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USMLE Step 2 Question of the Day

May 22, 2024

A 50-year-old female is admitted for fever and abdominal pain. She reports diarrhea that she describes as light-colored stools that are foul-smelling. On physical examination, she is jaundiced and has tenderness in the right upper quadrant of her abdomen. Labs reveal WBC 15,000 with 10% bands, Hgb 13.3, platelets 230,000, alkaline phosphatase 300, total bilirubin 7.4, and direct bilirubin 6.3. What is the most likely cause of this patient’s condition?

Correct Answer: 

A. Ascending cholangitis

Explanation:

The patient’s presentation reveals the classic signs of ascending cholangitis (fever, jaundice, and right upper quadrant pain) called Charcot’s Triad. Ascending cholangitis is caused by chronic obstruction, usually by gallstones (choledocholithiasis, option C) that becomes infected. Fever and increased WBC counts are signs of infection that distinguish cholangitis from choledocholithiasis. Diarrhea of light-colored stools that are foul-smelling is steatorrhea (fatty stool) since bile is unable to enter the GI tract and digest the fat.

Cholecystitis (option B) is an infection of the gallbladder which will present with fever and right upper quadrant pain (Murphy’s sign), but usually will not present with jaundice since bile flow is not obstructed. Although the gallbladder is obstructed due to a stone in the cystic duct, the common bile duct is clear, and bile can flow directly from the liver to the GI tract.

Gastroenteritis (option D) will present with fever and diarrhea, but will usually present with vomiting, and there is rarely any jaundice or rise in bilirubin.

Hereditary spherocytosis (option E) is an autosomal dominant condition of the membrane of red blood cells (RBCs) that causes hemolytic anemia. In hemolytic anemia, the lysis of RBCs will cause an increase in indirect bilirubin due to the breakdown of hemoglobin. In this case, the jaundice is caused by direct bilirubin and therefore cannot be attributed to hemolytic anemia.

Quick Concepts:

  • Charcot’s triad
    • Fever
    • Abdominal pain (usually RUQ pain)
    • Jaundice
  • Reynolds pentad
    • Fever
    • Abdominal pain (usually RUQ pain)
    • Jaundice
    • Hypotension
    • Changes in mental status

Summary:

Classic signs of ascending cholangitis include fever, jaundice, and right upper quadrant pain, also known as Charcot’s Triad. Ascending cholangitis can be caused by chronic obstruction of the common bile duct with gall stones that becomes infected.

Correct Answer: 

A. Ascending cholangitis

Explanation:




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