Long Case

Personal history:

FATMA MOHAMED EBRAHIM is a 60 year old female patient from El

SHOHADAA district , She has one daughters and 2 sons. She is a
housewife and used to eat spicy food with no other special habits of
medical importance. She had her menopause at the age of 49.

Complaint:
She came to the university hospital complaining of upper right
abdominal pain for 3 months.

History of present illness:

The patient was doing well until 3months ago when she suffered
fromepigastric pain of suden onset, progressive course, intermittent
for 3 months. It was colicky in character, radiating to the back.
Assoiciated with vomiting twice .aggravated by intake of fatty meals
with abdominal distention and discomfort after fatty meal and
relieved with medications as(anti-spasmodic). The patient sought
medical advice and did abdominal US revealed 2 gall stones largest
one is 2 cm and was prescribed medications.
for the last 2 weeks the pain increased , localized to Rt hypocondrium
and the condition was no longer improved by medications.

The symptoms were associated by decreased appetite , heart burn

,vomiting, food content, no odor, no blood, preceded by nausea, non-
projectile, patient also had fever unmeasured but improved with
antipyretics.

No diahhrea, constipation or change in stool color.

No history of jaundice.

No history of excessive using NASIDS

No anorexia or weight loss.

Not diagnostic as DM

No urinary symptoms such as dysuria, polyria, hematuria,change in

urine color, or frequency of micturation..
Review of other systems is irrelevant.

Past History:
She patient had hepatitis C which was treated, her last investigation
(PCR) was negative for the virus..
No history of previous operations, blood transfusion, or
hospitalization. No history of drug allergy.

Family history:
Her father is hypertensive. -ve consanguinity with her husband.

Socioeconomic:
She lives in a 3 room home with her family, good ventilation, sunlight,
water supply and sewage disposal.

Examination
General Examination:

General: Patient is conscious, cooperative, well oriented to time

place and person; over weight She looks well, not lying comfortably
in bed due to pain in her upper abdomen.

Vital Signs:
Pulse: 80 Beat per minute, regular, average volume, no special
character.
Blood pressure:110/ 75 mmHg

_________________________

Local Examination:
Abdominal examination:

By inspection :

Distended symmetrical abdomen

Abdomen moves freely with respiration (thoracoabdominal)

Acute subcostal angle

 Epigastric pulsations cannot be seen

No divercation of Recti

 Umbilicus is inverted , slightly shifted downwards with no

discharge

Normal distribution of suprapubic hair

No visible peristalsis or dilated veins

 No scars or pigmentations

Normal back (no scars , swelling or pigmentations)

By palpation:
-Superficial palpation :

showed localized tenderness over the right hypocondrium.

No superficial masses felt.

slight rigidity.

-Deep palpation:

confirmed tenderness localized over the right hypocondrium

 No deep masses felt.

-Palpation of organs:

Liver : showed no enlargement

Gall Bladder : showed +ve Murphy's sign

spleen : cannot be felt

kidneys : showed no masses

 bladder : cannot be felt

By percussion:
No shifting dullness

No hyperresonance in abdomen

Tympanic traube's are

By auscultation:

 Normal intestinal sounds

No venous hum or Arterial bruit.

Provisional diagnosis:
58 years old female patient complaining of moderate pain in the Rt
hypocondrium intermittent for 3 months aggravated by fatty meals ,
most probably due to chronic calcular cholecytitis not complicated.

Differential diagnosis ( for Rt upper quadrant pain):

Cholecytitis

acute pancreatitis

acute appendicitis

hepatitis

Irritable bowel syndrome

Management:
Investigations:

Abdominal Ultrasound (Inv. Of choice)

Plain X-Ray

For excluding complications:

Liver function test (inc. bilirubin indicating CBD stone)

Kidney function tests

ERCP

For excluding SAINT'S triad:

endoscopy.

 barium meal.
_______________________

Treatment:
Cholecystectomy.

Probably by laparoscopy
 ____________________________________________________________________________________________

Scientific background

Cholecystitis is the sudden inflammation of the gallbladder. If this

condition persists over time, such as for months, with repeated
attacks, or if there are recurrent problems with gallbladder function,
it’s known as chronic cholecystitis.

The gallbladder is a small, pear-shaped organ located on the

underside of your liver. It stores bile made by the liver and sends it to
the small intestine via the to aid in the digestion of fats. The CBD
connects the liver, the gallbladder, and the pancreas to the small
intestine. Gallstones blocking the CBD are the leading cause of
cholecystitis. This blockage causes bile to build up in the gallbladder,
and that buildup causes the gallbladder to become inflamed.

If this happens acutely in the face of chronic inflammation, it is a

serious condition. The gallbladder could rupture if it’s not treated
properly, and this is considered a medical emergency. Treatment
usually involves antibiotics, pain medications, and removal of the
gallbladder.

Common causes for cholecytitis:

 Gall stones

Gallstones form when substances in the bile form crystal-like

particles. They can range from the size of a grain of sand to the size of
a golf ball. The presence of gallstones causes pressure, irritation, and
may cause infection. The walls of the gallbladder begin to thicken
over time. Eventually, the gallbladder starts to shrink. These changes
make it harder for the gallbladder to function properly.

 genetic predisposition
 weight
 gallbladder activity
 dietary habits

Symptoms of cholecytitis:

 severe abdominal pains that may feel sharp or dull

 abdominal cramping and bloating
 pain radiating back or below right scapula
 fever
 chills
 nausea
 vomiting
 loose, light-colored stools
 jaundice
 itching

Complications of cholecytitis:

 pancreatitis.
 perforation of the gallbladder as a result of infection
 enlarged gallbladder due to inflammation
 infection may cause the bile to build up
 cancer of the gallbladder (this is a rare, long-term complication)
 death of gallbladder tissue (this can lead to a tear and ultimately a
burst of the organ)

Treatment of cholecytitis:
Depends on the patient's condition , the severity of symptoms
and the presence of complications
The options include:
 broad-spectrum antibiotics for fighting infection
 oral dissolution therapy using medications to help dissolve
gallstones (this is typically a last resort, reserved for individuals
who cannot undergo surgery)
 pain relievers for controlling pain during treatment
 Surgery is often the course of action in cases of chronic
cholecystitis. Recently , gallbladder surgery is generally
done laparoscopically.