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Choledocholithiasis differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adenike Eketunde

Overview

Overview

Choledocholithiasis must be differentiated from other diseases that cause jaundice, right upper quadrant pain, fever, nausea and vomiting, such as Cholecystitis, Perforated peptic ulcer, Acute peptic ulcer exacerbation, Amoebic liver abscess, Acute amoebic liver colitis, Acute pancreatitis, Acute intestinal obstruction, Renal colic, Acute retrocolic appendicitis.

Differentiating Choledocholithiasis from other Diseases

Differentiating Choledocholithiasis from other Diseases

Choledocholithiasis must be differentiated from

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram, US = Ultrasound

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute cholecystitis RUQ + βˆ’ + + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ Hypoactive Ultrasound shows:
  • Gallstone
  • Inflammation
Acute suppurative cholangitis RUQ + + + + βˆ’ βˆ’ βˆ’ βˆ’ + + + N
  • Abnormal LFT
  • WBC >10,000
  • Ultrasound shows biliary dilatation/stents/tumor
  • Septic shock occurs with features of SIRS
Acute cholangitis RUQ + βˆ’ βˆ’ + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ N
  • Ultrasound shows biliary dilatation/stents/tumor
  • Biliary drainage (ERCP) + IV antibiotics
Cholelithiasis RUQ/Epigastric Β± βˆ’ Β± Β± βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ Normal to hyperactive for dislodged stone
  • Fatty food intolerance
Primary biliary cirrhosis RUQ/Epigastric βˆ’ βˆ’ βˆ’ + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ N
  • Increased AMA level, abnormal LFTs
  • ERCP
  • Pruritis
Primary sclerosing cholangitis RUQ + βˆ’ βˆ’ + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ N ERCP and MRCP shows
  • Multiple segmentalΒ strictures
  • Mural irregularities
  • BiliaryΒ dilatation and diverticula
  • Distortion of biliary tree
  • The risk ofΒ cholangiocarcinomaΒ in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Hepatic causes Viral hepatitis RUQ + βˆ’ + + βˆ’ Positive in Hep A and E + βˆ’ Positive in fulminant hepatitis Positive in acute + N
  • Abnormal LFTs
  • Viral serology
  • US
  • Hep A and E have fecal-oral route of transmission
  • Hep B and C transmits via blood transfusion and sexual contact.
Liver abscess RUQ + + + + βˆ’ Β± + βˆ’ + + Β± Normal or hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + βˆ’ βˆ’ + βˆ’ βˆ’ + βˆ’ βˆ’ βˆ’ βˆ’
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Budd-Chiari syndrome RUQ Β± βˆ’ βˆ’ Β± βˆ’ βˆ’ βˆ’ Positive in liver failure leading to varices βˆ’ βˆ’ βˆ’ N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Hemochromatosis RUQ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ Positive in cirrhotic patients βˆ’ βˆ’ βˆ’ N
  • >60% TS
  • >240 ΞΌg/L SF
  • Raised LFT
    Hyperglycemia
  • Ultrasound shows evidence of cirrhosis
 Extra intestinal findings:
  • Hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Cirrhosis RUQ βˆ’ βˆ’ βˆ’ + βˆ’ βˆ’ + + + βˆ’ βˆ’ N US
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Disease Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Comments
Intestinal causes Acute appendicitis Starts in epigastrium, migrates to RLQ + Positive in pyogenic appendicitis + βˆ’ βˆ’ Β± βˆ’ βˆ’ Positive in perforated appendicitis + + Hypoactive
  • Ct scan
  • Ultrasound
  • Positive Rovsing sign
  • Positive Obturator sign
  • Positive Iliopsoas sign
Irritable bowel syndrome Diffuse βˆ’ βˆ’ βˆ’ βˆ’ Β± Β± + βˆ’ βˆ’ βˆ’ βˆ’ N Normal Normal Symptomatic treatment
Hollow Viscous Obstruction Biliary colic RUQ βˆ’ βˆ’ + + βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ N
  • Ultrasound
Extra-abdominal causes Pulmonary causes Pulmonary embolism RUQ/LUQ Β± βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ Β± βˆ’ βˆ’ N
  • ABGs
  • D-dimer
  • Dyspnea
  • Tachycardia
  • Pleuretic chest pain
Pneumonia RUQ/LUQ + + + βˆ’ βˆ’ Β± βˆ’ βˆ’ + βˆ’ βˆ’ Normal or hypoactive
  • ABGs
  • Leukocytosis
  • Pancytopenia
  • CXR
  • CT chest
  • Bronchoscopy
  • Shortness of breath
  • Cough

References

  1. ↑ “StatPearls”. 2020. PMIDΒ 28722990.

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