A lady with right upper quadrant p ain
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HKCEM College Tutorial. A Lady with Right Upper Quadrant P ain. Author Dr. LEE KF, Dr. TANG CO, Dr. TAM MK Revised by DR CHAN CHI MING May 2013. Triage Notes. F/75 c/o: RUQ pain for 1 day PMH: DM, IHD, old PTB BP 172/78 P 96/min T 37.8 ºC. Triage Cat III.

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A Lady with Right Upper Quadrant P ain

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A lady with right upper quadrant p ain

HKCEM College Tutorial

A Lady with Right Upper Quadrant Pain

Author

Dr. LEE KF, Dr. TANG CO, Dr. TAM MK

Revised by

DR CHAN CHI MING

May 2013


Triage notes

Triage Notes

  • F/75

  • c/o: RUQ pain for 1 day

  • PMH: DM, IHD, old PTB

  • BP 172/78

  • P 96/min

  • T 37.8 ºC

Triage Cat III


What are your differential diagnosis

What are your differential diagnosis ?

  • Cholecystitis

  • Cholangitis

  • Liver abscess

  • PPU

  • Basal pneumonia

  • AMI…

What would you like to ask in the history ?


History

History

  • Fever & system review

  • CVSischemia

  • Respcough…

  • GUrenal colic

  • PMH

  • Current med

  • Drug allergy

  • Pain = PQRST

    • Place RUQ

    • Qualityconstant

    • Radiateto scapula

    • Severitye.g. pain score

    • Timefor one day

  • GI symptoms

    • N, V, D,

    • Jaundice, tea color urine


Physical findings

Physical Findings

  • A fat lady with T 37.8°C

  • No pallor or jaundice

  • A palpable globular shape mass at RUQ of abdomen

  • Murphy’s sign positive

  • Other systems essentially normal


What is murphy s sign

What is Murphy’s sign ?

  • Murphy’s sign is a reliable sign of acute cholecystitis

  • The patient is asked to take a deep breath while the examiner palpates the gallbladder region

  • The breath catches at the zenith of inspiration as the inflamed gallbladder moves down into contact with the examining hand

  • Elicit tenderness Positive

Demonstration


What is courvoisier s law

What is Courvoisier’s law ?

  • Courvoisier’s law states that

    • if the gallbladder is palpable in the presence of jaundice, the jaundice is unlikely to be due to stone


What is charcot s triad

What is Charcot’s triad ?

= RUQ pain + pyrexia + jaundice

  • It suggests a diagnosis of cholangitis


What is the differential diagnosis of ruq mass

What is the differential diagnosis of RUQ mass ?

  • Gallbladder

  • Liver

  • Colon


What is the differential diagnosis for this lady

What is the differential diagnosis for this lady ?


What investigations would you order

X-ray

Blood

ECG

Ultrasound

What investigations would you order ?

Progress


What are the findings

What are the findings ?

X-ray

  • RUQ opacity likely gallstone

  • No pneumobilia

  • No dilated bowel

  • Clear lung fields

  • No free gas


X ray

X-ray

CXR (erect film)

  • to look for free gas under diaphragm, which may be caused by PPU or perforated gallbladder in case of acute cholecystitis

    AXR

  • to look for calcified lesion suggesting gallstone

  • Also look for sign of IO (gall stone ileus in case of acute cholecystitis)


Gallstone

Gallstone

  • Only 15% of stones contain enough calcium to be seen on a plain film

  • Ultrasound is a much more sensitive test for gallstone


Blood

Blood

CBC

  • Hb 12 g/dL

  • WCC12 x10^9 /L

    RFT

  • Urea6.2 mmol/L

  • Cr76 umol/L

LFT

  • Bili12 umol/L

  • ALT57 U/L

  • ALP40 U/L

    Amylase89 U/L

    Tn-I< 0.03 mmol/L

    Glucose / H’stix13.7 mmol/L


A lady with right upper quadrant p ain

ECG

AF with ventricular rate of about 90/min

no acute ischemic changes


What are the findings1

What are the findings ?

Ultrasound

Thickened GB wall & peri-cholecystic fluid

Distended Gallbladder

Gallstone with echogenic foci & posterior acoustic shadow


What are the findings2

What are the findings ?

Ultrasound

  • Echogenic foci with posterior acoustic shadowing suggesting gallstones

  • Distended gallbladder

  • Gallbladder wall thickened

  • Peri-cholecystic fluid

  • Positive sonographic Murphy’s sign

    • Not demonstrate in the picture

Compatible with acute cholecystitis

  • Also look for:

  • Ductal dilatation (CBD & intrahepatic) to exclude cholangitis

  • Liver tumor as hepatitis B is prevalent in our locality

  • Sub-hepatic fluid collection (abscess)

US demonstration


A lady with right upper quadrant p ain

Ultrasound

  • What is positive sonographic Murphy’s sign?

  • What are the sonographic diagnostic criteria for acute cholecystitis?

Positive sonographic Murphy’s sign —tenderness elicited by pressing the gallbladder with the US probe


What are the sonographic diagnostic criteria for acute cholecystitis

What are the sonographic diagnostic criteria for acute cholecystitis ?

Major diagnostic criteria:

  • Positive sonographic Murphy’s sign

  • Loss of definition of gallbladder margins

  • Thickening of the gallbladder wall > 3 mm

  • Linear or irregular hypoechoic areas within the wall

  • Peri-cholecysticfluid

  • Intramural gas

Minor criteria:

  • Distended gallbladder

  • Presence of calculi or sludge

(5% of cases are not associated with gallstones)

(If patient does not have ascites, chronic liver disease & right heart failure)

(Indicative of impending perforation)

Details


Progress

Progress


Treatment

Treatment

Progress

  • Resuscitate if necessary

  • Analgesia

  • Admit to surgical unit for further management


Treatment after admission

Treatment after admission

Progress

  • Confirm the diagnosis by blood tests, formal USG (by radiologist)

  • Conservative treatment (include: NPO, IV fluid, antibiotics, NG suction if appropriate)

    • 90% of cases will settle

  • Close monitor for complications:

    • sepsis, empyema, gangrene & perforation

  • Surgical treatment

    • laparoscopic or open cholecystectomy

  • If medically not fit for GA, may perform percutaneous cholecystostomy


  • The end

    The End

    Any Questions ?


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