A case of upper abdo painJoanna Wykes, FY2

You are an FY2 in general practice

O A 45 year old female called Mary attends with two episodes of upper abdominal pain. She has had one episode 5 months ago and another episode yesterday.

O What do you want to ask in your history?

HPCO Site: RUQO Onset: Built up graduallyO Character: squeezingO Radiation: noneO Associations: Mild nausea, no vomitingO Timing: lasted about 4 hours both timesO Exacerbating factors: occurred after

eating fatty food both timesO Severity: 6/10

PMHO HypercholesterolaemiaO ObesityO Gastric band, Dec 2013O T2DMO Hypertension

DHO Microgynon ODO NKDA

FHO Mother was told she had gallstones

though they never seemed to trouble her

SHO Smoker 20/dayO Alcohol 10 units/ weekO Works as a receptionist

Examination…O Is completely normal

What is the diagnosis?

What is the diagnosisO Biliary colic

What will you do for the patient?

What will you do for the patient?

O OP USS

USSO A solitary 2cm stone is found in the

gallbladder. The gallbladder wall is

not thickened. All other imaged

organs are normal.

You phone the patient to tell her the news

O It’s now 3 months since she came in to see you

O She’s not had any pain since the last episode she told you about

O What do you suggest?

Surgery/ watch and wait

O What does the patient want?

O She’s not very keen on the idea of surgery and would prefer to see how things go

O Other options could be smoking cessation advice, statins or weight loss

You have moved on to your next rotation in A+E

O You pick up the next patient to clerk and it’s Mary. She has upper abdominal pain again.

O None of her PMH, DH, FH or SH have changed

O You take a HPC

HPCO Site: RUQO Onset: Occurred graduallyO Characteristic: gripping painO Radiations: To the backO Associations: vomited, feels hot and

stickyO Timing: 4 hours nowO Exacerbating factors: nilO Severity: 8/10

You move on to examination

Abdo examO SoftO Tender in the RUQO Murphey’s sign positiveO No masses

ObsO Temp:38.0O Pulse: 105O BP: 130/78O RR: 16O Sats: 99% on air

What investigations do you do?

What investigations do you do?

O Urine dipO Bloods: FBC, U+Es, LFTs, G+S, bone,

amylaseO AXRO Erect CXRO Ultrasound (after senior review)

What do we expect on the bloods?

BloodsO WCC: 13.5O Billirubin: NADO ALP: 145O AST: NADO ALT: NADO Amylase: NAD

Where do these blood test results suggest the stone is?

The cystic duct

So where are all these ducts?

(Aside) If the AST/ALT and billirubin were deranged, what would this suggest?

(Aside)O The stone would be in the common

bile duct

O And if this were the case, what additional symptom would we see?

(Aside)O Jaundice

O An what procedure might we be able to use to remove the stone?

(Aside)O ERCP

Back to MaryO We get the AXR and erect CXR back

O What do we expect to see?

AXR and errect CXRO NAD

O Why havn’t we seen the gallstones?

USSO Thick walled gallbladder. Gallbladder

is distended and a stone is visualised in the gallbladder with pericholecystic fluid. A stone is also visualised in the cystic duct.

Treatment (as a junior doctor)

Treatment (as a junior doctor)

O Pain reliefO AntiemeticsO NBMO IV fluids

Treatment (as a surgeon)

Treatment (as a surgeon)

O Laparoscopic cholecystectomy

O When?

O In a few days time, when the inflammation has begun to settle

Everything goes very well for Mary but some patients aren’t so lucky…

O What complications can occur?

ComplicationsO PancreatitisO EmpyemaO Gallstone ileusO MucocoeleO Ascending cholangitis

SummaryO Gallstones are usually asymptomatic

but can produce pain (biliary colic) or infection (cholecystitis)

O Risk factors for gallstones include being a female, being overweight, hypercholesterolaemia and T2DM

O Laparaoscopic or open cholecstectomy or ERCP can be used in management