Presenting Complaint: 

• Acute abdominal pain and nausea

Symptoms (SOCRATES):

• Site: Right upper quadrant – “It’s in the top right part of my belly”
• Onset: Since this morning – “It started suddenly this morning”
• Character: Sharp – “It feels like someone is stabbing me”
• Radiation: Radiates to back – “The pain moves to my back”
• Associated symptoms: Nausea, vomited once, unable to go to work, feeling feverish – “I just feel terrible – I’ve vomited once and still feel sick and hot. There’s no way I can go into work today”
• Time: Progressive worsening “It’s just been getting worse and worse since this morning”
• Exacerbating/Alleviating factors: Nothing makes the pain better, pressing on the abdomen worsens the pain – “I’ve tried paracetamol and ibuprofen, but they haven’t touched the pain”
• Severity: Severe – “It’s definitely one of the worst pains I have ever felt”

Systemic Symptoms (answer only if specifically asked for):

• Urinary: noticed urine is darker than normal, normal frequency, no obvious blood
• Bowels: noticed no changes
• Fever: had a temperature and feeling feverish for two days
• Eyes: noticed they look slightly yellow 
• Weight loss: none unintentional, been trying to lose a bit of weight over the past 6 months as on a diet
• Night sweats: None
• Vomiting and nausea: vomited once and feeling nauseous
• Noticed slight itching the past two days

Past Medical History:

• One miscarriage
• Type II Diabetes

Past Surgical History:

• Appendicectomy as a child
• C-section with second child

Drug History:

• Metformin

Allergies:

• Allergic to aspirin, causes rash

Family History:

• Father died from pancreatic cancer at the age of 65
• Mother has type II diabetes 

Social History:

• Struggling to lose weight for years
• Smoker: 15 cigarettes a day
• Alcohol: Half a bottle of wine at weekends
• Occupation: Hospital ward manager 
• Diet: Trying to eat healthier, however admits diet often includes fatty foods
• Two children, both teenagers

Ideas, Concerns, and Expectations:

• Think it could be gallstones 
• Worried it could be cancer because of father dying from pancreatic cancer
• Wants a scan to look for cancer

Observations:

• Respiratory rate: 22
• Oxygen sats: 97% on room air
• Pulse: 105
• Blood pressure: 105/65
• Alert
• Temperature: 38.1

NEWS: 5

Physical Examination:

General Inspection:

– Small port scars visible from previous laparoscopic appendicectomy 

– Mildly jaundiced

Hands:

– No clubbing, pallor, or tremor

– Capillary refill time 3 seconds

– Regular pulse, tachycardic

– No palmar erythema or Dupuytren’s contracture

Face:

Author: Bobjgalindo. CC BY-SA 4.0. Wikimedia Commons.

– Mild scleral icterus present

– Slightly dry mucous membranes

Neck:

– JVP not raised

– No scars or palpable lymphadenopathy

Chest:

– No spider naevi 

Abdomen:

Inspection

– No distension 

– Small port scars from previous appendicectomy

Palpation

– Severe tenderness in right upper quadrant with voluntary guarding

– Abdomen soft and mildly tender on palpation of the right/left lower quadrants

– No hepatomegaly or splenomegaly palpable

– No palpable renal or aortic masses

– No suprapubic tenderness

Percussion

– Not tolerated due to percussion tenderness in the RUQ

Auscultation

– Bowel sounds present, normal on auscultation

Special tests:

– Fluid thrill -> negative

– If performed or asked for, DRE, examination of external hernial orifices and external genitalia normal

Other:

– No peripheral or sacral oedema

Examiner questions:

1. What is your main differential diagnosis and why is this more likely than other differentials?

Answer: Acute cholangitis

• Right upper quadrant pain with fever and jaundice (Charcot’s triad) is a constellation of symptoms associated with cholangitis
• Clinically differs from cholecystitis with features of obstructive jaundice (yellow sclera, dark urine, itching, pale stools)
• Acute pancreatitis classically presents with severe epigastric pain and vomiting, and could be a differential in a jaundiced patient, as gallstones are a common aetiology. But in this case, the presence of Charcot’s triad should point you towards cholangitis as the most likely differential
• Less likely to be a malignancy due to the absence of red flag symptoms (weight loss, night sweats, abdominal mass) and acute rather than chronic/subacute onset of symptoms

2. State two blood results that are likely to be raised with this condition and why this is the case

Possible answer: ALP, GGT, bilirubin, any inflammatory markers (count as one point)

• Rise in ALP, GGT and bilirubin is indicative of cholestasis or bile obstruction, a key factor in the pathophysiology of cholangitis
• Rise in inflammatory markers is due to acute inflammation/infection 

3. Name three risk factors that a patient may have that can predispose them to this condition

Possible answers:

• Aged over 50
• Cholelithiasis
• Strictures (benign or malignant)
• Procedural injury to bile ducts
• History of sclerosing cholangitis

4. Describe the management of this condition

Possible answer: 

• Basic management: Sepsis six, including taking lactate, bloods and cultures, providing analgesia, IV fluids, antiemetics if required, strict fluid balance monitoring and consider catheterisation
• Intravenous antibiotics in accordance with local guidelines
• Endoscopic retrograde cholangiopancreatography within 24-48 hours to relieve the obstruction by extracting the stone, and thereby decompressing the biliary tree
• Subsequent cholecystectomy in patients with cholangitis secondary to cholelithiasis (gallstones)

5. Mary is going to undergo an ERCP. Please briefly explain two complications of this procedure

Possible answer:

• Perforation of bile duct, pancreatic duct or duodenum – this is a serious complication which can potentially require urgent surgical intervention and ITU input
• Pancreatitis – traumatic manipulation and instrumentation of the biliary/pancreatic system can increase the risk of pancreatitis
• Infection and bleeding – invasive procedures such as ERCP tend to carry risk of infection and bleeding