Author: David S. Morris, M.D.
A patient comes into the emergency department with right upper quadrant abdominal pain. You have seen the patient and ordered all the tests. So, which patients with right upper quadrant pain should be seen by the surgeon in the emergency department?
Abdominal pain is one of the most common symptoms in patients who present to the Emergency Department. The abdomen contains a large number of organs and tissues and the splanchnic enervation of many of those organs results in symptoms that are often vague or difficult to pin down. Thus, abdominal pain creates a diagnostic and therapeutic challenge for providers. The list of potential causes of right upper quadrant pain is lengthy:
- Cholangitis (bile duct inflammation)
- Fecal impaction (hardened stool that can't be eliminated)
- Gallbladder cancer
- Gastritis (inflammation of the stomach lining)
- Hepatitis (liver inflammation)
- Hiatal hernia
- Intestinal obstruction
- Kidney cancer
- Kidney infection
- Kidney stones
- Liver abscess (pus-filled pocket in the liver)
- Liver cancer
- Liver hemangioma
- Pancreatic cancer
- Pancreatitis (pancreas inflammation)
- Peptic ulcer
- Pericarditis (inflammation of the tissue around the heart)
- Pleurisy (inflammation of the membrane surrounding your lungs)
- Pulmonary infarction (loss of blood flow to the lungs)
- Pyloric stenosis (in infants)
- Stomach cancer
(Source: Nagle A, “Acute Abdominal Pain.” In Scientific American Surgery. Accessed online at http://www.sciamsurgery.com)
Obviously, this list spans several medical and surgical specialties and making the diagnosis is important in determining whom to call for management. Many of these causes also can be successfully managed in the ED without hospital admission. Many are medical in nature, and of the diseases that may require surgical treatment, many are not urgent or emergent and outpatient surgical referral can be made.
So which patients should be seen by the surgeon in the ED? Which causes of RUQ pain are emergent and need to be seen in the middle of the night? This article will not touch on the atypical causes of surgical right upper quadrant pain (appendicitis, diverticulitis, hiatal hernia) nor will the pediatric causes be discussed (pyloric stenosis). The focus of this article will be on differentiating symptomatic cholelithiasis from cholecystitis and appropriate management of cholangitis with and without concomitant cholecystitis.
Gallstone disease is extremely common in the United States, with approximately 6% of men and 9% of women having asymptomatic gallstones. Only about one third of patients with gallstones will develop symptoms requiring surgery. Thus the presence of gallstones on imaging studies is not, in itself, sufficient to give a diagnosis. In addition, imaging studies are fraught with some degree of uncertainty (see below). Fortunately, the vast majority of patients with symptomatic gallstone disease have a history that is revealing.
Patients will typically (>95%) become symptomatic when there is obstruction of the cystic duct by a gallstone. Occasionally, patients without stones may experience signs and symptoms similar to gallstone obstruction (acalculous cholecystitis, biliary dyskinesia, etc.), but these episodes are often self-limited and patients are less likely to seek care in the emergency department. Obstruction of the cystic duct with contraction of the gallbladder leads to a very typical acute RUQ pain. This is termed “biliary colic” and often resolves over a short period of time after the gallstone moves out of the cystic duct (either back into the gallbladder or downstream into the common bile duct). Patients who have resolution of symptoms (i.e. pain relief that is independent of narcotic administration) can be dismissed from the emergency department with outpatient follow up scheduled with a surgeon.
If the obstruction persists, this leads to a local inflammatory process in the gallbladder wall and persistent pain. This pain can eventually lead to focal, somatic abdominal pain and focal peritonitis as the inflammatory process spreads to the parietal peritoneum. In fact, RUQ pain from gallbladder obstruction that persists for >6 hours is diagnostic of acute cholecystitis even in the setting of normal or equivocal imaging or laboratory findings. Patients who have pain lasting longer than 6 hours do not have symptomatic cholelithiasis and should be evaluated by the surgeon in the ED.
Imaging findings for patients with gallstone-related RUQ pain can be normal or equivocal. Ultrasound findings of acute cholecystitis include gallstones, gallbladder wall thickening (>3 mm), positive sonographic Murphy’s sign (pain with pressure over the gallbladder with the ultrasound probe), and/or pericholecystic fluid. The estimated sensitivity and specificity of these findings for acute cholecystitis is approximately 85% and 95%, respectively (Smith JA. In Clinical Ultrasound, 3rd Ed., Allan PL, Baxter GM, Weston MJ, eds. 2011. Elsevier Limited). Patients who present with early acute cholecystitis may not demonstrate these classic findings, and their absence should not be interpreted as an absence of clinical acute cholecystitis. Ultrasound is also operator and interpreter dependent, and the sensitivity and specificity in actual practice may vary from the numbers quoted here.
Computed tomography may be used to make the diagnosis of acute cholecystitis, particularly when the patient presents atypically. CT is able to detect only about 75% of gallstones, but pericholecystic inflammation and gallbladder wall thickening is readily apparent. Gallbladder wall thickening is nonspecific, however, and may represent chronic liver disease, intraperitoneal inflammatory conditions (ascites, peritoneal dialysis, spontaneous bacterial peritonitis, etc.), or right-sided heart failure.
Given the uncertainty of the imaging studies, the decision for imaging must be based on clinical history. If the patient’s presentation and time course of symptoms is highly suspicious for acute cholecystitis, consultation with a surgeon in the ED may be appropriate even if the imaging studies are equivocal. For example, a patient who presents with typical RUQ pain that has persisted for 8 hours after eating a high fat meal, with RUQ tenderness and/or Murphy’s sign and leukocytosis, but with only gallstones seen on US or CT, should be evaluated by a surgeon. The decision to operate may be deferred until a more optimal time (for example, first thing the following morning).
Acute cholecystitis should be managed by prompt cholecystectomy, or gallbladder drainage (percutaneous cholecystostomy tube) in patients who have unacceptable surgical risk. Studies (Gutt, Ann Surg. 2013; Gurusamy, Cochrane Database Syst Rev. 2013; Lo, Ann Surg. 1998) have shown that delay in removal of the gallbladder (>3 days) leads to increased rates conversion from laparoscopic to open cholecystectomy and higher rates of complications. Patients who require ICU management of septic shock or mechanical ventilation should have percutaneous drainage in the acute phase followed by cholecystectomy after an interval of several weeks (typically 6-8) after reversal of the shock state and optimization of other medical comorbidities. Laparoscopic placement of a drainage catheter can be performed in patients who will tolerate a general anesthetic where interventional radiologic expertise is unavailable.
Patients with choledocholithiasis (stones or sludge in the common bile duct) often present with RUQ pain, but lack the typical history of acute cholecystitis. They may present with or without pain, and are more likely to present with jaundice. Patients with jaundice need to be evaluated for common bile duct pathology, as this may be the initial sign of pancreatic or biliary malignancy. Diagnosis of these conditions is imperative, as the treatment approach may change dramatically.
There is ongoing debate about the optimal management of CBD stones. Typically, cholecystectomy is part of the treatment process to decrease the chance of future episodes of cholelithiasis. The optimal timing of the cholecystectomy from a patient care and resource utilization standpoint has not been definitively proven. Some authorities advocate endoscopic CBD evaluation (ERC) and stone extraction attempts prior to cholecystectomy, with surgical CBD exploration reserved for those patients whose stones cannot be extracted via endoscopic routes. Others maintain that many stones can be managed intraoperatively at the time of cholecystectomy, with ERC reserved for those patients whose stones remain after laparoscopic cholecystectomy. This decision is often provider and institution dependent.
Patients with acute cholecystitis may present with choledocholithiasis and jaundice. Cholecystectomy or gallbladder drainage should not be delayed for ERC in this group of patients even in the setting of markedly elevated bilirubin or other very high risk factors for choledocholithiasis. As noted above, delay in cholecystectomy or gallbladder drainage results in unacceptably high rates of conversion to open procedures and postoperative complications. Thus the diagnosis of acute cholecystitis is imperative to make early on.
Confounding the fairly straightforward treatment process advocated above is the patient who presents with acute cholangitis. If a patient presents with signs or symptoms of RUQ pain, jaundice, and fever (Charcot’s triad) or Charcot’s triad plus septic shock and mental status changes (Reynold’s pentad), the patient should be treated for ascending cholangitis. Treatment primarily consists of drainage of the CBD, primarily via ERC. Inflammation of the gallbladder may be present in these cases, but operative morbidity and mortality is high and should be avoided. It may be possible to provide gallbladder drainage via ERC, with stenting of the cystic duct. If this is not possible, the patient should have percutaneous gall bladder drainage. Cholecystectomy should be deferred until resolution of the cholangitis and the inciting factors are addressed. Thus, patients with ascending cholangitis may be admitted to non-surgical services, with close follow up by the surgeon. Consultation from a surgeon may be appropriate in the ED to confirm the diagnosis and participate in creating the plan of care.
RUQ pain due to gallstones can be a difficult from a diagnostic and management perspective. Many of these patients require urgent or emergency interventions that may be provided by specialists in different disciplines. A patient with simple symptomatic cholelithiasis, whose pain resolves, can have follow up in the outpatient setting. Patients with acute inflammation should be evaluated in the ED by a surgeon to help make the diagnosis and craft a plan of care that likely will include cholecystectomy as part of the management.