After excessive consumption of fatty food a 60-year-old woman suddenly developed pain in her right subcostal area, nausea, bile vomiting, sharp bitter taste in her mouth. In 2 days she developed jaundice, her urine darkened. Objectively: sclera and skin are icteric, the abdomen is distended, the liver is enlarged by 3 cm, soft and painful on palpation, Ortner’s, Murphy’s, Kehr’s, Zakharyin’s, Mayo-Robson’s signs are positive. What diagnostic technique should be used in the first place to confirm the diagnosis?

Answer options

1. Radionuclide scanning of the liver and gallbladder
2. Fibrogastroduodenoscopy
3. Laparoscopy
4. Abdominal X-ray
5. Ultrasound of the gallbladder and bile duct

Explanation

A diagnosis of gallstone disease is based on the history and physical examination with confirmatory radiological studies such as transabdominal ultrasonography and radionuclide scans. In the acute phase, the patient may have right upper quadrant tenderness that is exacerbated during inspiration by the examiner’s right subcostal palpation (Murphy’s sign). A positive Murphy’s sign suggests acute inflammation and may be associated with leukocytosis and moderately elevated liver function tests. A mass may be palpable as the momentum walls off an inflamed gall bladder. Fortunately, in most cases, this process is limited by the stone slipping back into the body of the gall bladder and the contents of the gall bladder escaping by way of the cystic duct. This achieves adequate drainage of the gall bladder and enables the inflammation to resolve. If resolution does not occur, empyema of the gall bladder may result. The wall may become necrotic and perforated, with the development of localized peritonitis. The abscess may then perforate into the peritoneal cavity with septic peritonitis – however, this is uncommon, because the gall bladder is usually localized by momentum around the perforation. palpable, non-tender gall bladder (Courvoisier’s sign) portends a more sinister diagnosis. This usually results from a distal common duct obstruction secondary to a peripancreatic malignancy. Rarely, a non-tender, palpable gall bladder results from complete obstruction of the cystic duct with reabsorption of the intraluminal bile salts and secretion of uninfected mucus secreted by the gall bladder epithelium, leading to a mucocele of the gall bladder. Bailey & Love’s short practice of surgery. – 25th edition. – P. 1121.