0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Quiz Case FREE

Roberta Molaro, MD; Emilio Morpurgo, MD
[+] Author Affiliations

Author Affiliations: Department of General Surgery, P. Cosma Hospital, Camposampiero, Italy.


SECTION EDITOR: CARL E. BREDENBERG, MD


Arch Surg. 2011;146(12):1449. doi:10.1001/archsurg.146.12.1449.
Text Size: A A A
Published online

A 70-year-old woman who had experienced sharp abdominal pain in the left lower quadrant during a 7-hour period was seen in the emergency department. She reported an episode of vomiting, her bowel function was normal, and she had not had a high temperature while at home. Her medical history included hypertension, for which she was being treated, and type 2 diabetes mellitus controlled with oral therapy.

On physical examination, the patient had a temperature of 39.6°C, and her abdomen was tender to deep palpation, with mild resistance. There was no rebound tenderness, and her bowel sounds were barely audible. A digital rectal examination revealed stools without blood.

Results of an abdominal radiograph were normal: no substantial free intra-abdominal gas was observed. Blood tests showed a normal white blood cell count and C-reactive protein level, a slight increase in total bilirubin (1.39 mg/dL) and creatinine (1.27 mg/dL) levels, and a significant increase in aspartate aminotransferase (518 U/L) and alanine aminotransferase (215 U/L) levels (to convert bilirubin level to micromoles per liter, multiply by 17.104; creatinine level to micromoles per liter, multiply by 88.4; and aspartate aminotransferase and alanine aminotransferase levels to microkatals per liter, multiply by 0.0167). An emergently acquired abdominal computed tomographic image showed free retroperitoneal air in the celiac area and devastation at the hepatic hilum; gas surrounded the portal vein and the splenic vein (Figure 1A), spreading along the periportal spaces inside the hepatic parenchyma up to the extremity of the liver (Figure 1B). The gallbladder showed thick walls and was surrounded by a liquid film, with minimal calcified opacity present inside. There was little fluid in the Douglas space, with a small amount around the liver.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Computed tomography shows free retroperitoneal air in the celiac area (A) and at the hepatic hilum (B). Gas is spreading along the periportal spaces inside the hepatic parenchyma.

The patient's general condition worsened rapidly. She developed septic shock, requiring treatment in the intensive care unit before being taken to the operating room.

WHAT IS THE DIAGNOSIS?

A.  Acute cholecystitis with perforation

B.  Duodenal perforation

C.  Fistula between the gallbladder and bowel

D.  Necrosis of the bile duct system

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Computed tomography shows free retroperitoneal air in the celiac area (A) and at the hepatic hilum (B). Gas is spreading along the periportal spaces inside the hepatic parenchyma.

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
JAMAevidence.com

Users' Guides to the Medical Literature
Acute Cholecystitis

The Rational Clinical Examination
Make the Diagnosis: Acute Cholecystitis