GI3 Case B Answers

A patient comes to your general surgery clinic, unexpectedly, with a number of radiologic/diagnostic studies that was done during a previous hospitalization, when she declined the curative therapy for her disease, due to extenuating circumstances, that has now come back to bother her again.

She hands you the following images.

An ultrasound:

"Four scans of different orientations through the gallbladder shows gallbladder wall thickening, pseudomembrane formation, sludge, and pericholecystic fluid." -Medscape

Your clinical fund of knowledge leads you towards a certain disease process even before the patient describes her story. You take one last look at the other imaging study she brought you and you recall what a normal study looks like.

"Normal cholescintigrams. Normal technetium-99m hepatic iminodiacetic acid (99mTc-HIDA) scans of the liver shows normal gallbladder filling within 45 minutes." -medscape

 Which makes you realize how abnormal her study is. See below.

Technetium-99m hepatic iminodiacetic acid (99mTc-HIDA) scan followed for 1 hour 30 minutes shows no filling of the gallbladder due to cystic duct obstruction.

So you start, as you normally do, by asking her for her story. :)

She said her pain started this morning after breakfast. She went to Hometown Buffet and had a large amount of cheese omelets, hash browns, and fried chicken. It was for her 40th birthday. She wanted to treat herself to an early celebration breakfast before getting treated out again for lunch. But, she never made it to lunch because her pain was so severe, even radiating to her shoulder, that she called your clinic to make a last minute appointment. She was in so much pain she vomited just before lunch and still feels nauseas now. She doesn't even have any appetite at all even though she last ate 8 hours ago. When prompted to point where she feels most of her pain, she moves her hand to the right upper quadrant. 

On physical exam, you note a positive Murphy's sign.

What is her diagnosis?

Acute Cholecystitis with possible obstruction in her cystic duct

You remember back in pathology and realize this woman satisfies many of the "F's" that you used as a mnemonic for memorizing the risk factors for this disease. Name 8 of these "F's" that are risk factors for cholelithiasis.

Female
Fat
Forty
Fertile
Flatulent
Familial
Fibrosis(cystic)
F-Hgb (sickle cell disease)

Name 4 bacteria implicated in overgrowth during stage 2 of this disease process. Which is the most common?

E.coli. Enterococci. Bacteroides fragilis, Clostridium sp

You review with her your diagnosis and she agrees with your plan to admit her and do a laproscopic cholecystectomy in 48-72 hours when her symptoms quiet down.

In your mind, you wonder if her histologic picture now fits a chronic presentation and you recall the following images you reviewed in pathology years ago. You remember the pathology because it predisposes her to a greater chance of perforation.
(Images from UTAS)

 

You get a call from the nurse, asking for more pain medication for your patient. You thought you already gave her an appropriate dose of an opiate analgesic, but you notice that the intern taking care of your patient ordered her morphine. What went wrong?

Morphine causes the sphincter of Oddi to contract and worsens pain. Use Meperidine for PAIN!