Internal Medicine Board Review Weekly Image Challenge: Radiological Findings in Obese Female with RUQ Pain

42-year-old obese female complains of right upper quadrant pain for three months. It is particularly severe following large fatty meals and at night. The pain radiates to the back and is occasionally accompanied by nausea. Below is an ultrasound image of her right upper quadrant.


Board Certification Question - Gallstones


What is the most likely cause of the pain this patient is experiencing?


A. Chronic cholecystitis

B. Biliary colic

C. Cholelithiasis

D. Choledocholithiasis



B. Biliary colic is the occasional blockage of the outflow tract of the gallbladder by gallstones or sludge. Because the blockage is only temporary, the patient experiences intermittent pain that resolves when the blockage resolves. The ultrasound image demonstrates a dependent echogenic structure with posterior shadowing in the lumen of the gallbladder, consistent with a gallstone. Given her history and the finding of cholelithiasis on ultrasound, biliary colic is the most likely source of the pain.


Explanation of wrong choices:

A. There is no gallbladder wall edema or wall thickening on the ultrasound images to suggest colic cholecystitis.

C. Although the ultrasound image does confirm the presence of gallstones, cholelithiasis alone is not responsible for the pain.

D. Although choledocholithiasis can cause similar symptoms, the ultrasound does not show the presence of a gallstone in the common bile duct.


You can see all the previous ABIM Exam image of the week blog posts at the Knowmedge Blog. You can find also additional topics and questions directly from the Knowmedge Internal Medicine ABIM Board Exam Review Questions QVault. _______________________________________________________________________________

Dr. Russell Kosik is a 2011 graduate of the David Geffen School of Medicine at UCLA. He is currently a radiology resident at Santa Clara Valley Medical Center.

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