Gastrointestinal System

Frame 1

You are sitting at your favorite cafe, sipping on an intricate Italian roast and idly flipping through a magazine.

"Nothing related to medicine today", you remind yourself, skipping past a glossy article on bariatric surgery. It's your day off and you don't want to see so much as a ball of cotton.

Right on cue, your phone rings. It's your colleague, Patrice.

"Hi! Can you please cover for me today? I have a huge family emergency and I really have to go. I'll owe you one, thanks!". She sounds frantic, and hangs up before you can utter a word.

With a sigh, you put down the periodical and trudge to the car. "So much for 'nothing related to medicine today'", you mutter to yourself.

Frame 2

A patient is already waiting by the time you arrive at the ER.

Forty-two-year-old Mrs. Parker complains of right upper quadrant abdominal pain that started quite suddenly and radiates to the right upper back.

She woefully states that she has also had severe nausea after her spaghetti dinner.

Frame 3

"Sometimes it gets a little better but then it gets really bad again", she says. When asked to rate the pain, Mrs. Parker marks it 9/10 on the pain scale.

She has taken some over-the-counter antacids, which were of no help. Changing her posture was of no use either, and the pain did not lessen after bowel movements.

She did not have fever, chills, vomiting, recent trauma, or urinary symptoms and denies any significant history of substance use.

She is not on any medications at present, and had her period three weeks ago.

Frame 4

You now proceed to examine her. Her vitals are as follows: Temperature 99.0 °F (37.2 °C), blood pressure 152/92 mmHg, pulse 110bpm, respiratory rate 20 cycles/min. Her BMI is 32kg/m2

Noticeably, Mrs. Parker is all hunched over and grimacing in pain.

As you examine her abdomen, you find no distension, severe right upper quadrant tenderness, mild rebound tenderness, no guarding, and no hepatosplenomegaly. Murphy's sign is positive.

An examination of her other systems reveal no abnormality.

Frame 5

You order a complete blood count, comprehensive chemistry, serum amylase and lipase, and liver enzymes.

Her urinalysis reveals no abnormalities, and a urine HCG test returns negative.

Frame 6

Her labs all come back normal.

Frame 7

What will you do now?

Choice Outcome Score Continues
Order a X-ray KUB Incorrect 0 → Frame 26
Request an abdominal ultrasound Correct 1 → Frame 8
Request an abdominal CT scan Incorrect 0 → Frame 27

Frame 8

Mrs. Parker has a mild fatty liver but no cirrhosis or hepatosplenomegaly on her ultrasound. The radiologist did not note gallstones. Her kidneys appeared normal as well, although the exam was somewhat limited owing to her post-prandial state.

Frame 9

Mrs. Parker's pain subsides with IV fluids and hydromorphone, and she insists that she is well enough to go home.

Frame 10

What will you do now?

Choice Outcome Score Continues
Observe her for some more time in the ER Incorrect 0 → Frame 24
Send her home with clear instructions on when she should be followed up Correct 1 → Frame 11
Admit her since she'll probably be back anyway Incorrect 0 → Frame 25

Frame 11

Subsequently, you send Mrs. Parker home with instructions to return to the ER, should she experience any more episodes of pain.

Frame 12

Five-and-a-half weeks later, Mrs. Parker is awakened by a severe pain in her right upper abdominal quadrant, which brings her back to your ER.

Her condition is nearly identical to the last time, except that the pain progressively increased over time, and is now steady at the maximal level.

"Figure it out and make it go away, please!" she begs of you, clearly in agony.

Her vitals are normal and there are no new signs on a physical.

Her labs are normal once again as well, although her stool is guaiac negative. You give her some diclofenac for the pain.

Frame 13

What will you do now?

Choice Outcome Score Continues
Order an abdominal CT with contrast Incorrect 0 → Frame 28
Request an abdominal ultrasound Correct 1 → Frame 14
Order a hepatobiliary iminodiacetic acid (HIDA) scan Incorrect 0 → Frame 29

Frame 14

Mrs. Parker is fasting today so the ultrasound is of better quality than the previous one, but once again, the radiologist is unable to detect any abnormality.

She is quite uncomfortable on the gurney; the diclofenac doesn't seem to have helped very much. She requests hydromorphone, since it helped previously.

Frame 15

Mrs. Parker's husband is with her today and is quite anxious when he sees his wife in so much pain.

"Can't she get the medication that helped her before?" he asks, looking distressed.

Frame 16

What will you do now?

Choice Outcome Score Continues
Give her some hydromorphone to reduce the pain Correct 1 → Frame 17
Give her alprazolam to calm her down Incorrect 0 → Frame 31
Withhold any further pain medications for the moment Incorrect 0 → Frame 30

Frame 17

You prescribe hydromorphone, making a special note in her charts about it. Mrs. Parker responds well to the analgesia.

Now that the immediate situation has been taken care of, you need to decide on her further management. Clearly, you must begin by identifying the pathology.

Frame 18

What do you do now?

Choice Outcome Score Continues
Request a HIDA scan with cholecystokinin Correct 1 → Frame 19
Refer her to a surgeon for an open laparotomy Incorrect 0 → Frame 32
Order an MRCP Incorrect 0 → Frame 33

Frame 19

You realize that a HIDA scan is the best way forward, despite the recent dose of opioids. You make sure to let radiology know about the time and dose of hydromorphone you've administered to Mrs. Parker.

Frame 20

The HIDA scan shows that her gallbladder has a very low ejection fraction. Considering this along with her symptoms, you diagnose functional gallbladder disorder, going by the Rome III criteria.

You decide to continue her IV fluids and keep her NPO for the time being.

You also ponder if Mrs. Parker requires surgery ...

Frame 21

Do you offer her surgery?

Choice Outcome Score Continues
No. This condition usually resolves spontaneously and surgery is not indicated Incorrect 0 → Frame 34
Yes. She does meet the criteria for surgery and there is a good chance it will relieve her symptoms Correct 1 → Frame 22

Frame 22

The on-call surgeon and her surgical residents agree to admit the patient.

Frame 23

Mrs. Parker has a big smile on her face a day after her laparoscopic cholecystectomy.

She tells anyone who will listen about the fine doctor in the ER who found out what the matter was with her.

You leave her bedside smilingly, to go find Patrice and tell her the story.

Well Done!

The end

Frame 24

You keep Mrs. Parker under observation in the ER for a few more hours, but the physician on the next shift calls you out on the waste of hospital resources and suggests you discharge her, as she is fit to go home for the moment.

You see the light and humbly write the discharge order ...

Frame 25

The chief medical resident and the surgical team both question the need for admission and you begin re-assessing your decision.

Frame 26

You request an X-ray KUB. The film appears normal with no signs of a renal calculus.

This was probably expected, given that Mrs. Parker didn't have any flank pain or hematuria that may suggest a renal pathology.

"Uh-oh, too late", goes the little voice in your head. You've already subjected her to an unnecessary dose of radiation and added an unnecessary test to her tab.

You decide to order an ultrasound instead.

Frame 27

You send Mrs. Parker over to radiology, requesting an abdominal CT.

You receive a call from one of the radiologists.

"I was going through your notes and I think an ultrasound may be more appropriate at this stage", he suggests.

You realize that he is right, thank him and request that he proceed with sonography instead.

Frame 28

Mrs. Parker's creatinine isn't raised and you decide that a contrast enhanced CT would be the best next option.

The CT comes back normal, you are no closer to a diagnosis, and you have exposed her to an unnecessarily heavy dose of radiation.

Frame 29

You consider a HIDA scan to identify any functional abnormalities and call radiology to see if there's an opening.

"A HIDA scan? Sure! What were her ultrasound findings?" the radiologist asks.

You're reminded that it is pointless to do a HIDA scan before excluding structural anomalies on an ultrasound.

"Ah, the ultrasound!" you pronounce, thanking the slightly confused radiologist before hanging up.

Frame 30

"I'm sorry Mr. Parker, but we can't give her any more pain meds at the moment", you say. Both husband and wife look perplexed

A senior colleague supervising on the case calls you aside to have a word.

"I know you're probably worried about the pain medication interfering with subsequent tests, but there's no justification for keeping a patient in pain", he advises, sternly but kindly.

Frame 31

You contemplate that sedation may help Mrs. Parker calm down and reduce her pain.

"Perhaps it's not the best idea", you think to yourself, unable to remember any indication for benzodiazepines in such a condition.

Frame 32

You call the surgical team and explain your treatment plan.

"What is the indication for surgery though, doctor? You said that there are no abnormalities on the ultrasound, are you suspecting a functional disorder? Did the HIDA scan throw up anything?"

You also realize that the surgeon is correct, and thank him. You need to perform a HIDA scan first.

Frame 33

You fill out the form for an MRCP and hand it over to the nurse. She looks at it questioningly.

"Doctor, I think you've accidently filled out the wrong form. This is the form for an MRCP, not a HIDA scan", she says, handing it right back to you.

Realizing your mistake, you thank her for her astute judgment and fill the form for a HIDA scan.

Frame 34

You tell Mrs. Parker that she will not need surgery at the moment, as her pain will resolve spontaneously.

"Are you sure, doctor?" she asks, looking confused.

"The doctor who did my scan earlier seemed quite certain that I would benefit from surgery! Was he wrong?"

This makes you re-think your decision. Patients like Mrs. Parker have been shown to benefit greatly from surgery. You quickly correct yourself, apologizing to her for your earlier hasty decision.

Frame 35

You suspect that Mrs. Parker is suffering from a functional disorder of the gallbladder, given that acute cholecystitis is unlikely with her clinical work up.

You also realize that further investigation would probably be fruitless, and that she can be sent home for the moment.