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 3/3 - What further tests would you perform first to confirm or rule out specific diagnoses?

Click on your selected option(s) below  (correct = 1, possible = 2, over-thinking = 3+)

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Correct! Ultrasound is the first and most sensitive method for determining if there are stones present in the gallbladder. These show as echogenic objects casing an acoustic shadow with sensitivity for all composition types of gallstones. The approach is low cost, no radiation and commonly available at point-of-care.

Incorrect. While CT can detect calcified stones, the method has limited sensitivity for other composition types (e.g. cholesterol stones). Thus, it would not be a frontline tool for a suspected gallstone case

Possible.  MRI has high sensitivity for detection of all composition types of gallstones and has a high fidelity for defining soft tissue structures. MRI is useful to examine the duct system, where if there are stones at the hepatopancreatic ampulla a 'double duct sign' is observed where dilation of the common bile duct and the pancreatic duct are observed.

However, while an eminently suitable test, it is more costly and time consuming than ultrasound.  MRI is typically used as a secondary method when ultrasound is unable to be effectively employed (e.g. due to depth of the gallbladder being outside the range of ultrasound in specific patients) or high detail on areas such as the hepatopancreatic ampulla is needed.

Incorrect. While X-ray can detect calcified stones, the method has limited sensitivity for other composition types (e.g. cholesterol stones). Thus, it would not be a frontline tool for a suspected gallstone case

Possible, but a second line choice. A blood profile would show the presence of markers for a bacterial infection allowing that possibility to be ruled out.

While this patient has clear indications for gallstones, bloodwork could be used to rule out metabolic (non-obstructive) forms of jaundice as an adjunct.