A case of upper abdo pain

1. A case of upper abdo pain Joanna Wykes, FY2

2. You are an FY2 in general practice • A 45 year old female called Mary attends with two episodes of upper abdominal pain. She has had one episode 5 months ago and another episode yesterday. • What do you want to ask in your history?

3. HPC • Site: RUQ • Onset: Built up gradually • Character: squeezing • Radiation: none • Associations: Mild nausea, no vomiting • Timing: lasted about 4 hours both times • Exacerbating factors: occurred after eating fatty food both times • Severity: 6/10

4. PMH • Hypercholesterolaemia • Obesity • Gastric band, Dec 2013 • T2DM • Hypertension

5. DH • Microgynon OD • NKDA

6. FH • Mother was told she had gallstones though they never seemed to trouble her

7. SH • Smoker 20/day • Alcohol 10 units/ week • Works as a receptionist

8. Examination… • Is completely normal

9. What is the diagnosis?

10. What is the diagnosis • Biliary colic

11. What will you do for the patient?

12. What will you do for the patient? • OP USS

13. USS • A solitary 2cm stone is found in the gallbladder. The gallbladder wall is not thickened. All other imaged organs are normal.

14. You phone the patient to tell her the news • It’s now 3 months since she came in to see you • She’s not had any pain since the last episode she told you about • What do you suggest?

15. Surgery/ watch and wait • What does the patient want? • She’s not very keen on the idea of surgery and would prefer to see how things go • Other options could be smoking cessation advice, statins or weight loss

16. You have moved on to your next rotation in A+E • You pick up the next patient to clerk and it’s Mary. She has upper abdominal pain again. • None of her PMH, DH, FH or SH have changed • You take a HPC

17. HPC • Site: RUQ • Onset: Occurred gradually • Characteristic: gripping pain • Radiations: To the back • Associations: vomited, feels hot and sticky • Timing: 4 hours now • Exacerbating factors: nil • Severity: 8/10

18. You move on to examination

19. Abdo exam • Soft • Tender in the RUQ • Murphey’s sign positive • No masses

20. Obs • Temp:38.0 • Pulse: 105 • BP: 130/78 • RR: 16 • Sats: 99% on air

21. What investigations do you do?

22. What investigations do you do? • Urine dip • Bloods: FBC, U+Es, LFTs, G+S, bone, amylase • AXR • Erect CXR • Ultrasound (after senior review)

23. What do we expect on the bloods?

24. Bloods • WCC: 13.5 • Billirubin: NAD • ALP: 145 • AST: NAD • ALT: NAD • Amylase: NAD

25. Where do these blood test results suggest the stone is?

26. The cystic duct

27. So where are all these ducts?

29. (Aside) If the AST/ALT and billirubin were deranged, what would this suggest?

30. (Aside) • The stone would be in the common bile duct • And if this were the case, what additional symptom would we see?

31. (Aside) • Jaundice • An what procedure might we be able to use to remove the stone?

32. (Aside) • ERCP

33. Back to Mary • We get the AXR and erect CXR back • What do we expect to see?

34. AXR and errect CXR • NAD • Why havn’t we seen the gallstones?

35. USS • Thick walled gallbladder. Gallbladder is distended and a stone is visualised in the gallbladder with pericholecystic fluid. A stone is also visualised in the cystic duct.

36. Treatment (as a junior doctor)

37. Treatment (as a junior doctor) • Pain relief • Antiemetics • NBM • IV fluids

38. Treatment (as a surgeon)

39. Treatment (as a surgeon) • Laparoscopic cholecystectomy • When?

40. In a few days time, when the inflammation has begun to settle

41. Everything goes very well for Mary but some patients aren’t so lucky… • What complications can occur?

42. Complications • Pancreatitis • Empyema • Gallstone ileus • Mucocoele • Ascending cholangitis

43. Summary • Gallstones are usually asymptomatic but can produce pain (biliary colic) or infection (cholecystitis) • Risk factors for gallstones include being a female, being overweight, hypercholesterolaemia and T2DM • Laparaoscopic or open cholecstectomy or ERCP can be used in management