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 / 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 Recurrent biliary colic without radiographic evidence of gallstones History of biliary type pain Normal ultrasound

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 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

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…