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…