Case report: an unrecognized etiology of transient gallbladder pain in heart failure diagnosed with internist-performed point-of-care ultrasound

Christine N Desautels,Terry K Rosborough,Federico Rossi,David M Tierney

doi:10.1186/s13089-014-0019-8

Christine N Desautels, Terry K Rosborough + Show 2 more

Open Access

https://doi.org/10.1186/s13089-014-0019-8

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Abstract

The excellent sensitivity and specificity of right upper quadrant (RUQ) ultrasound for gallbladder pathology in patients with abdominal pain is heavily relied upon in routine diagnostic evaluation. The hour-to-hour timing of this test in a patient with fluctuating symptoms is not widely recognized as having a significant impact on its sensitivity. However, we present a case report describing the essential role of symptom-timed point-of-care ultrasound in making an elusive diagnosis of transient cholecystalgia in a patient with RUQ pain and congestive heart failure (CHF). This case also demonstrates an important etiology of RUQ pain in patients with CHF beyond that of congestive hepatopathy. A review of the related entities of acalculous cholecystitis, congestive hepatopathy, and diffuse gallbladder wall thickening is provided.

Highlights

The initial differential diagnosis for this patient's right upper quadrant pain included acute gallstone-mediated cholecystitis, acalculous cholecystitis, and congestive hepatopathy
A definite focal Murphy sign was present at the time of the wall thickening and resolved with resolution of wall thickening. This case describes an important additional diagnosis to consider for the common clinical presentation of right upper quadrant (RUQ) pain in a patient with congestive heart failure
It illustrates the under-recognized entity of transient secondary cholecystalgia fluctuating hour-by-hour with the patient's right-sided filling pressures

Summary

Introduction

The initial differential diagnosis for this patient's right upper quadrant pain included acute gallstone-mediated cholecystitis, acalculous cholecystitis, and congestive hepatopathy. It was noted that the patient had been admitted 1 month prior with RUQ abdominal pain and vomiting at which time a formal diagnostic ultrasound showed gallstones, a thickened gallbladder wall (8 mm), and pericholecystic fluid consistent with acute cholecystitis.

Results

Conclusion