Acute thoracolumbar pain due to cholecystitis: a case study
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CASE REPORT
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Acute thoracolumbar pain due to cholecystitis: a case study Chris T. Carter Abstract Background: This article describes and discusses the case of an adult female with cholecystitis characterized on initial presentation as acute thoracolumbar pain. Case Presentation: A 34-year-old female presented for care with a complaint of acute right sided lower thoracic and upper lumbar pain with associated significant hyperalgesia and muscular hypertonicity. The patient was examined, referred, and later diagnosed by use of ultrasound imaging. Conclusion: Despite many initial physical examination findings of musculoskeletal dysfunction, this case demonstrates the significance of visceral referred pain, viscerosomatic hyperalgesia & hypertonicity, and how these neurological processes can mimic mechanical pain syndromes. A clinical neurological discussion of cholecystitis visceral pain and referred viscerosomatic phenomena is included.
Background Chiropractors are trained as primary contact providers and well positioned to provide initial assessment, diagnosis and treatment for patients with spinal pain in addition to assisting in referral to other practitioners [1]. The presentation of back pain is common to chiropractors and differentiating acute musculoskeletal (somatic) from visceral pain presentation may be difficult as they can present with a similar clinical pain picture. These challenging clinical presentations can lead to inappropriate and delayed patient care, serving as a reminder of the importance of performing a thorough history and physical examination. Visceral pathology as a presenting complaint to chiropractors is generally considered rare, however a survey of American chiropractors indicated that 5.3 % of primary complaint presentations are non-musculoskeletal in origin [2]. It is estimated that up to 15 % of the American population have gallstones, 10-18 % of whom will develop biliary pain, and 7 % of which will require operative intervention [3]. With over 700,000 cholecystectomies performed annually in America, gallbladder disease is considered the most costly digestive disorder [3]. Although the majority of those with cholelithiasis will not develop acute cholecystitis, 1-3 % inevitably will. The transition of acute cholecystitis leading to a secondary bacterial infection of the gallbladder may occur in up to Correspondence: [email protected] School of Health Professions, Murdoch University, 90 South Street, Murdoch, WA 6150, Australia
50 % of cases. This increases the chance of complications such as the formation of an empyema, perforation, widespread peritonitis, sepsis and abdominal abscesses [4, 5]. Earlier intervention of acute cholecystitis has been increasingly recognized in a recent meta-analysis study that demonstrated performing early laparoscopic cholecystectomy (within 1–7 days of symptom onset) decreased incidence of complications including wound infections, provided shorter length of hospital stay and decreased costs versus delayed cholecystectomy. No difference
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