Differential Diagnosis
The patient's presentation with a distended gallbladder, mild wall edema, and right upper and right lower quadrant pain after consuming a pork sandwich, in the context of a complex cardiac history, suggests a multifaceted differential diagnosis. The following categories outline potential diagnoses:
Single Most Likely Diagnosis
- Cholecystitis: The patient's symptoms of right upper quadrant pain and a distended gallbladder with mild wall edema, especially after consuming a fatty meal (pork sandwich), are highly suggestive of cholecystitis. The condition is often precipitated by gallstones but can also occur in the absence of stones, especially in critically ill patients or those with significant cardiac disease.
Other Likely Diagnoses
- Myocardial Infarction: Given the patient's history of double vessel disease, including a 100% occlusion of the I ostial branch of the LAD and 50% RCA occlusion, along with a significantly reduced ejection fraction (EF of 30%) and elevated end-diastolic pressure, myocardial infarction is a plausible diagnosis. Chest pain or discomfort can sometimes be referred to the abdomen.
- Gallstone Pancreatitis: The consumption of a fatty meal can precipitate gallstone pancreatitis if a gallstone obstructs the ampulla of Vater. The patient's right upper and lower quadrant pain could be consistent with this diagnosis, especially if there is associated back pain or elevated pancreatic enzymes.
- Cardiac Congestive Failure: With an EF of 30% and a history of significant coronary artery disease, the patient is at risk for congestive heart failure. Abdominal pain and distension can occur due to hepatic congestion, although this would typically be accompanied by more systemic signs of heart failure.
Do Not Miss Diagnoses
- Mesenteric Ischemia: This is a potentially life-threatening condition that can present with abdominal pain out of proportion to physical examination findings. The patient's cardiac history increases the risk of embolic events, which could lead to mesenteric ischemia.
- Pulmonary Embolism: Although the primary symptoms are abdominal, pulmonary embolism can sometimes present atypically, especially in patients with significant cardiac disease. The right ventricle is already under strain due to the patient's cardiac condition, making a pulmonary embolism potentially catastrophic.
- Aortic Dissection: This is a rare but critical diagnosis to consider, especially given the patient's history of hypertension (implied by the coronary artery disease) and cardiac dysfunction. Abdominal pain can be a presenting symptom if the dissection involves the abdominal aorta.
Rare Diagnoses
- Amyloidosis: This condition can involve the heart (restrictive cardiomyopathy) and gastrointestinal system, potentially explaining some of the patient's symptoms. However, it would be an unusual diagnosis without other supporting evidence such as systemic symptoms or specific findings on biopsy.
- Sphincter of Oddi Dysfunction: This condition can cause biliary-type abdominal pain and could potentially explain the patient's symptoms after eating a fatty meal. However, it is less likely given the presence of a distended gallbladder and the patient's cardiac history.