Acute cholecystitis

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Acute cholecystitis



Acute cholecystitis


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USMLE® Step 1 questions

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Acute cholecystitis

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USMLE® Step 1 style questions USMLE

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A 42-year-old woman, gravida 3 para 3, is brought to the emergency department due to severe abdominal pain that started 3 hours ago. She describes the pain as sharp, constant, and rates it as 7/10 in intensity. Since the pain started, she has been feeling nauseous and has vomited twice. She reports a few episodes of similar abdominal discomfort in the past but says that this time it “feels different.” Temperature is 38.0°C (100.4°F), pulse is 80/min, and blood pressure is 135/85 mmHg. BMI is 32 kg/m2. The patient is in acute distress due to pain and points to the upper abdomen. The abdomen is tender to touch. No rebound tenderness or hepatomegaly is present. An abdominal ultrasound is performed and reveals a normal common bile duct with concomitant gallbladder wall thickening and free fluid around the gallbladder. Laboratory results are obtained and shown below:  
 Laboratory value  Result 
 Hemoglobin  14 g/dL 
 Leukocyte count  15,000 mm3 
 Platelet count    250,000 mm3 
 Mean corpuscular volume  90 μm3 
 Creatinine   0.8 g/dL 
 BUN  11 mg/dL 
 Total   0.8 mg/dL 
 Direct  0.2 mg/dL 
 Alanine aminotransferase   18 U/L 
 Aspartate aminotransferase   20 U/L 
 Amylase  55 U/L 
 Lipase  62 U/L 
 Alkaline phosphatase   65 U/L 
Which of the following is the most likely diagnosis?

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Acute cholecystitis, or inflammation of the gallbladder, usually comes about because of a gallstone being lodged in the cystic duct. The cystic duct is the one that leaves the gallbladder and connects to the common bile duct.

So let’s say this person’s gallbladder’s got a few gallstones in it, and they go to eat a hamburger, the small intestine secretes cholecystokinin, sometimes shortened to CCK, into the blood where it makes it’s way to the gallbladder, and signals it to squeeze out some bile to give it a hand with digestion of that hamburger. The gallbladder contracts and one of these stones gets lodged right in the cystic duct, which blocks bile what? Well this person probably start experiencing some pain, specifically midepigastric pain, which happens because the gallbladder’s trying to squeeze on a blocked duct...and just like if you squeezed a partly filled balloon with the end blocked off, it physically stretches out and irritates the nerves in the gallbladder and duct. This can also lead to nausea and vomiting, which can last for long periods of time. And as the gallbladder squeezes more and more, the stone might get even more stuck, and at this point the bile, being stuck in the same place, or in a state of stasis, becomes a kind of chemical irritant, and causes the mucosa in the walls to start secreting mucus and inflammatory enzymes, which results in some inflammation, distention and pressure buildup.

At this point, there might also start to be some bacterial growth, most commonly E coli which is all over the gut, but also Enterococci, Bacterioides fragilis, and Clostridium, which can also be found there. As it sort of balloons up, the pain might start to shift to the right upper quadrant, and it’ll be this kind of dull, achy pain that can even radiate up to the right scapula and shoulders. After a while, bacteria starts invading into the gallbladder wall and eventually through the wall, causing peritonitis, inflammation of the peritoneum, which can cause what’s called rebound tenderness, where pain is brought on when pressure is actually taken off the belly rather than when it’s applied.


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  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "CURRENT Medical Diagnosis and Treatment 2020" McGraw-Hill Education / Medical (2019)
  5. "Acute Calculous Cholecystitis" New England Journal of Medicine (2008)
  6. "Does Using a Laparoscopic Approach to Cholecystectomy Decrease the Risk of Surgical Site Infection?" Annals of Surgery (2003)
  7. "Systematic review of antibiotic treatment for acute calculous cholecystitis" British Journal of Surgery (2016)

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