Right upper quadrant (RUQ) abdominal pain is a common reason for patients to ask for doctor assistance. Presence of a clinical Murphy’s sign with an ultrasonography revealing a gallbladder wall thickening with pericholecystic fluid makes doctors always think on a cholecystitis. However, a good clinical history is mandatory along with serial patient examination because sometimes gallbladder is the cause of neither the RUQ pain nor the Murphy’s sign.
Christine Desautels from the Department of Medical Education in Minneapolis, USA, published an interesting case of a patient with transient RUQ pain and gallbladder wall thickening because of a congestive heart failure (CHF). Yes, this is true, and many surgeons had arguments with other colleagues who only rely on imaging findings for making a diagnosis and do not accept CHF as a cause of RUQ pain.
Transient RUQ pain and gallbladder wall thickening can be caused by congestive heart failure.
In the case reported a patient with known CHF resorted to the emergency room because of cough, myalgia, dyspnoea and fever. First abdominal ultrasound showed small stones within the gallbladder, but no more abnormalities. Flue was the most probable diagnosis. In the second day abdominal pain in the RUQ arose, along with elevated bilirubin, alkaline phosphatase and aminotransferase. At this time acute cholecystitis become the probable cause of complaints. However, ultrasonography was still normal. Two days latter (4th day) there was a huge increase in RUQ abdominal pain and another ultrasonography was performed. Pulmonary oedema was found along with a gallbladder wall thickening, pericholecystic fluid and a sonographic Murphy’s sign. Antibiotics and aggressive diuretics were initiated. Interesting is that an ultrasonography performed 6h latter showed a decrease in gallbladder thickening. Doctors were thinking on surgery versus percutaneous drainage at this time. HIDA scan was performed in the next day excluding the presence of a cholecystitis. For the next three days antibiotics were stopped and aggressive diuretic therapy continued. Doctors focused their attention in optimization patient’s CHF as the cause of cholecystalgia, and patient got better. At day 8 an ultrasonography showed no pulmonary oedema, non-thicken gallbladder wall and no sonographic Murphy’s sign. Patient was discharged home asymptomatic and without plans for surgery.
Transient cholecystalgia fluctuating in real time with volume status of the patient is a reality in patients with CHF.
I believe this is a very important report since CHF as a cause of cholecystalgia is almost never in doctors’ minds. Transient cholecystalgia fluctuating in real time with volume status of the patient is a reality in patients with CHF. Being aware of this rare entity could avoid unnecessary exams. However, many doctors refuse to think on this entity and even refuse to believe in it. Rely on ultrasonography for making a diagnosis of acute cholecystitis is not free of errors. Ultrasonography has a sensitivity of 94% but a specificity of only 78% for acute cholecystitis. According to the authors, the “clinical impression” (clinical history, physical exam, laboratory findings) is what gives us the best test of diagnosing a cholecystitis.
CHF can cause congestive hepatopathy and RUQ abdominal pain due to stretching of the liver capsule. In that setting, there can be elevated serum bilirubin, elevated alkaline phosphatase, and elevated aminotransferase (>400 U/L). Ultrasound findings are non-specific. Controlling the CHF will solve the congestive hepatopathy and the RUQ pain. Diuretics will be crucial for this.
Additionally to congestive hepatopathy, CHF can cause diffuse gallbladder wall thickening, and according to the authors it can also be responsible for the presence of a Murphy’s sign.
It is important to retain from the report published by Christine Desautels that the gallbladder wall thickening and the RUQ abdominal pain solved completely with aggressive diuretic therapy in order to control a decompensated CHF. Neither antibiotics nor surgery or percutaneous drainage were necessary. How hard is to make cardiologists/internists accept this? How obsessed with exams and techniques is the today’s doctor that makes him deny clinical evidences? Should many doctors repeat medical school to learn the philosophical basis of medicine again? I believe so… “Supra-specialization” is some how killing medicine.
The gallbladder wall thickening and the RUQ abdominal pain solved completely with aggressive diuretic therapy.
Not needing surgery is of crucial importance due to the type of patient’s we are dealing with. Even if a cholecystectomy is a “simple” operation for the surgeon (sometimes it is not), for a patient with a severe CHF any operation is never “simple”. Many non-surgical doctors fail to have this idea, I think. Surgeons must know that the best way to avoid surgical complications is to not perform an unnecessary operation. For this, a correct diagnosis is crucial. Once again, you must always think that clinical history and physical examination are the cornerstone for making a correct diagnosis, not imaging findings. You should always suspect on imaging findings that do not fit the clinical evaluation.
But clinical evaluation can be hard to understand. I must share with you one idea stated by the authors: “The specificity of the Murphy sign for acute cholecystitis, even when seen with wall thickening and in the presence of gallstones, should be cautiously applied in this patient population at generally higher surgical risk”.
Medicine is not easy. Medicine is not a guideline or a protocol. Medicine is the art to apply scientific knowledge in real time.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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