Right Upper Quadrant Pain: When Being in the "Fold" Means Double Trouble.

A 26-year-old woman with a 6-month history of intermittent right upper quadrant pain, radiating to the epigastrium, was initially evaluated in the gastroenterology outpatient clinic for a second opinion. She further characterized her pain as being intermittent, occurring a few times per week, colicky, at times sharp, and lasting from a few days to up to a week from onset, but not associated with nausea or vomiting. She drinks alcohol only occasionally and does not routinely take nonsteroidal anti-inflammatory medications. Although she had been trying to reverse a recent weight gain by reducing food intake and by increasing physical exertion, her nutrition was adequate. Her last episode of abdominal pain had occurred 2 months before initial evaluation. An ultrasonographic evaluation of her abdomen performed at another clinic to evaluate the same complaints was reported as showing an enlarged liver but was otherwise normal, including examination of the gall bladder. She had undergone laparoscopic surgery for an ectopic pregnancy in the right fallopian tube 2 years previously, but reported no other major illness. Her vital signs were unremarkable including her being afebrile, normotensive (blood pressure 120/70 mmHg), with a normal respiratory rate (14/min) and an oxygen saturation of 98 % while breathing room air. Her weight was 71 km, her height 163 cm and calculated body mass index (BMI) was 26.8. The remainder of the physical examination was unremarkable, including anicteric sclera and normal skin color; abdominal examination revealed no tenderness in the right upper quadrant or epigastric areas, and there was no palpable hepatosplenomegaly, masses, or hernias. Laboratory tests obtained during her initial evaluation were essentially unremarkable with a normal white blood cell count of 4.7 K/mm, hemoglobin of 13.7 g/dL, hematocrit of 42 %, and a platelet count of 232 K/mm. Serum concentrations of aspartate aminotransferase 20 U/mL (normal \58 U/mL), alanine aminotransferase 29 U/mL (normal\67 U/mL), alkaline phosphatase 40 U/mL (normal \150 U/mL), albumin 4.4 g/dL (normal 3.4–4.7 g/dL), total bilirubin of 0.4 mg/dL (normal\1.2 mg/dL), and direct bilirubin of 0.1 mg/dL (normal\0.4 mg/dL) were all normal. A urine test for pregnancy was negative. The visualized portions of the pancreas, hepatic contours and parenchyma, aorta, and inferior vena cava were all sonographically unremarkable. A ‘‘fold’’ in the mid-portion of the gallbladder without evidence of cholelithiasis or cholecystitis was visualized; no intrahepatic biliary ductular dilatation or abnormality of the extrahepatic biliary tree was noted, with the common bile duct measuring 4 mm without other ductal dilatation or masses, and patency of the portal, hepatic, and splenic veins, with hepatopetal flow documented in the portal vein. The spleen was normal in size and appearance, and the right and left kidneys were unremarkable. Upper endoscopy was essentially unremarkable, with multiple duodenal biopsies histologically normal. Biopsies of the gastric antrum revealed the presence of mild chronic inactive gastritis, without Helicobacter pylori present. & Ramya Muralimohan rmuralimohan@salud.unm.edu