Examkin

Question

Difficulty: EasyInterpreting Imaging Results

A 42-year-old woman presents to the emergency department reporting severe, colicky pain in her right upper abdomen that began shortly after eating a large, fatty meal. The pain radiates to her right scapula. She is febrile to 38.3°C (101°F). Physical examination reveals marked tenderness to palpation in the right upper quadrant, with a sudden halt in inspiration when the area is deeply palpated. A right upper quadrant abdominal ultrasound is obtained, which demonstrates an echogenic focus within the gallbladder with posterior acoustic shadowing, a gallbladder wall thickness of 5.5 mm, and a rim of anechoic fluid surrounding the gallbladder. Based on these imaging findings, which of the following is the most accurate diagnosis?

  1. Acute cholecystitisAnswer
  2. B
    Uncomplicated cholelithiasis
  3. C
    Choledocholithiasis
  4. D
    Acute cholangitis
  5. E
    Acute acalculous cholecystitis

Answer

Acute cholecystitis
The correct answer is acute cholecystitis. The patient's clinical presentation (fever, right upper quadrant pain, positive Murphy sign) is highly suggestive of gallbladder inflammation. The ultrasound definitively confirms this diagnosis by demonstrating a gallstone (echogenic focus with posterior acoustic shadowing) accompanied by signs of active local inflammation, specifically a thickened gallbladder wall (5.5 mm, which is abnormally >3 mm) and a rim of anechoic pericholecystic fluid.

Step-by-Step Solution

1
Analyze the patient's clinical presentation.
The patient has right upper quadrant pain radiating to the scapula, fever, and a positive Murphy sign (halt in inspiration on deep palpation), which strongly suggest gallbladder pathology.
Establishing the clinical context is essential before interpreting imaging results, as imaging should always be correlated with the patient's symptoms.
2
Interpret the specific findings on the right upper quadrant ultrasound.
The ultrasound shows an echogenic focus with shadowing (diagnostic of a gallstone), a gallbladder wall thicker than 3 mm (indicating inflammation), and anechoic pericholecystic fluid (indicating exudate/inflammation).
Identifying these specific sonographic markers allows for differentiation between simple gallstones and active inflammatory disease of the gallbladder.
3
Synthesize the clinical and imaging findings to establish the final diagnosis.
The combination of a gallstone with objective sonographic evidence of severe gallbladder inflammation confirms acute calculous cholecystitis.
Acute cholecystitis requires both the presence of gallstones (usually) and objective signs of inflammation on imaging to differentiate it from biliary colic.

Key Concept

The sonographic hallmarks of acute cholecystitis include the presence of gallstones (echogenic foci with posterior shadowing), gallbladder wall thickening (greater than 3 mm), and pericholecystic fluid.
Rate this question

Topics

Interpreting Imaging Results

More questions from this topic