Differentials
Peptic ulcer disease (PUD)
SIGNS / SYMPTOMS
May have ulcer risk factors: Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, smoking, increased age, or positive family history of PUD. Presents with burning or gnawing pain in the upper abdomen, particularly with food consumption and often improved with antacids.
INVESTIGATIONS
EGD: peptic ulcer.
H pylori breath/stool antigen test: may be positive if H pylori causative.
Gallbladder cancer
SIGNS / SYMPTOMS
Can present with painless jaundice and/or weight loss, although often presents late with upper abdominal pain.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends consideration of an urgent direct access ultrasound scan (to be performed within 2 weeks) to exclude gallbladder cancer in any patient who has an upper abdominal mass consistent with an enlarged gallbladder.[83]
INVESTIGATIONS
CT abdomen: may reveal intrahepatic mass lesion, dilated intrahepatic ducts, and/or localised lymphadenopathy.
Gallbladder polyps
SIGNS / SYMPTOMS
Often found incidentally on imaging for other conditions.
INVESTIGATIONS
Abdominal ultrasound: polypoidal lesion.
Acalculous cholecystitis
SIGNS / SYMPTOMS
Positive Murphy's sign (tenderness suddenly becomes worse during deep inspiration, and produces inspiratory arrest). In the intensive care unit setting, findings are often subtle.
INVESTIGATIONS
Abdominal ultrasound: no gallstones; may produce Murphy's sign.
Hepatobiliary iminodiacetic acid (HIDA) scan: gallbladder non-visualisation.
Sphincter of Oddi dysfunction (SOD)
SIGNS / SYMPTOMS
Postcholecystectomy biliary pain.
INVESTIGATIONS
Endoscopic retrograde cholangiopancreatography with biliary manometry: lack of sludge or retained stones; should only be undertaken in those with abdominal pain after cholecystectomy who have significant laboratory or imaging abnormalities (type I or type II SOD).[104]
Non-biliary acute pancreatitis
SIGNS / SYMPTOMS
History is helpful in identifying alcohol use, possible offending medications, or recent biliary tract endoscopy/surgery.
INVESTIGATIONS
Triglycerides: elevated; usually >11.3 mmol/L (>1000 mg/dL) (can be lower in fasting patients).
Calcium: elevated; checking ionised calcium is useful.
IgG4: for autoimmune pancreatitis.
Magnetic resonance cholangiopancreatography/abdominal ultrasound: normal bile ducts.
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