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Chapter 18 ♦ Acute Abdominal Surgical Emergencies

C. Abdominal ultrasound: Imaging test of choice for cholecystitis. 1. Findings: Gallbladder wall thickening, pericholecystic fluid, and gallstone shadows. 2. In pregnancy: Often used for evaluation of suspected appendicitis. D. Computed tomography (CT) of the abdomen/pelvis 1. Gives more specific information than any other single study. 2. Often takes longer to obtain, ideally requires oral (PO) and intravenous (IV) contrast.

Differential Diagnosis I. RUQ pain A. Cholecystitis

1. Pain typically worse with fatty foods, often with history of previous episodes. 2. Treat with antibiotics and cholecystectomy. B. Hepatitis 1. Acutely can present with RUQ pain and tenderness. 2. Confirmed by elevated liver function tests and positive serology. 3. Supportive, nonsurgical treatment. C. Peptic ulcer disease 3. Presentation: Pain, bleeding, obstruction, or perforation. 4. Treatment: Antibiotics and proton pump inhibitors (PPIs). D. Pancreatitis 1. Patients often lean forward to relieve pain. 2. Commonly caused by alcohol or gallstones. 3. Diagnosis: Elevated amylase and lipase; CT scan with IV contrast is necessary to determine presence of necrosis. 4. Treatment: Aggressive fluid resuscitation and close monitoring. E. Liver mass 1. Typically causes pain only if stretching the hepatic capsule. 2. Biliary obstruction from a mass is characteristically painless jaundice. F. Gastritis 1. Can present with acute abdominal pain. 2. More serious causes of pain must be ruled out and supportive care offered. G. Choledocholithiasis 1. Caused by gallstones lodging in the common bile duct and usually associated with some element of biliary obstruction. 2. Diagnosis: Confirmed with magnetic resonance. cholangiopancreatography or ERCP. 3. Treatment: ERCP can be therapeutic with sphincterotomy and stone extraction; pathology and treatment can both lead to pancreatitis. 1. Located in stomach and duodenum. 2. Associated with H. pylori infection.