
R7
Equivocal ultrasound, still suspicious?
Answer
- HIDA scan.
R8
Jaundice + dilated CBD?
Answer
- Choledocholithiasis.
R9
Fever + jaundice + RUQ pain?
Answer
- Charcot triad.
R10
Add hypotension + confusion?
Answer
- Reynolds pentad.
R11
Treatment for severe cholangitis?
Answer
- Give antibiotics and arrange urgent biliary decompression.
R12
Epigastric pain to back + lipase >3× normal?
Answer
- Pancreatitis.
R13
Critically ill patient + inflamed gallbladder but no stones?
Answer
- Acalculous cholecystitis.
R14
Septic shock category?
Answer
- Distributive shock.
R15
Still boarding in your ED?
Answer
- The patient remains your responsibility while boarding in your ED.