Clinical case review
Review the complete Medicine case, its five progressive clues, the diagnosis, and the clinical reasoning behind the answer.
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Play today's Medicine caseThese are the case findings in their original reveal order, moving from the broader presentation to the most discriminating evidence.
Clue 1
A 44-year-old woman who restores vintage sewing machines has had three attacks of severe abdominal pain in the past fortnight. Each one built over an hour or so, held her for a few hours, and then let go entirely — well enough afterwards, each time, to go back to the workbench that evening. This fourth attack started nine hours ago and has not let go at all, which is why she is here.
Clue 2
The pain is gripping and colicky rather than constant and burning. It sits under the right ribs and travels through to the right shoulder blade, and it brings nausea with it. Through all four attacks, across a fortnight, she has never once had a fever, never had a shaking chill, and has never been confused or drowsy.
Clue 3
Since yesterday the whites of her eyes have been yellow. She noticed it in the bathroom mirror and then started paying attention to other things: her urine has turned the colour of strong tea, and her stools over the last two days have gone pale — a light clay colour instead of brown.
Clue 4
On examination she is comfortable between waves and unwell during them. Temperature 36.9 °C, pulse 84, blood pressure 128/76. Pressing firmly beneath the right costal margin while she breathes in is tender, but it does not catch her breath and she does not stop the inspiration; there is no guarding and no rebound. The blood count matches the temperature: white cells 7.8 with a normal differential, haemoglobin 133, platelets 265.
Clue 5
The liver tests separate cleanly into two groups. The markers that rise when bile cannot get out are high: alkaline phosphatase 410, gamma-GT 520. The markers that rise when liver cells are being destroyed have barely moved by comparison: ALT 96, AST 84. Total bilirubin is 4.6 mg/dL and it is the conjugated fraction that has climbed.
Diagnosis
Three things have to line up, and in this case they do. The first is the pattern of the pain: colicky, right-sided, radiating to the scapula, intermittent and recurrent, with complete resolution between attacks. That is a stone moving rather than an organ inflaming — inflammation does not switch off and on over a fortnight. The second is obstructive jaundice arriving late in the sequence, after several attacks have already come and gone. Yellow sclerae, tea-coloured urine and clay-pale stools together describe conjugated bilirubin entering the circulation and not reaching the gut, which places the blockage in the duct rather than in the gallbladder. The third — and this is the one that decides between the three biliary diagnoses that share the first two — is what is absent. She has never had a fever or a rigor, her temperature is 36.9 °C, and her white cell count is 7.8 with a normal differential. Cholangitis is infection in the setting of biliary obstruction, and it announces itself with fever, jaundice and abdominal pain together; take the fever away and what is left is the obstruction on its own. Acute cholecystitis is separated by the examination: firm pressure under the right costal margin during inspiration is tender but does not arrest her breath, which is not what an acutely inflamed gallbladder does. The blood tests then confirm the mechanism rather than merely echo it. Alkaline phosphatase at 410 and gamma-GT at 520 dwarf an ALT of 96 and AST of 84, which is a cholestatic pattern rather than a hepatocellular one, and a total bilirubin of 4.6 mg/dL sits above the 3 to 4 mg/dL level that is strongly associated with a stone in the common bile duct. Confirmation is by imaging: ultrasound will typically show a duct dilated beyond 6 mm but finds the stone itself only 15 to 40 per cent of the time, whereas MRCP is 92 per cent sensitive and 100 per cent specific. Treatment is duct clearance, by ERCP or by cholecystectomy with bile duct exploration.
The explanation and decisive case findings were checked against the source below.
Open the clinical referenceFor education and entertainment only. This fictional case is not medical advice and does not replace supervised clinical training, diagnosis, or treatment.
