1. A case of upper abdo pain Joanna Wykes, FY2

2. You are an FY2 in general practice O A 45 year old female called Mary attends with two episodes of upper abdominal pain. She has had one episode 5 months ago and another episode yesterday. O What do you want to ask in your history?

3. HPC O Site: RUQ O Onset: Built up gradually O Character: squeezing O Radiation: none O Associations: Mild nausea, no vomiting O Timing: lasted about 4 hours both times O Exacerbating factors: occurred after eating fatty food both times O Severity: 6/10

4. PMH O Hypercholesterolaemia O Obesity O Gastric band, Dec 2013 O T2DM O Hypertension

5. DH O Microgynon OD O NKDA

6. FH O Mother was told she had gallstones though they never seemed to trouble her

7. SH O Smoker 20/day O Alcohol 10 units/ week O Works as a receptionist

8. Examination… O Is completely normal

9. What is the diagnosis?

10. What is the diagnosis O Biliary colic

11. What will you do for the patient?

12. O OP USS

13. USS O A solitary 2cm stone is found in the gallbladder. The gallbladder wall is not thickened. All other imaged organs are normal.

14. You phone the patient to tell her the news O It’s now 3 months since she came in to see you O She’s not had any pain since the last episode she told you about O What do you suggest?

15. Surgery/ watch and wait O What does the patient want? O She’s not very keen on the idea of surgery and would prefer to see how things go O Other options could be smoking cessation advice, statins or weight loss

16. You have moved on to your next rotation in A+E O You pick up the next patient to clerk and it’s Mary. She has upper abdominal pain again. O None of her PMH, DH, FH or SH have changed O You take a HPC

17. HPC O Site: RUQ O Onset: Occurred gradually O Characteristic: gripping pain O Radiations: To the back O Associations: vomited, feels hot and sticky O Timing: 4 hours now O Exacerbating factors: nil O Severity: 8/10

18. You move on to examination

19. Abdo exam O Soft O Tender in the RUQ O Murphey’s sign positive O No masses

20. Obs O Temp:38.0 O Pulse: 105 O BP: 130/78 O RR: 16 O Sats: 99% on air

21. What investigations do you do?

22. O Urine dip O Bloods: FBC, U+Es, LFTs, G+S, bone, amylase O AXR O Erect CXR O Ultrasound (after senior review)

23. What do we expect on the bloods?

24. Bloods O WCC: 13.5 O Billirubin: NAD O ALP: 145 O AST: NAD O ALT: NAD O Amylase: NAD

25. Where do these blood test results suggest the stone is?

26. The cystic duct

27. So where are all these ducts?

29. (Aside) If the AST/ALT and billirubin were deranged, what would this suggest?

30. (Aside) O The stone would be in the common bile duct O And if this were the case, what additional symptom would we see?

31. (Aside) O Jaundice O An what procedure might we be able to use to remove the stone?

32. (Aside) O ERCP

33. Back to Mary O We get the AXR and erect CXR back O What do we expect to see?

34. AXR and errect CXR O NAD O Why havn’t we seen the gallstones?

35. USS O Thick walled gallbladder. Gallbladder is distended and a stone is visualised in the gallbladder with pericholecystic fluid. A stone is also visualised in the cystic duct.

36. Treatment (as a junior doctor)

37. O Pain relief O Antiemetics O NBM O IV fluids

38. Treatment (as a surgeon)

39. O Laparoscopic cholecystectomy O When?

40. O In a few days time, when the inflammation has begun to settle

41. Everything goes very well for Mary but some patients aren’t so lucky… O What complications can occur?

42. Complications O Pancreatitis O Empyema O Gallstone ileus O Mucocoele O Ascending cholangitis

43. Summary O Gallstones are usually asymptomatic but can produce pain (biliary colic) or infection (cholecystitis) O Risk factors for gallstones include being a female, being overweight, hypercholesterolaemia and T2DM O Laparaoscopic or open cholecstectomy or ERCP can be used in management