It will, it won’t but it might…
Patient details.• Mrs RF 62 years old
• Background history1. Renal transplant (PCKD)
2. Bilateral nephrectomies
3. Type 2 DM / Hypertension / hyper lipidemia
Presentation.
• Self referral to renal day care
• I year history of intermittent RUQ / epigastric pain →→→ back
• Worse post prandially
• Progressively worse over last month
• Associated nausea and burping
No…..• Fevers / sweats / vomiting
• Change in urine or stool colour
• Change in bowels/ weight / appetite
• History of gallstones / PCLD
• Alcohol / non smoker / OTC NSAIDS
• Travel abroad / blood transfusion
• Cough / sputum production
Examination.
• Patient appeared well
• Bilateral nephrectomy / RIF scars
• RIF mass - transplant
• Tender over lower right ribs on inspiration
• No organomegaly, jaundice, anaemia
Investigations.
• AST 26 (0-40)
• GGT 36 (0-38)
• Amylase 56
• Hb 12g/dl
• WCC 7.83
• CRP 29 (0-10)
• ESR 88
• Diffuse echogenicity throughout liver – simple cysts
• No evidence of gall stones
• No evidence of intra hepatic duct dilatation
• However position of gall bladder abnormal….
CT scan.
• Fundus of gall bladder herniated between lower 2 ribs
• Focal area of right basal consolidation
• Liver findings consistent with USS
• Rest of examination…
Acalculus cholecystitis.No other causes
Normal ultrasoundHistory of biliary type pain
Complication of serious medical / surgical illness.
• Risk factors - Male - Trauma - Burns - Diabetes - Sepsis - CABG - Transplant
• Pathophysiology - Visceral hypo perfusion - Bile stasis - Small vessel occlusion - visceral hyperalgesia - altered epithelial
permeability
Rome III criteria.• Functional gall bladder disorders
1. Epigastric and or RUQ pain with
2. Episodes > 30 mins and progressive
3. Symptoms at different times
4. Impairs ADLs or needs ED admission
5. No relief with defecation / antacids / postural changes
6. Exclusion of other structural problems
+ / - nausea, vomiting, radiation to back
Investigations?
• As for suspected gallstone disease
• Cholecystokinin cholecystography
• Tc99 labelled HIDA scan
• Problems??
Management.
• Influence of investigations
• Recommendations vary
• Long term outcomes of cholecystectomy
Mrs RF.
• Elective open cholecystectomy
• Risks V’s benefits
• Findings
• Post op period
• It will, it won’t, it might…
• It did…
Learning points.
• Rule out other causes
• Treat the patient not the test?
• It will, it won’t but it might…
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