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| === Differentiating ascending cholangitis from other diseases on the basis of abdominal pain, fever, and jaundice === | | === Differentiating ascending cholangitis from other diseases on the basis of abdominal pain, fever, and jaundice === |
| {| class="wikitable"
| |
| |-
| |
| ! colspan="3" rowspan="3" |Classification of pain in the abdomen based on etiology
| |
| ! rowspan="3" |Disease
| |
| ! colspan="13" rowspan="1" |'''Clinical manifestations'''
| |
| ! colspan="2" rowspan="2" |Diagnosis
| |
| ! rowspan="3" |Comments
| |
| |-
| |
| ! colspan="9" rowspan="1" |'''Symptoms'''
| |
| ! colspan="4" rowspan="1" |Signs
| |
| |-
| |
| !Abdominal Pain
| |
| ! colspan="1" rowspan="1" |Fever
| |
| !Rigors and chills
| |
| !Nausea or vomiting
| |
| !Jaundice
| |
| !Constipation
| |
| !Diarrhea
| |
| !Weight loss
| |
| !GI bleeding
| |
| !Hypo-
| |
| tension
| |
| ! colspan="1" rowspan="1" |Guarding
| |
| !Rebound Tenderness
| |
| !Bowel sounds
| |
| ! colspan="1" rowspan="1" |Lab Findings
| |
| !Imaging
| |
| |-
| |
| ! rowspan="16" |Abdominal causes
| |
| ! rowspan="15" |Inflammatory causes
| |
| ! rowspan="6" |Pancreato-biliary disorders
| |
| | colspan="1" rowspan="1" |Acute suppurative cholangitis
| |
| |[[RUQ]]
| |
| | +
| |
| | +
| |
| | +
| |
| | +
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| | +
| |
| | +
| |
| | +
| |
| |N
| |
| |
| |
| * Abnormal [[LFT]]
| |
| * WBC >10,000
| |
| |
| |
| * Ultrasound shows [[biliary]]<nowiki/>dilatation/stents/tumor
| |
| |
| |
| * Septic shock occurs with features of [[SIRS]]
| |
| |-
| |
| | colspan="1" rowspan="1" |[[Cholangitis|Acute cholangitis]]
| |
| |[[RUQ]]
| |
| | +
| |
| |−
| |
| |−
| |
| | +
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |N
| |
| |
| |
| * Abnormal [[LFT]]
| |
| |
| |
| * Ultrasound shows [[biliary]]<nowiki/>dilatation/stents/tumor
| |
| |
| |
| * Biliary drainage ([[Endoscopic retrograde cholangiopancreatography|ERCP]]) + IV antibiotics
| |
| |-
| |
| | colspan="1" rowspan="1" |[[Acute cholecystitis]]
| |
| |[[RUQ]]
| |
| | +
| |
| |−
| |
| | +
| |
| | +
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |Hypoactive
| |
| |
| |
| * [[Hyperbilirubinemia]]
| |
| * [[Leukocytosis]]
| |
| |Ultrasound shows:
| |
| * Gallstone
| |
| * Inflammation
| |
| |
| |
| * [[Murphy's sign|Murphy’s sign]]
| |
| |-
| |
| | colspan="1" rowspan="1" |[[Acute pancreatitis]]
| |
| |[[Epigastric]]
| |
| | +
| |
| |−
| |
| | +
| |
| |±
| |
| |−
| |
| |−
| |
| | +
| |
| |−
| |
| |±
| |
| |−
| |
| |−
| |
| |N
| |
| |
| |
| * Increased [[amylase]] / [[lipase]]
| |
| |
| |
| * Ultrasound shows evidence of [[inflammation]]
| |
| * CT scan shows severity of pancreatitis
| |
| |
| |
| * Pain radiation to back
| |
| |-
| |
| | colspan="1" rowspan="1" |[[Primary sclerosing cholangitis]]
| |
| |[[RUQ]]
| |
| | +
| |
| |−
| |
| |−
| |
| | +
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |N
| |
| |
| |
| * Increased liver enzymes
| |
| * Increased [[IgM]], [[IgG]]4
| |
| * [[Anti-neutrophil cytoplasmic antibody]] ([[p-ANCA]])
| |
| * [[Anti-nuclear antibody]] ([[ANA]])
| |
| * [[Anti-smooth muscle antibody]] (Anti-Sm)
| |
| * Anti-endothelial antibody
| |
| * Anti-cardiolipin antibody
| |
| |ERCP and MRCP shows
| |
| * Multiple segmental [[strictures]]
| |
| * Mural irregularities
| |
| * [[Biliary]] dilatation and diverticula
| |
| * Distortion of biliary tree
| |
| |
| |
| * The risk of [[cholangiocarcinoma]] in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
| |
| |-
| |
| | colspan="1" rowspan="1" |[[Cholelithiasis]]
| |
| |[[RUQ]]/[[Epigastric]]
| |
| |±
| |
| |−
| |
| |±
| |
| |±
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |Normal to hyperactive for dislodged stone
| |
| |
| |
| * [[Leukocytosis]]
| |
| |
| |
| * Ultrasound shows [[gallstone]]
| |
| |
| |
| * Fatty food intolerance
| |
| |-
| |
| !Gastric causes
| |
| |[[Gastrointestinal perforation]]
| |
| |Diffuse
| |
| | +
| |
| |±
| |
| | -
| |
| |±
| |
| |−
| |
| |−
| |
| |−
| |
| | +
| |
| | +
| |
| | +
| |
| |±
| |
| |Hyperactive/hypoactive
| |
| |
| |
| * WBC> 10,000
| |
| |
| |
| * Air under [[diaphragm]] in upright [[CXR]]
| |
| |
| |
| * [[Hamman's sign]]
| |
| |-
| |
| ! rowspan="3" |Intestinal causes
| |
| !Disease
| |
| !Abdominal Pain
| |
| !Fever
| |
| !Rigors and chills
| |
| !Nausea or vomiting
| |
| !Jaundice
| |
| !Constipation
| |
| !Diarrhea
| |
| !Weight loss
| |
| !GI bleeding
| |
| !Hypo-
| |
| tension
| |
| !Guarding
| |
| !Rebound Tenderness
| |
| !Bowel sounds
| |
| !Lab Findings
| |
| !Imaging
| |
| !Comments
| |
| |-
| |
| |[[Inflammatory bowel disease]]
| |
| |Diffuse
| |
| |±
| |
| |−
| |
| |−
| |
| |±
| |
| |−
| |
| | +
| |
| | +
| |
| | +
| |
| |−
| |
| |−
| |
| |−
| |
| |Normal or hyperactive
| |
| |
| |
| * [[Anti-neutrophil cytoplasmic antibody]]([[P-ANCA]]) in [[Ulcerative colitis]]
| |
| * [[Anti saccharomyces cerevisiae antibodies]] (ASCA) in [[Crohn's disease]]
| |
| |
| |
| * [[String sign]] on [[abdominal x-ray]] in [[Crohn's disease]]
| |
| |Extra intestinal findings:
| |
| * [[Uveitis]]
| |
| * [[Arthritis]]
| |
| |-
| |
| |[[Whipple's disease]]
| |
| |Diffuse
| |
| |±
| |
| |−
| |
| |−
| |
| |±
| |
| |−
| |
| | +
| |
| | +
| |
| |−
| |
| |±
| |
| |−
| |
| |−
| |
| |N
| |
| |
| |
| * [[Thrombocytopenia]]
| |
| * [[Hypoalbuminemia]]
| |
| * [[Small intestinal]] [[biopsy]] for [[Tropheryma whipplei]]
| |
| |[[Whipple's disease other diagnostic studies|Endoscopy]] is used to confirm diagnosis.
| |
| Images used to find complications
| |
| * [[Whipple's disease x ray|Chest and joint x-ray]]
| |
| * [[Whipple's disease CT|CT]]
| |
| * [[Whipple's disease MRI|MRI]]
| |
| * [[Whipple's disease ultrasound|Echocardiography]]
| |
| |Extra intestinal findings:
| |
| * [[Uveitis]]
| |
| * [[Endocarditis]]
| |
| * [[Encephalitis]]
| |
| * [[Dementia]]
| |
| * [[Hepatosplenomegaly]]
| |
| * [[Arthritis]]
| |
| * [[Ascites]]
| |
| |-
| |
| ! rowspan="4" |Hepatic causes
| |
| |[[Hepatitis|Viral hepatitis]]
| |
| |[[RUQ]]
| |
| | +
| |
| |−
| |
| | +
| |
| | +
| |
| |−
| |
| |Positive in Hep A and E
| |
| | +
| |
| |−
| |
| |Positive in fulminant hepatitis
| |
| |Positive in acute
| |
| | +
| |
| |N
| |
| |
| |
| * Abnormal LFTs
| |
| * Viral serology
| |
| |
| |
| * US
| |
| |
| |
| * Hep A and E have fecal-oral route of transmission
| |
| * Hep B and C transmits via blood transfusion and sexual contact.
| |
| |-
| |
| |[[Liver abscess]]
| |
| |RUQ
| |
| | +
| |
| | +
| |
| | +
| |
| | +
| |
| |−
| |
| |±
| |
| | +
| |
| |−
| |
| | +
| |
| | +
| |
| |±
| |
| |Normal or hypoactive
| |
| |
| |
| * CBC
| |
| * Blood cultures
| |
| * Abnormal [[Liver function test|liver function tests]]
| |
| |
| |
| * US
| |
| * CT
| |
| |
| |
| |-
| |
| |[[Hepatocellular carcinoma]]/Metastasis
| |
| |RUQ
| |
| | +
| |
| |−
| |
| |−
| |
| | +
| |
| |−
| |
| |−
| |
| | +
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |
| |
| * Normal
| |
| * Hyperactive if obstruction present
| |
| |
| |
| * High levels of [[Alpha-fetoprotein|AFP]] in serum
| |
| * Abnormal [[Liver function test|liver function tests]]
| |
| |
| |
| * US
| |
| * CT
| |
| * Liver biopsy
| |
| |Other symptoms:
| |
| * [[Splenomegaly]]
| |
| * [[Variceal bleeding]]
| |
| * [[Ascites]]
| |
| * [[Spider nevi]]
| |
| * [[Asterixis]]
| |
| |-
| |
| |[[Budd-Chiari syndrome]]
| |
| |[[RUQ]]
| |
| |±
| |
| |−
| |
| |−
| |
| |±
| |
| |−
| |
| |−
| |
| |−
| |
| |Positive in liver failure leading to varices
| |
| |−
| |
| |−
| |
| |−
| |
| |N
| |
| |
| |
| * Elevated [[Aspartate aminotransferase|serum aspartate aminotransferase]] and [[alanine aminotransferase]] levels may be more than five times the upper limit of the normal range.
| |
| * Elevated serum [[alkaline phosphatase]]<nowiki/>and [[Bilirubin|bilirubin levels]], decreased [[Albumin|serum albumin level]].
| |
| |
| |
| {| class="wikitable"
| |
| |Findings on [[CT scan]]<nowiki/>suggestive of Budd-Chiari syndrome include:
| |
| * Early enhancement of the [[caudate lobe]] and central liver around the [[Inferior vena cavae|inferior vena cava]]
| |
| * Delayed enhancement of the peripheral [[liver]]<nowiki/>with accompanying central low density (flip-flop appearance)
| |
| * Peripheral zones of the [[liver]] show reversed [[portal]] [[venous]] [[blood flow]]
| |
| * In the [[chronic]] phase, there is [[caudate lobe]]<nowiki/>enlargement and [[atrophy]] of the [[Liver|peripheral liver]] in affected areas
| |
| |}
| |
| |[[Ascitic tap|Ascitic fluid examination]] shows:
| |
| * [[Total protein]] more than 2.5 g per deciliter
| |
| * [[White blood cells]] are usually less than 500/μL.
| |
| |-
| |
| ! rowspan="1" |Peritoneal causes
| |
| | colspan="1" rowspan="1" |[[Spontaneous bacterial peritonitis]]
| |
| |Diffuse
| |
| | +
| |
| |−
| |
| |−
| |
| |Positive in cirrhotic patients
| |
| |−
| |
| | +
| |
| |−
| |
| |−
| |
| |±
| |
| | +
| |
| | +
| |
| |Hypoactive
| |
| |
| |
| * Ascitic fluid [[PMN]]>250 cells/mm<small>³</small>
| |
| * Culture: Positive for single organism
| |
| |
| |
| * Ultrasound for evaluation of liver cirrhosis
| |
| |
| |
| |-
| |
| ! colspan="2" |Hollow Viscous Obstruction
| |
| |[[Biliary colic]]
| |
| |RUQ
| |
| |−
| |
| |−
| |
| | +
| |
| | +
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |−
| |
| |N
| |
| |
| |
| * ↑ [[bilirubin]] and [[alkaline phosphatase]]
| |
| |
| |
| * Ultrasound
| |
| *
| |
| |}
| |
|
| |
|
| ==References== | | ==References== |