Identification/Demographic Data

Patients name : Mr CHBZ

R/N : 13296

Date of admission :
6/4/2016

Age : 65 years old

Gender : Male

Date of clerking :
8/4/2016

Ethnic : Malay

Occupation : businessman

Address : Tanah Merah

Status : married

Chief Complaint
Mr. CHBZ, 65 years old Malay Male, working as businessman, living in Tanah
Merah came to the hospital with right hypochondriac pain for three days.
History of Presenting Illness
On 4 April 2016, patient was admitted to the ward with complaint of pain at the
right hypochondrium region on the abdomen for three days. The pain was gradually
increased and worsened on the third day. He characterized the pain as burning pain.
He experienced intermittent pain for the past three days and the pain did not radiate
to anywhere else in the body. Duration of pain lasted for one hour but he did not
remember the exact frequency of the pain throughout the three days. He also
complained that the pain became worse when he was moving or coughing. The pain
even affected his daily activities and work and he took medical leave for past three
days. He needed to lie down to relieve the pain. The pain was quite severe and he
characterized the severity of the pain with a scale of seven out of ten where zero is
not in pain and ten is the most severe pain.
On further clerking, he went for a consult with a general practitioner regarding
his pain on the first day of his illness. He was treated as gastritis and was prescribed
with gastric medication, as he described it as a white chalky liquid. However, there
was no improvement for the pain to relieve.
The right hypochondriac pain is also associated with vomiting and low-grade
fever. He described the vomiting occurs two times on the day before admission and the
vomitus consisted of food particles with no blood or bile. He has low-grade fever on
the day before admission to the ward with chills & rigors.

He denied any tea-coloured urine and pale stool for the past three days before
the admission. He also denied any nausea, diarrhoea, constipation, loss of appetite,
loss of weight, alteration of bowel habit, dysphagia or haematemesis.
Systemic Review
Cardiovascular System
He denied any chest pain, palpitations, orthopnoea, paroxysmal nocturnal dyspnoea or
ankle oedema.
Respiratory System
He complained of coughing. However, he denied any shortness of breath, haemoptysis,
wheezing or night sweats.
Urinary System
He denied any dysuria, passing tea-coloured urine, urinary incontinence, or frequency.
Central Nervous System
He complained of headache. However, he denied any dizziness, syncope, blurry vision
or double vision.
Musculoskeletal System
He denied any joint pain or back pain.
Past Medical and Surgical History
He was a known hypertensive and diabetic patient when he was diagnosed last
year at Klinik Kesihatan Tanah Merah. He was still on follow-up at the Klinik Kesihatan.
He was diagnosed with asthma for four years and still under medication. His last
attack of acute exacerbation was last year.
For his surgical history, this was his first time hospitalized.

Drug History

Regarding his asthma, he was prescribed with ventolin inhaler, only using it if he
has an acute exacerbation, which occured last year.
He was also under medication of perindopril 2mg od for his hypertension and
metformin 250 mg bd for his diabetes and he said he had compliance towards his
prescription. Patient showed the drugs to me as he did not remember the name of
drugs exactly.
He denied any medications from pharmacy or traditional medicine. He had no
allergy towards any drugs.
Family History
He was a single son in his family and his parents died of unknown reason but
most probably due to aging. His children were all healthy. There was no family history
of hypertension, cardiac disease, diabetes, asthma and malignancy.
Social and Personal History
He lived with his wife who had hypertension and four children. He lived in the
first floor of a double-storey terrace house. He never smoked and consumed alcohol.
He had no allergy to any food. He also denied any abdominal pain or vomiting after
taking oily or fatty food. The vomiting was also not associated with heavy post-meal.
Summary
Mr. CHBZ, a 65-year old diabetic and hypertensive man was presented with
severe burning right hypochondriac pain associated with fever and vomiting 3 days
prior to admission. The pain worsens when the patient was moving and coughing.
However, he denied that the pain was not aggravated by oily or fatty food. The
vomiting contained food particles and the fever was associated with chills and rigors.

PHYSICAL EXAMINATION

General Inspection
Patient is conscious, alert & orientated to time, person & place. The patient was
lying flat comfortably in supine position supported with one pillow. He did not look ill.
He was not in pain or respiratory distress and his hydrational and nutritional status was
adequate. There was no muscle wasting, no gross deformity and he was not obese.
There was a branula attached to his right wrist.
General Systemic Examination
Vital signs
Pulse rate

: 89 beat per minute, normal volume, regular rhythm

Blood pressure

: 136/65 mmHg

Respiratory rate

: 18 breaths per minute

Temperature

: 38.9 C

Impression
temperature

: Normotensive, normal pulse & respiratory rate, normal body

Hands
Palms were dry, warm and pink. There was no sign of pallor. There was no
presence of palmar erythema. From inspection of the fingers and nails, there was no
peripheral cyanosis. There were no finger clubbing, no leuconychia and no koilonychia.
Head and Face
From inspection, there is no superficial or dilated veins at face and no spider
naevi. Conjunctiva was pink and the sclera was white. From inspection of the mouth
and tongue, the tongue was coated, no glossitis and angular stomatitis. There was no
central cyanosis and oral hygiene was good.
Neck
There was no gross enlargement of thyroid. Jugular venous pressure was not
elevated and carotid artery was palpable. There was no carotid bruit heard.

Chest Wall and Axillae

There was no spider naevi, gynaecomastia and axillary hair loss.

Heart sounds revealed dual rhythms sound and no murmur heard. Other
abnormality was not found on examination.
Lower Limb
There was no pitting oedema.
Specific Abdominal Examination
Inspection
The abdomen was symmetrical and not distended. Abdomen moves with
respiration and pattern of respiration is abdomino-thoracic. The umbilicus was inverted
and centrally located. There were no striae, no surgical scars, no prominent and
dilated veins, no skin discolouration, no visible peristalsis, no pulsation and no obvious
mass seen.
Cough impulse shown right reducible inguinal hernia, measuring 5x5 cm in
diameter. Upon further questioning, the patient said that the hernia was noticed ten
years ago but he never went to hospital for follow-up.
Palpation and Percussion
Upon superficial palpation, the abdomen was soft and tender at right
hypochondrium and right lumbar region on the abdomen.
Upon deep palpation, the liver was palpable with two finger breadths below
the costal margin. The spleen was not palpable. The kidney was not ballotable.
There was no palpable mass found on the abdomen. Other parts of the abdomen
were soft and normal.
Upon percussion, the abdomen was resonance except the part where the
liver was palpable and at the left iliac region on the abdomen.
Murphys sign was negative. There was no shifting dullness and fluid thrill
was negative.
Auscultation
There was increased bowel sound heard. There was no renal artery bruit heard.
Per rectal examination and genitalia examination were unremarkable.
All other systems were unremarkable.

Provisional diagnosis

Acute cholecystitis

Points for

Points against

Severe burning and colicky

pain
in the
right
upper quadrant of

Hepatomegaly,
headache,

abdomen, vomiting,
fever
associated with chills and
rigors,
jaundice,

tender

hypochondrium

right

coughing

Differential diagnosis
Differential
diagnosis
Chronic
Cholecystitis

Points for

Points against

Colicky pain in the right

upper
quadrant of abdomen,
vomiting,

Repeate acut
d
e
cholecystitis
and biliary colic, pain
worsen
meals
after
,
recurrent
flatulenc
e,
fatty
food
intolerance, feeling
of
distension, heartburn

jaundice

Ascending
cholangitis

Choledocholithiasi
s

Severe pain in the

uppe Look very ill, pain worsen
right
r after eating spicy or fatty
abdomen
food
quadrant of ,
fever
associate
with
d
chills
and
rigors, vomiting,
jaundice
No pale stool, no stone
Colicky pain in the right
presented at the bile
upper
duct in ultrasound
fever
quadrant of abdomen,
,
vomiting

Cholangiocarcinoma Pain
abdomen, chills, fever

in

the

upper right No loss of appetite, no

abnormal mass presented
at the
bile duct in ultrasound

Hepatitis
right

Abdominal pain at upper

quadrant, jaundice, fever,
vomiting, hepatomegaly

No yellowing of the skin,

no ascites, no generalized
itching at the body, no
loss of apetite

Final diagnosis
Acute cholecystitis secondary to cholelithiasis

LABORATORY INVESTIGATIONS
Full Blood Count
Objective:

To check for any sign of anaemia or underlying infection

Type of specimen: Whole blood

Results

Normal range

Haemoglobin

13.6 g/dL

13.0 18.0

Haematocrit

41.2 %

40.0 54.0

Platelet

235 x 109/L

150 400

Total White Blood Cells

18.3 x 109/L

4.0 11.0

Percentage of Neutrophils

73 %

40 75

Impression : Total white blood cell count and neutrophils were increased which
might be due to infection. Haemoglobin and haematocrit level were slightly low which
might be due to anaemia.
Liver Function Test
Objective:

To rule out any jaundice, liver disease or liver dysfunction

Type of specimen:

Whole blood
Results

Normal range

Total Protein

80 g/L

64 83

Albumin

40 g/L

35 50

Globulin

40 g/L

34 50

Albumin/Globulin Ratio

1.00

Total Bilirubin

40.3 mol/L

3.4 20.5

Alanine Transaminase

22 U/L

<44

Alkaline Phosphatase

60 U/L

40-150

Impression : Total bilirubin was markedly increased which indicates

hyperbilirubinaemia. This may lead to jaundice.

Renal Profile
Objective:

To monitor level of fluid loss and renal function

Type of specimen:Whole blood

Results

Normal range

Urea

5.1 mmol/L

3.2 9.2

Sodium

132 mmol/L

3.2 9.2

Potassium

3.7 mmol/L

3.5 5.1

Chloride

95 mmol/L

98 107

Creatinine

96 mol/L

62 115

Impression : Slight low level of chloride indicates there was electrolyte imbalance
occurred to the patient.

Other Tests
Tests

Results

Normal range

Serum Amylase

54 U/L

25 125

Calcium

2.19 mmol/L

2.10 2.55

Magnesium

1.04 mmol/L

0.85 1.05

RADIOLOGICAL INVESTIGATIONS
Chest X-ray
Impression: Minimal right sided perihilar haziness was seen on erect view chest
X-ray. There was no perforated gasterointestinal viscus seen and no gas bubbles seen
at below of the diaphragm.

Abdominal X-ray
Impression: Faecal loaded was seen at the left iliac region. There
was no sign of intestinal obstruction.
Ultrasound of Hepatobiliary System
The liver had a normal homogenous parenchymal echotexture with
raised echopattern. There was no focal lesion within the parenchyma.
There was no biliary tree dilatation. The portal vein and common bile
duct were normal in calibre.
However, the gallbladder wall was thickened and blurred in
outline. Multiple stones of varying sizes were seen in the gallbladder.
The largest stone measured about 2.5 cm in diameter. There was
associated pericholecystic fluid denoting underlying inflammation of the
gallbladder.
The visualised pancreas and the spleen were normal.
DISCUSSION
V.

Physiology of bile acids

The physiology of bile acid formation can be simplified by the
figure below:
(Bacte
r
i
a
l

Liver
Cholesterol Bile acids (0.20.6g/24hr)

Gallbladder
(Bile 5
10mmol)

d
e
g
r
a
d
a
t
i
o
n
&

Intestine

ormation of secondary
bile acids)

Faeces
(0.2
0.6g/hr)

Figure 1: Enterohepatic circulation of bile acids

Serum
(2
5mol/L)

Renal
clearance
(Urine
8mol/24hr)

VI.

Risk factors of gallstones/cholelithiasis

Middle-aged (>40), obese, multiparous women
Familial cholelithiasis in tribes of North Americal Indians because small
bile salt pool and Chileans because high cholesterol excretion
High calorie or high cholesterol diets which can produce supersaturated
gallbladder bile
Drastic weight reduction and diets to lower cholesterol which can lead to
mobilization of cholesterol and increased cholesterol excretion
Disease or resection of terminal ileum which favours cholesterol
nucleation by reducing bile salt pool
13

 Drugs such as cholestyramine, oral contraceptive pills, diuretics and

clofibrate which give effect of bile salt depletion
Pregnancy can increase bile stasis within gallbladder
Other metabolic conditions such as diabetes, cystic fibrosis, familial
hyperlipidaemia may increase plasma cholesterol which in turns produce
more bile cholesterol
VII.

Pathogenesis of gallstones
The pathogenesis of gallstones formation can be explained by the figure below:
Formation of cholesterol crystals

Cholesterol nucleation
due to combination of cholesterol molecules with particles of mucus,
bacteria, calcium bilirubinate or mucosal cells

Excessive cholesterol excretion, reduction in amount of bile salt, lecithin

available for micelle formation, bile is concentrated in gallbladder
(favoured by stasis or decreased gallbladder contractility)

Bile becomes supersaturated with cholesterol

Gallstone formation
Figure 2: Formation of gallstone
VIII.

Acute cholecystitis
It is an acute inflammation of gallbladder. It occurs when there is an
obstruction at the neck of gallbladder or cystic duct by a stone and is
associated with infection and thus causes systemic illness.

14

This will cause severe right hypochondriac pain radiating to the right scapular
region and to the back. The pain usually associated with other symptoms such
as fever, tachycardia, nausea, vomiting, chills and rigors.
Upon physical examination, there is often generalized abdominal tenderness
and rigidity and most markedly felt over the gallbladder. Murphys sign is
usually present in patient with very inflamed gallbladder.
The results of laboratory investigations may show leukocytosis as a sign of
bacterial infection. Raised total bilirubin may indicate obstructive jaundice as
presence of gallstones.
Based on findings of ultrasound of the abdomen, multiple stones are present
usually in the neck of gallbladder or cystic duct. The wall of gallbladder is also
thickened with pericholecystic fluid indicating inflammation of gallbladder.
Usually, 90% of the case is settled down with conservative treatment by
keeping the patient nil by mouth, replacing intravenous fluids, giving
antibiotics and painkiller and nasogastric suction is performed if appropriate.
However, 10% of the case may develop disease progression with life-threatening
complications such as gallbladder empyema, gangrene and perforation which
will require surgical intervention such as open cholecystectomy.

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REFERENCES
Subashini CT, Intan NS & Zalinah A. Problem Based Learning: Gallstone. Universiti
Putra Malaysia, 2012, 13-21.
Zulkhairi A. Physiology of the Bile. Universiti Putra Malaysia, 2011, 7-12.
Razana MA. Biliary Tract and the Exocrine Pancreas. Universiti Putra Malaysia, 2011,
7-12.
Williams NS, Bulstrode CJK & OConnell PR. Bailey & Loves Short Practice of Surgery
(25th ed.). Hodder Arnold, 2008, 1119-1126.
Isman H et al. USM History Taking & Physical Examination (2nd ed.). NADI Corporation,
2006, 95-103.
Norman LB, John B, Kevin GB & William EGT. Browses Introduction to the Symptoms
and
Signs of Surgical Disease (4th ed.). Hodder Arnold, 2005, 398-399.

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