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It will, it won’t but it might…

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Presentation on theme: "It will, it won’t but it might…"— Presentation transcript:

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…



11 Acalculus cholecystitis.
No other causes Recurrent biliary colic without radiographic evidence of gallstones History of biliary type pain Normal ultrasound

12 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

13 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

14 Investigations? As for suspected gallstone disease
Cholecystokinin cholecystography Tc99 labelled HIDA scan Problems??

15 Management. Influence of investigations Recommendations vary
Long term outcomes of cholecystectomy

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

17 It will, it won’t, it might…
It did…

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

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