{"id":11366,"date":"2026-11-04T00:05:29","date_gmt":"2026-11-04T08:05:29","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=11366"},"modified":"2026-10-18T12:40:42","modified_gmt":"2026-10-18T20:40:42","slug":"pance-question-of-the-day-acute-abdominal-pain","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-acute-abdominal-pain","title":{"rendered":"PANCE\u00ae Question of the Day: Acute abdominal pain"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_89 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-acute-abdominal-pain\/#The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\" >The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-acute-abdominal-pain\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-acute-abdominal-pain\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-acute-abdominal-pain\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-acute-abdominal-pain\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-acute-abdominal-pain\/#References\" >References&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the PANCE\u00ae with this hospital scenario involving a 70-year-old<\/em><\/strong> <strong><em>patient experiencing acute abdominal pain for 12 hours. What&#8217;s the diagnosis? Let\u2019s find out!<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>70-year-old man<\/strong> comes to the hospital for evaluation of <strong>acute abdominal pain<\/strong> that began 12 hours ago. The <strong>pain is constant and stabbing<\/strong>. He also reports <strong>one episode of non-bloody, nonbilious emesis<\/strong>. Medical history is notable for <strong>hypertension <\/strong>and <strong>intermittent episodes of abdominal pain triggered by consuming fatty foods<\/strong>. The patient has a 40-pack-year smoking history. On arrival, temperature is 38.6\u00b0C (101.5\u00b0F), blood pressure is 103\/71 mmHg, and pulse is 104\/min. Physical examination is <strong>notable for scleral icterus<\/strong>. Abdominal examination reveals <strong>right upper quadrant tenderness to palpation<\/strong>. The <strong>mucous membranes are dry, and capillary refill is delayed<\/strong>. Cardiac and pulmonary examinations are noncontributory. Laboratory testing reveals the findings shown below. <\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td><strong>Laboratory value\u00a0<\/strong><\/td><td><strong>Result\u00a0<\/strong><\/td><td><strong>Reference range\u00a0<\/strong><\/td><\/tr><tr><td>Total bilirubin&nbsp;<\/td><td>4.5 mg\/dL&nbsp;<\/td><td>0.1\u20131.0 mg\/dL&nbsp;<\/td><\/tr><tr><td>Conjugated bilirubin&nbsp;<\/td><td>3.8 mg\/dL&nbsp;<\/td><td>0\u20130.3 mg\/dL&nbsp;<\/td><\/tr><tr><td>Aspartate aminotransferase&nbsp;<\/td><td>87 U\/L&nbsp;<\/td><td>8\u201340 U\/L&nbsp;<\/td><\/tr><tr><td>Alanine aminotransferase&nbsp;<\/td><td>79 U\/L&nbsp;<\/td><td>8\u201340 U\/L&nbsp;<\/td><\/tr><tr><td>Alkaline phosphatase&nbsp;<\/td><td>240 U\/L&nbsp;<\/td><td>40\u2013130 U\/L&nbsp;<\/td><\/tr><tr><td>Lipase&nbsp;<\/td><td>40 U\/L&nbsp;<\/td><td>12\u2013170 U\/L&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following <em>best describes <\/em>the underlying cause of the patient\u2019s presentation?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Inflammation secondary to cystic duct obstruction<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Obstruction of the common bile duct<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Ascending infection of the biliary tract<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Inflammation of the liver parenchyma<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Rupture of an abdominal aortic aneurysm<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!&nbsp;<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Ascending infection of the biliary tract<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct: <\/strong>See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Inflammation secondary to cystic duct obstruction<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This answer choice describes <strong>acute cholecystitis<\/strong>, which most commonly occurs when <strong>cystic duct obstruction causes gallbladder distention and inflammation<\/strong>. Patients can develop right upper quadrant pain and fever. However, prominent jaundice, conjugated hyperbilirubinemia, and an elevated alkaline phosphatase level are more suggestive of common bile duct obstruction than isolated cystic duct obstruction.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Obstruction of the common bile duct<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This describes <strong>choledocholithiasis<\/strong>, which can cause <strong>right upper quadrant pain, nausea\/vomiting, jaundice, and a cholestatic pattern of lab test abnormalities<\/strong>. However, uncomplicated choledocholithiasis alone does not account for this patient\u2019s systemic signs of infection, including fever and tachycardia. In this patient, common bile duct obstruction has been complicated by ascending biliary infection, resulting in acute cholangitis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Inflammation of the liver parenchyma<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> This describes <strong>hepatitis, right upper quadrant discomfort, jaundice, and elevated aminotransferases. <\/strong>However, hepatitis typically produces a predominantly hepatocellular pattern of liver injury, whereas this patient has findings suggestive of cholestasis, including conjugated hyperbilirubinemia and an elevated alkaline phosphatase level. In combination with fever, jaundice, and right upper quadrant pain, these findings are more consistent with acute cholangitis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Rupture of an abdominal aortic aneurysm<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> A <strong>ruptured abdominal aortic aneurysm (AAA) can cause acute abdominal pain, tachycardia, and hypotension, and cigarette smoking is an important risk factor for AAA<\/strong>. However, a ruptured AAA would not account for this patient\u2019s fever, jaundice, conjugated hyperbilirubinemia, and elevated alkaline phosphatase level.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image alignleft size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"975\" height=\"795\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/11\/image_080cc6.png\" alt=\"Osmosis.org style illustration of the biliary system showing five gallstone-related conditions and their anatomical locations: cholecystitis in the cystic duct, choledocholithiasis in the common bile duct, ascending cholangitis involving bile duct infection, gallstone pancreatitis near the pancreatic duct, and gallstone ileus at the terminal ileum or cecum.\" class=\"wp-image-11369\" style=\"aspect-ratio:1.2264751984628608;width:552px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/11\/image_080cc6.png 975w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/11\/image_080cc6.png?resize=300,245 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/11\/image_080cc6.png?resize=768,626 768w\" sizes=\"auto, (max-width: 975px) 100vw, 975px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This patient most likely has <strong>acute cholangitis<\/strong>, also known as <strong>ascending cholangitis<\/strong>. Acute cholangitis is an ascending <strong>bacterial infection of the biliary tract<\/strong> that develops in the setting of <strong>biliary obstruction<\/strong>. The most common cause of biliary obstruction is choledocholithiasis. Obstruction of bile flow increases intrabiliary pressure and promotes bacterial proliferation and ascending infection. Other causes of biliary obstruction include benign or malignant strictures, tumors, parasites, and biliary stent obstruction.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Patients with acute cholangitis may present with the <strong>Charcot triad<\/strong> of fever, right upper quadrant pain, and jaundice. In the setting of severe infection and hemodynamic instability, patients may progress to the <strong>Reynolds pentad<\/strong>, which adds hypotension and altered mental status.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Laboratory testing in acute cholangitis commonly demonstrates a <strong>cholestatic pattern<\/strong>, including <strong>conjugated hyperbilirubinemia<\/strong> and <strong>elevated alkaline phosphatase<\/strong> levels. Aminotransferases may also be elevated. In this patient, the conjugated hyperbilirubinemia and elevated alkaline phosphatase support biliary obstruction, while the fever and tachycardia indicate superimposed infection.\u00a0<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><strong><strong>Acute cholangitis<\/strong> is an ascending bacterial infection of the biliary tract that occurs in the setting of biliary obstruction. Patients may develop the <strong>Charcot triad<\/strong> of fever, right upper quadrant pain, and jaundice. Severe disease may progress to the <strong>Reynolds pentad<\/strong>, which adds hypotension and altered mental status.\u00a0<\/strong><\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Review this Osmosis content: <\/strong><a href=\"https:\/\/www.osmosis.org\/learn\/Choledocholithiasis_and_cholangitis:_Clinical_sciences\">Choledocholithiasis and cholangitis: Clinical sciences<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Ahmed M. Acute cholangitis \u2013 an update. <em>World Journal of Gastrointestinal Pathophysiology<\/em>. 2018;9(1):1\u20137. doi:10.4291\/wjgp.v9.i1.1.\u00a0<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-large\"><a href=\"http:\/\/osmosis.org\/plans\/pa\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?w=700\" alt=\"\" class=\"wp-image-5904\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><strong><em>Get your&nbsp;<a href=\"http:\/\/osmosis.org\/plans\/pa\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;today to discover why millions of clinicians and caregivers love learning by Osmosis.<\/em><\/strong><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A 70-year-old patient presents with acute abdominal pain, fever, jaundice, and abnormal liver tests. Can you identify the underlying cause based on his symptoms, medical history, and laboratory findings?<\/p>\n","protected":false},"author":208,"featured_media":11370,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[20,38,1371,37,1366],"tags":[1432,3362,2967,489,3108,1025,440,3490,3195,3489,1595,3359,462,280,967],"class_list":["post-11366","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exam-prep","category-pance","category-pance-questions","category-pa","category-questions","tag-abdominal-pain","tag-biliary-disorders","tag-board-exam-prep","tag-clinical-reasoning","tag-clinical-vignette","tag-differential-diagnosis","tag-emergency-medicine","tag-gallbladder-disease","tag-gastroenterology","tag-hepatobiliary-disease","tag-jaundice","tag-liver-function-tests","tag-osmosis","tag-pance","tag-physician-assistant-education"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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