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It will, it won’t but it might…

It will, it won’t but it might…. Patient details. Mrs RF 62 years old Background history Renal transplant (PCKD) Bilateral nephrectomies Type 2 DM / Hypertension / hyper lipidemia. Presentation. Self referral to renal day care I year history of intermittent RUQ /

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It will, it won’t but it might…

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  1. It will, it won’t but it might…

  2. Patient details. • Mrs RF 62 years old • Background history • Renal transplant (PCKD) • Bilateral nephrectomies • Type 2 DM / Hypertension / hyper lipidemia

  3. 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

  4. 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

  5. Examination. • Patient appeared well • Bilateral nephrectomy / RIF scars • RIF mass - transplant • Tender over lower right ribs on inspiration • No organomegaly, jaundice, anaemia

  6. Investigations. • AST 26 (0-40) • GGT 36 (0-38) • Amylase 56 • Hb 12g/dl • WCC 7.83 • CRP 29 (0-10) • ESR 88

  7. Diffuse echogenicity throughout liver – simple cysts • No evidence of gall stones • No evidence of intra hepatic duct dilatation • However position of gall bladder abnormal….

  8. 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…

  9. Acalculus cholecystitis. No other causes History of biliary type pain Normal ultrasound

  10. Risk factors - Male - Trauma - Burns - Diabetes - Sepsis - CABG - Transplant Pathophysiology - Visceral hypo perfusion - Bile stasis - Small vessel occlusion - visceral hyperalgesia - altered epithelial permeability Complication of serious medical / surgical illness.

  11. Rome III criteria. • Functional gall bladder disorders • Epigastric and or RUQ pain with • Episodes > 30 mins and progressive • Symptoms at different times • Impairs ADLs or needs ED admission • No relief with defecation / antacids / postural changes • Exclusion of other structural problems + / - nausea, vomiting, radiation to back

  12. Investigations? • As for suspected gallstone disease • Cholecystokinin cholecystography • Tc99 labelled HIDA scan • Problems??

  13. Management. • Influence of investigations • Recommendations vary • Long term outcomes of cholecystectomy

  14. Mrs RF. • Elective open cholecystectomy • Risks V’s benefits • Findings • Post op period

  15. It will, it won’t, it might… • It did…

  16. Learning points. • Rule out other causes • Treat the patient not the test? • It will, it won’t but it might…

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