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 female presents to the ER with severe right upper quadrant abdominal pain. The patient reports that her discomfort started shortly after eating lunch. Upon physical examination, when the patient is asked to breath in while her liver is being palpated she cuts her breath short because of the severity of her pain. The abdominal CT scan is displayed below. Which of the following symptoms is most likely to occur in this patient?]]
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's presentation and physical findings are suggestive of a biliary colic secondary to cholecystitis (Murphy's sign is positive). The presence of air in the biliary tree (pneumobilia) is most commonly observed in patients following a sphincterotomy or biliary-enteric anastomosis. Nonsurgical causes of pneumobilia are relatively uncommon and are usually indicative of serious disease including infection, neoplasm, biliary-enteric fistula, emphysematous cholecystitis, and incompetence of the sphincter of Oddi. Educational Objective: Large biliary stones can create a fistula between the gallbladder and duodenum and block the ileocecal valve leading to gallstone ileus. References: Le T, Bhushan V. First Aid for the USMLE Step 1 2014. McGraw-Hill Medical; 2014.]]
Approved	Approved::Not at all'''
Keyword	WBRKeyword::Gallstone ileus, WBRKeyword::Cholelithiasis, [[WBRKeyword::Cholecystitis ]]
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