A 47-year-old woman presents to the emergency department with cra mping/colicky abdominal pain. The current episode of pain began several hours ago, following a fatty meaI. The pain began slowly, and rose in intensity to a plateau over the course of several hours. The patient reports that she had had several other episodes of similar pain during the past several months, with long intervening periods of freedom from pain. On physical examination, she is noted to have tenderness to deep palpation in the right upper quadrant of the abdomen near the rib cage. The patient also reports that she is experiencing shoulder/back pain at a site she identifies near the right lower scapula, but no tenderness can be elicited during the back and shoulder examination.
Q 1
Which of the following organs is the most likely source of this woman's pain?
/ A. Appendix
/ B. Diaphragm
/ C. Esophagus
/ D. Gallbladder
/ E. Stomach
Q 2
Which of the following techniques would be most appropriate to demonstrate the patient's most likely diagnosis?
/ A. Colonoscopy
/ B. CT scan of the abdomen
/ C. Esophagoduodenoscopy
/ D. MRI scan of the abdomen
/ E. UItrasonography
Q 3
Following appropriate diagnostic studies, the patient is taken to the surgical suite. During the surgery, the surgeon inserts his fingers from
right to left behind the hepatoduodenal ligament. As he does so, his fingers enter which of the following?
/ A. Ampulla of Vater
/ B. Common bile duct
/ C. Epiploic foramen
/ D. Greater peritoneal sac
/ E. Portal vein
Q 4
During the cholecystectomy, the surgeon ligates the cystic artery. This is typically a branch of which of the following?
/ A. Gastroduodenal artery
/ B. Left gastroepiploic artery
/ C. Right gastroepiploic artery
/ D. Right hepatic artery
/ E. Superior pancreaticoduodenal artery
Q 5
Pathologic examination of the specimen removed by the surgeon demonstrates the presence of numerous yellow stones (shown above).
These are most likely composed primarily of which of the following?
/ A. Bilirubinate
/ B. Calcium phosphate
/ C. Cholesterol
/ D. Cystine
/ E. Struvite
Q 6
If this patient had a small stone lodge near the ampulla of Vater, which of the following complications would be most likely to occur?
/ A. Crohn disease
/ B. Diabetes mellitus
/ C. Pancreatitis
/ D. Peptic ulcer
/ E. Polyarteritis nodosa
Q 7
If this patient had refused surgical treatment, which of the following would be the most appropriate pharmacotherapy to provide definitive
treatment and thereby relieve associated pain?
/ A. Ampicillin
/ B. CIofibrate
/ C. Meperidine
/ D. Oxycodone
/ E. Ursodiol
Abdominal pain Case 2 Answers
A1
The correct answer is D. This woman most likely has gallstones. Cholelithiasis, or the formation of calculi (gallstones) within the gallbladder, is very common in the United States, with over 500,000 cholecystectomies being performed yearly. While many cases of gallstone disease are symptomatic, right upper quadrant pain with referral of the pain to the lower right scapula should specifically suggest gallbladder disease. The pattern of episodes of several hours of pain followed by long periods of freedom from pain is also typical of symptomatic gallstone disease.
The appendix (choice A) would most likely cause lower abdominal pain.
Pain from irritation of the diaphragm (choice B) can cause right upper quadrant pain and referred pain in the supraclavicular area (rather than the subscapular pain of biliary colic). The absence of right upper quadrant tenderness to palpation, and the history of pain after a fatty meal also argue against this diagnosis.
Esophageal pain (choice C) related to regurgitation of gastric contents (heartburn) can occur postprandially, but tends to radiate into the neck, throat, or even face.
Peptic ulcer pain of gastric origin (choice E) is usually described as causing burning, gnawing, or hunger, and may be relieved by eating.
A2
The correct answer is E. Real-time ultrasonography, with 98% sensitivity and 95% specificity, is considered the method of choice for diagnosing possible gallbladder stones.
Colonoscopy (choice A) and esophagoduodenoscopy (choice C) might be helpful for excluding alternative diagnoses, but would not themselves establish a diagnosis of gallstone disease.
CT (choice B) and MRI (choice D) scans of the abdomen are expensive tests whose use is not warranted, since real-time ultrasonography performs as well or better.
A3
The correct answer is C. The space behind the stomach, hepatoduodenal ligament, and hepatogastric ligament is the omental bursa. This space can be entered by passing through the epiploic foramen of Winslow, as described in the question stem.
The common bile duct enters the duodenum through the ampulla of Vater (choice A).
The hepatoduodenal ligament contains the common bile duct (choice B), the portal vein (choice E), and the hepatic artery.
The greater peritoneal sac (choice D) lies anterior to the stomach and hepatoduodenal ligament.
A4
The correct answer is D. The cystic artery is generally a branch of the right hepatic artery.
The gastroduodenal artery (choice A) is a branch of the (common) hepatic artery.
The left gastroepiploic artery (choice B) is a branch of the splenic artery.
The right gastroepiploic artery (choice C) is a branch of the gastroduodenal artery.
The superior pancreaticoduodenal artery (choice E) is a branch of the gastroduodenal artery.
A5
The correct answer is C. The stones are gallstones, and their yellow color indicates that they are composed of cholesterol. Cholesterol stones are the most common form of gallstones. Risk factors include female sex, multiparity, obesity, increased age (female, fat, forty, and fertile) and North American Indian race.
Bilirubinate (choice A) gallstones, which are usually associated with hemolytic anemias, are less common, brown, rather than yellow, and often faceted.
Calcium phosphate (choice B), cystine (choice D), and struvite (choice E) composition can be seen in kidney stones
A6
The correct answer is C. A small gallstone obstructing the pancreatic outflow is a well-known cause of acute pancreatitis. The other conditions listed are not caused by gallstones
A7
The correct answer is E. The question is asking, "Which of the following will eradicate a gallstone?" When a gallstone is eliminated the pain will subsequently be eliminated. This question is NOT asking, "which of the following is the most appropriate form of pain control?". Ursodiol (ursodeoxycholic acid) is a hydrophilic bile acid that is used to dissolve small (<>
Analgesics and antibiotics, such as ampicillin (choice A), are administered when appropriate, but do not help eradicate the stones.
Clofibrate (choice B) is an antihyperlipidemic that is associated with the development of gallstones. High-risk patients, such as diabetics and the elderly, should be watched closely.
As a side note, if this question were asking: "which of the following is the most appropriate form of pain control in this patient", the most appropriate answer would be meperidine. Meperidine (choice C) is the narcotic of choice since it causes the least amount of spasm of the sphincter of Oddi. In other words, meperidine is preferred over oxycodone (choice D).
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