Case

A 42-year-old is seen by their primary care physician complaining of intermittent colicky pain (sharp, localized gastrointestinal pain that comes in spasms/waves). The patient describes the pain as being right upper quadrant (RUQ), starting shortly after eating a meal, and lasting about 30 minutes. During these episodes, she says she feels bloated and nauseated. The patient also states that over the past 2 days, her stools have become very light in color, like the color of sand, and her skin and eyes have become yellow. They have not experienced these symptoms before.

Question 1/3 - What is the most likely diagnosis?

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Incorrect. The patient symptoms are consistent with jaundice, which involves in ability of the liver to excrete bilirubin. The tail of the pancreas is distant from the biliary system and thus a tumor here would not exert a mass effect (compression) of the biliary system.

Incorrect. While cancer of the head of the pancreas is a risk for obstructive jaundice due to the merging of the common bile duct with the pancreatic duct at the head of the pancreas. The patient symptoms match to jaundice, however, tumors are usually non painful in nature and emerge slowly and rarely cause acute onset jaundice.

Correct!  This patient has the typical symptoms of biliary colic pain, which is intermittent crampy abdominal pain in the epigastric region of the RUQ. These symptoms typically appear after meals, particularly fatty meals. The more concerning signs are the light-colored stools (acholic) and jaundice (icterus). The most common cause for these symptoms and acute onsite painful jaundice are gallstones.

Gallstones (cholelithiasis) are precipitated bile salts in the gallbladder, which may produce inflammation of the gallbladder (cholecystitis). Obstruction of the common bile duct prevents bilirubin produced in the liver from reaching the small intestines. The stools thus are lacking this pigment. As a secondary result of the obstruction, serum bilirubin is elevated, precipitated in the skin and sclera of the eyes, resulting in the yellow tint.

Incorrect. Peritonitis would result in abdominal pain and discomfort, but would not directly result in the jaundice symptoms of stool and eye pigmentation changes.

Correct!  A bacterial infection of the biliary system could cause inflammation and pus resulting in acute blockage of the biliary system (particularly infection of the duct system). Infection is also consistent with the acute onset painful nature of the jaundice the patient exhibits.