1. Case 1  40 year old female  Right quadrant pain that started 2 months age  The pain is precipitated by fatty meals, begin approximately 60 mins after eating and lasts for several hours.  On occasion, she feels the pain in the inferior aspect of the scapula, the shoulder, and the epigastrium  She frequently feels nauseous with pain  She has occasional emesis.  Ultrasound~ multiple stones

2. Case 1 (con’d)  During PE, she is found to have a tender right upper quadrant with mild guarding and a positive Murphy’s sign. Her temperature is 37.8C orally. Lab data showed a leukocyte count of 10000/mL, normal electrolyte levels, and a total bilirubin of 1.8mg/dL. Plain radiograph of the abdomen shows a normal bowel pattern but no stones.

3. Question ?  What are other possible diagnoses in this woman? GI tract~ peptic ulcer (gastric ulcer or duodenal ulcer ) duodenal diverticulitis T-colon or A-colon disease (diverticulitis or Chron’s disease) Pancreatitis Hepatobili~ liver abscess, acute cholangitis, CV ~ myocarditis, acute coronary artery disease. Lung ~ empyema, pleural effusion, pneumonia

4. Question?  Does the lack of an elevated white blood cell count and high fever rule out acute cholecystitis ? No. Murphy’s sign ~ 97.2 % sensitivity Frequently lacked fever and leukocytosis

5. Question ?  Does a negative abdominal radiograph rule out gallstone? Radiopaque ~ 15% Renal stone ~ 85%

6. Question ?  Are there any conditions associated with the formation of gallstones? In elderly patients, certain ethnic groups, women, immediate family members of a patient with choleithiasis, obese patients, diabetic patients, cirrhotic patients, patients with truncal vagotomy, patients receiving long-term total parenteral nutrition (TPN )

7. Question?  Should asymptomatic gallstones be treated? a.Not to treat cholelithiasis until symptoms develop. b.Morbidity and mortality rates of asymptomatic patients treated with observation versus cholecystectomy are similar. c.However ~~~ prophylactic cholecystectomy 1.children with gallstones (almost) 2.sickle cell disease (25%) 3.calcified gallbladder (50% GB cancer) 4.stone larger than 2.5cm (frequent) 5.non-functioning gallbladder (25%) 6.diabetes patient

8. Case 2 Tammy is a 24-year-old woman who goes to the ER on Sunday evening with lower abdominal pain. The pain started on Saturday afternoon as a general discomfort in her abdomen. She attributed the discomfort to beer and chips. She consumed at a foot ball game, but she became concerned when she woke up Sunday morning with a sharp pain in her right lower abdomen. She had no appetite for breakfast and had increasing pain throughout the day.

9. Case 2 (con’d)  In ER, her temperature n 37.9 C. Abdominal examination shows a non distended abdomen with hypoactive bowel sounds. There in involuntary guarding and rebound tenderness, and the right lower quadrant in exquisitely tender to palpation. The leukocyte count in 11.5K with 78% segmentation. Serum electrolytes, BUN-Cr ratio, bilirubin, and amylase are within normal limits. KUB radiograph shows normal gas pattern without any free intraperitoneal air. Urinalysis is unremarkable.

10. Question?  Is this presentation typical or atypical of appendicitis ? In second and third decade. M:F = 3:2 Classic pain : begin as a dull periumbilical discomfort, then settles in the right lower quadrant (RLQ) of the abdomen as a sharp pain occurring over a short time.

11. Question ?  What are other possible diagnoses in this young woman? GYN ~ inflammatory disease (PID), ectopic pregnancy, ovarian cyst rupture, Mittelschmerz, endometriosis, ovarian torsion, ovarian vein thrombosis GI tract ~ Crohn’s disease, cholecystitis, perforated ulcer, renal or ureteral calculi.