WBR0657
| Author | [[PageAuthor::Rim Halaby, M.D. [1]]] |
|---|---|
| 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 exam, you note marked tenderness to palpation, and when the patient is asked to breath in while her liver is being palpated she cuts her breath short because of her pain. 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 gallstone 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). The air seen in the biliary tree is indicative that a large gallbladder stone has probably 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.
Le T, Bhushan V. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014. |
| Approved | Approved::No |
| Keyword | WBRKeyword::Gallstone ileus, WBRKeyword::Cholelithiasis, WBRKeyword::Cholecystitis |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |