Interesting Case - Srinakharinwirot...

Interesting CaseGroup 4 Presenting to Radiology Department:

Srinakharinwirot University

Patient History:

HN: 15964-56

Social History:

A 38 year-old Married Thai Buddhist female

Career: Freelance

Allergy: No food & drug allergy

Substances: No alcohol use/ No smoking

Chief complaint:

More severe Epigastrium pain 3 day PTA

Present illness:

Intermittent Epigastrium pain

Radiate to back, no migration, with no

relationship to posture

No Fever (after 1 tab Tylenol)

Dysphagia, nausea-vomiting

Present illness:

No diarrhea, 2 days constipation

No gastric reflux and heartburn

More severity leads to hospital admission

Physical examination:

Vital sign:

BT 36.6 oC, PR 60 beat/min, RR 22/min

BP 140/80 mmHg, O2 Sat 99%

General appearance:

A Thai female, good consciousness

no jaundice


HEENT :

not pale conjunctiva, clear sclera

CVS : WNL

RS : WNL


Abdomen :

flat shape, no surgical scar was seen

tender at epigastrium and RUQ,

Soft, no rebound tenderness, no guarding,

Normoactive bowel sound


Extremities : no rash, no petechiae ,

no pitting edema

Neuro : E4M6V5 , orientated to time place

person, motor grade V all

Murphy’s sign positive

Problem list:

Tender at epigastrium and RUQ

Murphy’s sign positive

Differential diagnosis:

Acute Cholecystitis

Choledocholithiasis CBD stone

Cholangitis

Pancreatitis

Provisional diagnosis:

Acute Cholecystitis since it is the most

common biliary tract disease which shows

fever with right upper quadrant abdominal

pain, no jaundice and Murphy’s sign positive

Lab investigation:

CBC :

Hct 13.7 Hb 37.7

WBC 9,920 N67.7% L21.9% Plt 411,000

UA:

Sp.gr. 1.010

WBC 1-2 RBC 0-1 epi 0-1

Bact. Few TB 2.65 / DB 2.38

Laboratory Evaluation

Lab investigation:

LFT:

AST 142 ALT 209 ALP 208

Amylase 79 Lipase 138


Lab investigation:

U/S upper abdomen:

Gallbladder no wall thickening

Hyperechoic with posterior acoustic shadow

Suspected gallstone


Lab investigation:

Radiology Evaluation

Approach film:

Normal GB wall < 3 mm

Approach film:

Approach film:

Normal CBD

Conclusion:

A Thai female, 38 years old presented with

epigastrium pain and Murphy’s sign positive.

US:

Gallbladder wall thickening

Hyperechoic with posterior acoustic shadow

Conclusion:

CT scan:

Dense calcified stone in Gallbladder and distal

CBD

Final Diagnosis:

Acute cholecystitis with CBD stone

Treatment:

Antibiotics

• Piperacillin-tazobactam

• Ceftriaxone + Metronidazole

• Levofloxacin + Metronidazole

Cholecystectomy

• Open procedure

• Laparoscopy

Knowledge

Knowledge:

Acute Cholecytstitis


Cholangitis

Acute Pancreatitis

Acute cholecystitis

90% due to calculous obstruction of

gallbladder neck or cystic duct

More common in female 90%

Acute pain in right upper quadrant

Acute cholecystitis

US finding

Major criteria

Minor criteria

Acute cholecystitis

US finding

Major criteria

Gallstone

Sonographic

Murphy’s sign

Acute cholecystitis

US finding

Major criteria

Minor criteria

Gallbladder wall

thickening>3mm

Pericholecystic fluid

Acute cholecystitis

QUIZ:

RANDOM _ FLASH

Knowledge:



Cholangitis

Acute Pancreatitis

Most common cause of biliary tract

obstruction

Mostly cause by passing gall stone

Often asymptomatic

Suspected in patients with jaundice and

biliary colic

Lab : elevated bilirubin, ALP, ALT

Choledocholithiasis(CBD stone)

Ultrasound

> Hyperechoic structure

> Posterior acoustic shadow


CT with contrast : Target sign

> Central rounded density: stone

> Surrounding lower density: bile


Knowledge:



Cholangitis

Acute Pancreatitis

Cholangitis

Broad descriptive term refer to

inflammation of the bile duct

Infective cholangitis : Most common

Primary sclerosing cholangitis

Chemotherapy induced cholangitis

Eosinophilic cholangitis

Acute cholangitis

Charcot’s triad : Fever, jaundice and

abdominal pain

Cause : bacterial infection in a patient with

biliary obstruction ascending from the

duodenum

E. coli 25-50% , Klebsiella 15-20% ,

Enterobacter 5-10%

Ascending cholangitis

Acute cholangitis

Laboratory test

Elevated white blood cell count

neutrophil

Elevated serum ALP, AST

Ascending cholangitis

Ultrasound : Bile duct wall thickening

Acute cholangitisAscending cholangitis

Acute cholangitisAscending cholangitis

ERCP :

Multiple round shaped

filling defect in dilated

common bile duct

Most often in 30-60 years; more common

in men 70%

Idiopathic; autoimmune

Inflammation damage bile duct

scaring obstruct bile stasis & back

pressure liver damage bile lake


Clinical finding

Asymptomatic

Pain in upper right abdomen

diarrhea

Fever

Elevated serum ALP and AST


jaundice

Pruritus

Endoscopic retrograde cholangiopancreatography ERCP :

> Multiple segmental stricture

> intervening normal segment beaded

> Dilated segment of intrahepatic ducts


Knowledge:



Cholangitis

Acute Pancreatitis

Acute pancreatitis

Classical features

Gradual development of severe central

epigastrium pain and radiates through to the

back

Exacerbated by supine positioning

Lab

Elevated amylase and lipase enzyme

Acute pancreatitis

Plain film : colon cut-off sign

Acute pancreatitis

CT

Enlarged pancreas with shaggy margin

Peripancreatic fluid

Infiltration of peripancreatic fat

Acute pancreatitis

QUIZ:

1.

What is the finding of Acute Cholecystits

in Plain Film Abdomen?

Take Home Message:

Modality of choice for Acute Cholecystitis is

US

In US Triad signs suspected Acute Cholecystitis:

1. Gallbladder wall thickening (>3mm)

2. Gallstone

3. Sonographic Murphy’s sign positive

Take Home Message:

4 types of Gall stone:

• Cholesterol stone

• Pigment/Calcium bilirubinate stone

• Mixed stone

• Calcium Carbonate stone

Questions?

Interesting Case - Srinakharinwirot...

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