RUQ Pain and a Normal Abdominal Ultrasound右上腹疼痛和常规腹部超声课件

RUQPainandaNormalAbdominalUltrasound

FurqaanAhmad;EvanL.FogelPublished:12/02/2008FromClinicalGastroenterologyandHepatologyRUQPainandaNormalAbdomina1ClinicalScenario

A30-year-oldwomanisreferredforevaluationofa1-yearhistoryofintermittent,debilitating,postprandialrightupperquadrantpainassociatedwithnausea

andoccasionalvomiting.Thepaincanlastfrom30minutesto2hours,oftenradiatestotheupperback,andisnotassociatedwithbowelmovementsorexercise.ClinicalScenario

A30-year-o2ClinicalScenario

Thepatientdeniesahistoryofweightloss,fever,chills,changeinurineorstoolcolor,orjaundice.Shedeniessignificantalcoholuse.Trialsofantacids,protonpumpinhibitors,andantispasmodicshavenotbeenhelpful.Attimesthepainhasbeensevereenoughtointerruptherdailyactivities.ClinicalScenario

Thepatient3ClinicalScenario

Thepatientreportsthatliverchemistriesandamylaseandlipaselevelshavebeenpersistentlynormal.ultrasoundrevealsanormal-appearinggallbladderwithoutgallbladderwallthickeningorgallstones.bileductsarenotdilated.Theliverandlimitedviewsofthepancreasarealsounremarkable.Thepatientunderwentanendoscopy(EGD)1monthagothatwasnormal.ClinicalScenario

Thepatient4Whatisthemostlikelycauseforthispatient'ssymptoms?Whatisthenextstepinthediagnosticevaluationofthispatient?Whatisthemostlikelycause5TheProblem

Therightupperquadrantpaininthispatientissuggestiveofbiliaryorigin.However,thispainsyndromeaccompaniedbyanormalgallbladderultrasoundandnormalliverfunctiontestssuggestssubtleacalculousgallbladderdisease.TheProblem

Therightupper6Differentialdiagnosis:pepticulcerdisease,choledocholithiasisandmicrolithiasis,pancreatobiliaryneoplasia,irritablebowelsyndrome,musculoskeletalpainTypeIIIsphincterofOddidysfunction(SOD)Differentialdiagnosis:peptic7Thepathophysiologyofacalculousgallbladderpain:primarydisorderofgallbladdermotility:entrapmentofsupersaturatedcholesterolcrystalsinthegallbladderwall,impairedresponsetocholecystokinin(CCK),orintrinsicdefectsinthegallbladdermusculature.Visceralhypersensitivity:(biliarydyskinesia)analogoustothatinotherfunctionaldisordersofthegastrointestinaltract.Thepathophysiologyofacalcul8DiagnosticCriteriafor…FunctionalGallbladderDisorders1.Episodesofpainlasting30minutesorlonger2.Recurrentsymptomsoccurringatvaryingintervals(notdaily)3.Gradualbuildupofpainintensitytoasteadylevel4.Thepainissevereenoughtointerruptthepatient'sactivities.5.Thepainisnotrelievedbybowelmovements.6.Thepainisnotrelievedbyposturalchanges.DiagnosticCriteriafor…Funct9Diagnosticcriteria…7.Thepainisnotrelievedbyantacids.8.Structuraldiseasesthatcouldexplainthepatient'ssymptomshavebeenexcluded.Thepainmightpresentwith1ormoreofthefollowingsupportivecriteria:1.Painassociatedwithnauseaandvomiting2.Painradiatestothebackand/orrightsubscapularregion.3.Painawakenspatientfromsleepinthemiddleofthenight.Diagnosticcriteria…7.Thepain10Diagnosis:99mtechnetium-labeledhepato-iminodiaceticacid(99mTcHIDA)cholescintigraphy

HIDAscanAlowejectionfraction(lessthan40%)isindicativeofgallbladderdysfunction.Diagnosis:99mtechnetium-labele11Cholescintigraphy

Measurementsofgallbladderejectionfractionareinfluencedbythedose,rate,

anddurationofCCK

infusion,noneofwhicharecurrentlystandardized..auniformthresholdforabnormalgallbladderejectionfractioncannotbestandardizedwithoutuniformadministrationofCCK.Mostpublisheddatahavedefinedgallbladderdysfunctionasanejectionfractionlessthan35%–40%.pain.Cholescintigraphy

Measurements12Cholescintigraphy

ThefindingofHIDAscanisnot100%specificforgallbladderdysfunction.Severalotherconditionsmightalsocauseimpairedemptying,includingobesity,diabetes,

pregnancy,cirrhosis,celiacdisease,andmedications(calciumchannelblockers,

opioids,anticholinergics,andsexhormone)Cholescintigraphy

Thefinding13OutcomesAfterCholecystectomy

:ThepatientsthathaveabnormalHIDAscanrecommendedcholesystectomybutthebenefitofsurgeryinreliefofpainofpatientsiscontraversy.

studies:partialreliefafterremovalofadysfunctionalgallbladderinsomepatients.A

study:similarresponsestosurgeryinpatientsbothwithandwithoutabnormalgallbladderemptyingOutcomesAfterCholecystectomy14Cholecystectomy

:Themeanfollow-upperiodofthestudiesincludedinthemeta-analysisbyPonskyandcolleaguesrangedfrom9–30months.Outcomeofstudy:patientswhounderwentsurgeryhadahighrateofsymptomaticresponsetosurgeryat1-monthfollow-up.However,at2-yearfollow-up,theproportionofpatientswithsymptomaticimprovementwassimilaramongthosewhounderwentsurgeryandthosewhodidnot.Cholecystectomy

:Themeanfoll15SphincterofOddiDysfunction

:Thisclassicallypresentsasrecurrentorcontinuedupperquadrantpainaftercholecystectomy.(1)doesSODoccurinpatientswithanintactgallbladder?(2)isthereanassociationbetweenSODandgallbladderdysfunction?SphincterofOddiDysfunction

16SODwithanintactgallbladder?

TherearelimiteddataonthefrequencyofSODinpatientswithanintactgallbladder.However,SODhasbeendocumentedinupto10%ofpatientswithsymptomaticgallstonesand50%ofpatientswithbiliary-typepainandanormalgallbladderultrasound.SODwithanintactgallbladder17associationbetweenSODandgallbladderdysfunction?

InaprospectivestudyconductedtostudytherelationshipbetweenSODandgallbladderdysfunction,81patientswithbiliary-typepainandanintact,sonographicallynormalgallbladderunderwentbothsphincterofOddimanometryandHIDAcholescintigraphy.Of41patientswithanormalHIDAscan,57%hadSOD;of40patientswithanabnormalHIDAscan,50%hadSOD.associationbetweenSODandga18DatafromthisstudysuggestthatbothSODandgallbladderdysfunctionarecommoninthisgroupofpatientsandappeartooccurindependentlyofoneanother.Datafromthisstudysuggestt19AlgorithmofpatientswithRUQpain&Normalsonography.Algorithm20RUQPainandaNormalAbdominalUltrasound

FurqaanAhmad;EvanL.FogelPublished:12/02/2008FromClinicalGastroenterologyandHepatologyRUQPainandaNormalAbdomina21ClinicalScenario

A30-year-oldwomanisreferredforevaluationofa1-yearhistoryofintermittent,debilitating,postprandialrightupperquadrantpainassociatedwithnausea

andoccasionalvomiting.Thepaincanlastfrom30minutesto2hours,oftenradiatestotheupperback,andisnotassociatedwithbowelmovementsorexercise.ClinicalScenario

A30-year-o22ClinicalScenario

Thepatientdeniesahistoryofweightloss,fever,chills,changeinurineorstoolcolor,orjaundice.Shedeniessignificantalcoholuse.Trialsofantacids,protonpumpinhibitors,andantispasmodicshavenotbeenhelpful.Attimesthepainhasbeensevereenoughtointerruptherdailyactivities.ClinicalScenario

Thepatient23ClinicalScenario

Thepatientreportsthatliverchemistriesandamylaseandlipaselevelshavebeenpersistentlynormal.ultrasoundrevealsanormal-appearinggallbladderwithoutgallbladderwallthickeningorgallstones.bileductsarenotdilated.Theliverandlimitedviewsofthepancreasarealsounremarkable.Thepatientunderwentanendoscopy(EGD)1monthagothatwasnormal.ClinicalScenario

Thepatient24Whatisthemostlikelycauseforthispatient'ssymptoms?Whatisthenextstepinthediagnosticevaluationofthispatient?Whatisthemostlikelycause25TheProblem

Therightupperquadrantpaininthispatientissuggestiveofbiliaryorigin.However,thispainsyndromeaccompaniedbyanormalgallbladderultrasoundandnormalliverfunctiontestssuggestssubtleacalculousgallbladderdisease.TheProblem

Therightupper26Differentialdiagnosis:pepticulcerdisease,choledocholithiasisandmicrolithiasis,pancreatobiliaryneoplasia,irritablebowelsyndrome,musculoskeletalpainTypeIIIsphincterofOddidysfunction(SOD)Differentialdiagnosis:peptic27Thepathophysiologyofacalculousgallbladderpain:primarydisorderofgallbladdermotility:entrapmentofsupersaturatedcholesterolcrystalsinthegallbladderwall,impairedresponsetocholecystokinin(CCK),orintrinsicdefectsinthegallbladdermusculature.Visceralhypersensitivity:(biliarydyskinesia)analogoustothatinotherfunctionaldisordersofthegastrointestinaltract.Thepathophysiologyofacalcul28DiagnosticCriteriafor…FunctionalGallbladderDisorders1.Episodesofpainlasting30minutesorlonger2.Recurrentsymptomsoccurringatvaryingintervals(notdaily)3.Gradualbuildupofpainintensitytoasteadylevel4.Thepainissevereenoughtointerruptthepatient'sactivities.5.Thepainisnotrelievedbybowelmovements.6.Thepainisnotrelievedbyposturalchanges.DiagnosticCriteriafor…Funct29Diagnosticcriteria…7.Thepainisnotrelievedbyantacids.8.Structuraldiseasesthatcouldexplainthepatient'ssymptomshavebeenexcluded.Thepainmightpresentwith1ormoreofthefollowingsupportivecriteria:1.Painassociatedwithnauseaandvomiting2.Painradiatestothebackand/orrightsubscapularregion.3.Painawakenspatientfromsleepinthemiddleofthenight.Diagnosticcriteria…7.Thepain30Diagnosis:99mtechnetium-labeledhepato-iminodiaceticacid(99mTcHIDA)cholescintigraphy

HIDAscanAlowejectionfraction(lessthan40%)isindicativeofgallbladderdysfunction.Diagnosis:99mtechnetium-labele31Cholescintigraphy

Measurementsofgallbladderejectionfractionareinfluencedbythedose,rate,

anddurationofCCK

infusion,noneofwhicharecurrentlystandardized..auniformthresholdforabnormalgallbladderejectionfractioncannotbestandardizedwithoutuniformadministrationofCCK.Mostpublisheddatahavedefinedgallbladderdysfunctionasanejectionfractionlessthan35%–40%.pain.Cholescintigraphy

Measurements32Cholescintigraphy

ThefindingofHIDAscanisnot100%specificforgallbladderdysfunction.Severalotherconditionsmightalsocauseimpairedemptying,includingobesity,diabetes,

pregnancy,cirrhosis,celiacdisease,andmedications(calciumchannelblockers,

opioids,anticholinergics,andsexhormone)Cholescintigraphy

Thefinding33OutcomesAfterCholecystectomy

:ThepatientsthathaveabnormalHIDAscanrecommendedcholesystectomybutthebenefitofsurgeryinreliefofpainofpatientsiscontraversy.

studies:partialreliefafterremovalofadysfunctionalgallbladderinsomepatients.A

study:similarresponsestosurgeryinpatientsbothwithandwithoutabnormalgallbladderemptyingOutcomesAfterCholecystectomy34Cholecystectomy

:Themeanfollow-upperiodofthestudiesincludedinthemeta-analysisbyPonskyandcolleaguesrangedfrom9–30months.Outcomeofstudy:patientswhounderwentsurgeryhadahighrateofsymptomaticresponsetosurgeryat1-monthfollow-up.However,at2-yearfollow-up,theproportionofpatientswithsymptomaticimprovementwassimilaramongthosewhounderwentsurgeryandthosewhodidnot.Cholecystectomy

:Themeanfoll35SphincterofOddiDysfunction

:Thisclassi