The ability to distinguish between cholecystitis and other diagnoses is crucial for providing quick and effective treatment. Listed below are three potential differential diagnoses and their relation to the patient presentation provided on the previous page.
Differential Diagnosis I: Appendicitis
The vermiform appendix is located in the large intestine, attached to the cecum with little or no known physiologic function. Appendicitis is inflammation of the appendix. Although the exact pathophysiology for appendicitis is unknown a common theory is that the lumen becomes obstructed. This obstruction can be caused by stool, tumors, or a foreign body. As mucous continues to be secreted it is unable to drain out of the appendix due to the obstruction and pressure is increased. This increased pressure leads to a decrease in blood flow and hypoxia in the appendix. The buildup of mucous also increases the risk for bacterial growth and infection, and inflammation and edema occur. If the mucosa continues to ulcerate the appendix can perforate (McCance & Huether, 2019).
Figure 3. Inflamed Appendix. (U.S. National Library of Medicine, 2019).
Rationale:
Mrs. G.B. verbalizes experiencing severe abdominal pain to the right side of the abdomen which can be indicative of appendicitis, where pain is typically reported at the right lower quadrant (Mcburney’s point). Patients with appendicitis also experience rebound tenderness and nausea, as Mrs. G.B. is presenting with. Her fever would be expected as a response to the inflammation of the appendix. Her attempt at using antacids would not provide relief and while ibuprofen may decrease her level of pain to some extent it would not significantly resolve the pain as her appendicitis worsened. Her lab values including an increase in WBC count and CRP are both consistent with a diagnosis of appendicitis. Although it is more likely occur between the ages of 10 and 19, appendicitis can occur at any age. Despite the many commonalities between her presentation and appendicitis there are a few key differences to be considered. The pain associated with appendicitis is typically a result of the inflamed tissue and may start out generalized and increase in intensity although this would more likely occur over 3-4 hours versus the week of intermittent pain she has described. It is also less likely that she would experience radiating pain and Murphy’s sign would not be present with this diagnosis. Further testing such as imaging of the abdomen would be needed to distinguish between various diagnoses (McCance & Huether, 2019).
Differential Diagnosis II: Acute Pancreatitis
The pancreas is a gland located behind the stomach in the epigastric region and has both endocrine and exocrine roles. The endocrine pancreas contains the islets of Langerhans, which contains four types of hormone-secreting cells. The exocrine pancreas is made up of acinar cells that produce digestive enzymes. These digestive enzymes are secreted in their inactive form and are activated by an enzyme once in the duodenum. Pancreatitis is inflammation of the pancreas. This occurs from injury to the acinar cells, which allows the digestive enzymes to be released and activated while still inside of the pancreas. The injury to the acinar cells can occur directly such as from drugs or trauma. There can also be damaged to the acinar cells due to an obstruction of flow such as from a gallstone, which creates inflammation and edema. The release of activated enzymes inside of the pancreas causes autodigestion of the pancreatic cells and hemorrhage occurs as blood vessels around the pancreas are broken down (McCance & Huether, 2019).
Figure 4. Acute Severe Pancreatitis. (McCance & Huether, p. 1355, 2019).
Rationale:
Mrs. G.B.’s complaint of severe abdominal pain that radiates to the back is very similar to that expected with acute pancreatitis. The pain associated with acute pancreatitis is due to the edema and inflammatory response taking place. Her fever would be a result of the inflammatory response associated with the pathophysiology of acute pancreatitis. Her nausea could be present due to paralytic ileus that can occur secondary to pancreatitis. It is possible for CRP to be elevated in pancreatitis although it would indicate a more severe disease. Acute pancreatitis affects men and women equally. One risk factor is hyperlipidemia, which Mrs. G.B. could possibly have due to her obesity and lack of exercise risk factors but there is no data present to indicate this. Despite the many commonalities between Mrs. G.B.’s reports and history, there are a few key factors that warrant further investigation. Her severe abdominal pain would more likely originate in the midabdominal or epigastric area and would be more constant versus the intermittent pain she had reported over the past week leading up to the now constant pain. Acute pancreatitis is also more common between ages 50-60 with other risk factors including alcoholism, abdominal trauma, and certain medications. Bruising patterns may also be seen in acute pancreatitis such as Cullen’s sign (bruising around the umbilicus) or Grey Turner’s sign (bruising of the flank). A diagnosis of pancreatitis is often made based on an elevated serum lipase, which Mrs. G.B.’s lab value came back normal for. You would also expect to see an elevation in serum amylase. (McCance & Huether, 2019).
Differential Diagnosis III: Peptic Ulcer Disease
Peptic ulcer disease is a break in the mucosal lining that can occur in the lower esophagus, stomach, or the duodenum. Peptic ulcers can manifest in many ways including single versus multiple and acute versus chronic. Peptic ulcers can be either gastric or duodenal. The pathophysiology occurs as a result of an increase in acid and or a decrease in the protective mucous. The submucosal layers become exposed to acidic gastric secretions which then causes breakdown and ulceration. Contributing factors commonly include H. pylori infection, NSAID use, and stress. The most common form is duodenal ulcers, which can occur as a result of any combination of the risk factors and is most typically associated with an infection of H. pylori (McCance & Huether, 2019).
Figure 5. Duodenal Ulcer. (McCance & Huether, p. 1333, 2019).
Rationale:
Mrs. G.B’s complaint of abdominal pain often occurring after dinner time is concerning for a duodenal ulcer. These typically cause chronic intermittent pain, which she has reported over the past week. The pain associated with a duodenal ulcer occurs when the stomach is empty, 30 minutes to 2 hours after eating. The pain can also occur throughout the middle of the night, which could explain why she is having trouble sleeping from the pain. Her now severe pain could potentially be a complication such as perforation from a duodenal ulcer, which is why it is important to investigate this as an option. Her elevated CRP could be due to the inflammation associated with the ulcer. Mrs. G.B. has risk factors for a duodenal ulcer including obesity, and possibly stress. Duodenal ulcers typically occur between 20-50 years of age and are equally common in men and women. Although she mentioned ibuprofen did not relieve the pain it would be important to ask her about her use of NSAIDS as this may be a risk factor for the development of an ulcer. Despite these similarities between her presentation and a duodenal ulcer there is more information that warrants further review. The use of an antacid can typically resolve the symptoms of a duodenal ulcer and she did not feel any relief. It would also not be typical for her pain to radiate to another location and despite her pain being intermittent over the past week it is now constant and severe. This new onset of pain that is not resolving would indicate that this may not be a duodenal ulcer and Murphey’s sign would not be present. Patients with a duodenal ulcer may become anemic due to bleeding, but Mrs. G.B. presents with a normal Hgb level. Further diagnostics such as the urea breath test to detect H. pylori and endoscopic evaluation can be used to help differentiate between a duodenal ulcer and other diagnoses (McCance & Huether, 2019).