Differential Diagnosis for 63y/o Male with Severe CHF, COPD, CKD, and Acute Abdominal Symptoms
- Single Most Likely Diagnosis
- Acute acalculous cholecystitis (AAC): This condition is likely given the patient's severe comorbidities (CHF, COPD, CKD), acute onset of sharp abdominal pain, and distension, along with imaging findings of pericholecystic fat stranding and a thickened gallbladder wall (6.4mm) without evidence of gallstones. AAC is a known complication in critically ill patients and can occur without gallstones.
- Other Likely Diagnoses
- Hepatic congestion or liver capsule strain due to CHF: The patient's history of severe CHF could lead to hepatic congestion, causing abdominal pain and potentially some of the imaging findings.
- Mesenteric ischemia: Although less likely given the lack of specific findings on CT or ultrasound, the patient's history of severe CHF and COPD increases the risk for mesenteric ischemia, which can present with acute abdominal pain.
- Do Not Miss Diagnoses
- Gallbladder perforation: Although the ultrasound did not show gallstones, a perforation could still occur, especially in the context of AAC, and would require immediate surgical intervention.
- Mesenteric ischemia (repeated for emphasis): Given its high mortality rate if missed, it's crucial to consider mesenteric ischemia, even if the initial findings are not strongly suggestive.
- Bowel obstruction: The patient's symptoms of abdominal distension and pain could also be indicative of a bowel obstruction, which would need prompt diagnosis and treatment.
- Rare Diagnoses
- Cholecystenteric fistula: This is a rare condition where there's a fistulous connection between the gallbladder and the intestine, which could potentially explain some of the patient's symptoms and imaging findings, although it's less likely.
- Mirizzi syndrome without gallstones: A rare condition where a stone (or potentially other pathology) in the cystic duct causes obstruction of the common hepatic duct, leading to jaundice and potentially abdominal pain. However, the normal bilirubin and liver function tests make this less likely.