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A 45-yr-old school bus driver presents to the emergency department complaining of severe abdominal pain. She reports that the pain began approximately 8 hours ago, after eating lunch at a fast-food restaurant. The pain has become increasingly severe and radiates to her back. She recalls a similar episode, lasting 3 hours, 2 months earlier and another episode, lasting 12 hours, during her last pregnancy. She is febrile, with a temperature of 38.1 C (100.5 F), and has right upper quadrant tenderness with deep palpation of this area. A rectal examination reveals brown, guaiac-negative stool. Her WBC is 12,900/mm3, and her hematocrit is 39%. Her total bilirubin is 2.1 mg/dL.
Which of the following is the most appropriate diagnostic test?
A. CT scan of the abdomen and pelvis
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. HIDA scan
D. Percutaneous transhepatic cholangiogram (PTC)
E. Upper gastrointestinal barium study
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ya ans is C....cholecystis pain....best ix is HIDA scan...
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C. This patient has the classic presentation of acute cholecystitis. The episodes she had several months ago and during pregnancy suggest a prior history of biliary colic. A HIDA scan is a noninvasive nuclear medicine test that will reveal obstruction of the cystic duct, which is caused by an impacted gallstone and is the cause of acute cholecystitis.
A CT scan (choice A) may show a distended gallbladder, but it is not as accurate as a HIDA scan for evaluating the cystic duct.
Endoscopic retrograde cholangiopancreatography (ERCP) (choice B) is useful for evaluation of the common bile duct but is of a less value in evaluation of the cystic duct and, furthermore, is a far more invasive test than a HIDA scan.
Percutaneous transhepatic cholangiography (PTC) (choice D) is an examination that is performed by the interventional radiologist by injecting the intrahepatic biliary tree percutaneously. This is rarely done since ERCP is a more accurate evaluation of the biliary of tree. PTC is of limited value in evaluating the cystic duct and it is an invasive procedure.
An upper gastrointestinal barium study (choice E) may be useful for the evaluations of peptic ulcer disease but the symptoms here are far more suggestive of acute cholecystitis. Furthermore, if the patient has been vomiting she is unlikely to tolerate this examination.
