Sandwiched

A 57 year old woman presents with nausea and worsening pain in the right upper quadrant for 1 day. The pain was sharp and colicky, and radiated to the right shoulder.

Her medical history is significant for gastroesophageal reflux disease for 5 years, and chronic back pain for 2 years, for which she is on omeprazole and ibuprofen respectively. Her family history is unremarkable, she only drinks socially, and does not smoke.

Serial ECGs are found to be normal. A complete blood count is significant for a leukocytosis of 13,000/mm3, with 70% neutrophils and 26% lymphcytes.

Select Relevant Investigations
Amylase + Lipase

Performed

Serum Amylase: 80 U/L (23-85)
Serum Lipase: 100 U/L (30-210)
Liver Profile

Performed

AST: 20 U/l (5-40)
ALT: 20 U/l (5-40)
Direct Bilirubin: 0.6 mg/dl (<1.2)
Albumin: 4.2 g/dL (3.5 - 5)
INR: 1.0
Ultrasound Abdomen

Performed

The gallbladder appears normal, no gallstones are visualized, and the extrahepatic and intrahepatic bile ducts are not dilated.
There are gas echoes of different sizes over the right hepatic lobe and hepatodiaphragmatic space. Their location is not altered by the patient's posture.
The liver and pancreas appear normal.
CT Abdomen

Performed

The CT scan reveals interposition of a loop of colon between the liver and right hemidiaphragm. Mild thickening of the walls of the mid-transverse colon and descending colon is also noted. There is no evidence of intestinal obstruction.

Select Relevant Management
Exploratory Laparotomy
Nasogastric Tube
Enema
IV Antibiotics