It will, it won’t but it might…. Patient details. Mrs RF 62 years old Background history 1.Renal...
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Transcript of It will, it won’t but it might…. Patient details. Mrs RF 62 years old Background history 1.Renal...
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…