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…