WBR0657

Author	[[PageAuthor::Serge Korjian M.D. (Reviewed by Serge Korjian)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathophysiology
Sub Category	SubCategory::Gastrointestinal
Prompt	[[Prompt::A 32-year-old woman presents to the emergency department for 3 hours of severe right upper quadrant abdominal pain. The patient reports that her crisis started shortly after a lunch of chicken nuggets and french fries. On physical examination, you note marked tenderness to palpation, and a sudden interruption of her breathing when the liver is palpated. Abdominal ultrasound is unremarkable. Magnetic resonance cholangiogram reveals air in the biliary tree but no evidence of stone. What would you expect the patient to complain of other than her pain?]]
Answer A	AnswerA::Bloody diarrhea
Answer A Explanation	AnswerAExp::Bloddy diarrhea is not usually seen with gallstones that perforate.
Answer B	AnswerB::Fever, chills and abdominal rigidity
Answer B Explanation	AnswerBExp::Fever, chills and abdominal rigidity can sometimes be seen in severe ascending cholangitis with continued obstruction.
Answer C	AnswerC::Bloating, vomiting, and obstipation
Answer C Explanation	AnswerCExp::Bloating, vomiting, and obstipation are characteristic of ileus.
Answer D	AnswerD::Jaundice and icterus
Answer D Explanation	AnswerDExp::Jaundice and icterus are seen in active biliary tract obstruction absent in this patient.
Answer E	AnswerE::Shortness of breath
Answer E Explanation	AnswerEExp::Shortness of breath is not typical of large perforating stones.
Right Answer	RightAnswer::C
Explanation	[[Explanation::The patient has the typical presentation of a biliary colic with physical exam suggestive of cholecystitis (Murphy's sign is positive). Murphy's sign is assessed by asking the patient to inhale deeply while the approximate location of the gallbladder is palpated (right upper quadrant, midclavicular line). As the patient inhales and pushed the bowel contents down, the pressure exerted on the inflamed gallbladder causes the patient to stop breathing suddenly. The air that was observed in the biliary tree on cholangiogram is indicative that a large gallbladder stone has likely created a fistula between the gallbladder and the small intestine allowing it to escape. Classically, if the stone is large enough, it would obstruct the narrowest part of the intestinal lumen, usually the ileocecal valve. Obstruction would cause a syndrome of ileus with bloating, nausea and vomiting, and obstipation known as gallstone ileus. Treatment is usually surgical. Despite treatment, mortality can be as high as 30% of patients affected. Educational Objective: Large biliary stones can create a fistula between the gallbladder and duodenum and block the ileocecal valve leading to gallstone ileus. References: Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60(6):441-6.]]
Approved	Approved::Yes
Keyword	WBRKeyword::Gallstone ileus, WBRKeyword::Cholelithiasis, WBRKeyword::Cholecystitis
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::