Painful gallstone removal?

*For medical professionals to read and reference, there will be a small gift at the end of the article~ Dr.
Xiao Jiang "Dr.
Yang, come and look at the 3-bed patient who was admitted to the hospital today.
The upper abdominal pain is very severe!" Dr.
Xiao Jiang from the department trotted into the office and hurriedly said
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Case review: strange abdominal pain This is a patient with gallstones and cholecystitis who has just been admitted to the hospital.
A 58-year-old female was admitted to the hospital because of "distending pain in the right upper quadrant for 12 hours"
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After eating greasy food 12 hours ago, persistent pain in the right upper quadrant, paroxysmal exacerbation, no radiating pain, accompanied by nausea and vomiting; no chills, fever, chest tightness, chest pain, no cough, expectoration, no diarrhea, frequent urination, Urinary urgency and other symptoms
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She had a history of "cholecystolithiasis and cholecystitis" for many years, and had performed gallbladder-preserving lithotripsy
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Denied "hypertension, coronary heart disease, diabetes" history
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Physical examination on admission: body temperature 36.
2°C, pulse 74 beats/min, respiration 20 beats/min, blood pressure 140/90 mmHg, clear consciousness, no yellowing of the skin and sclera of the whole body, no rales in both lungs, heart rate 74 beats/min, regular rhythm, No noise
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The abdomen was flat, with no gastrointestinal type and peristaltic waves, soft abdominal muscles, positive right upper quadrant tenderness, no rebound tenderness, no palpation of the liver and spleen under the ribs, positive Murphy sign, and normal bowel sounds
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At this time, some of the patient's inspection reports have been published: blood routine: white blood cells: 11.
72*109/L, neutrophil ratio: 90.
9%; blood biochemistry: glutamyl transpeptidase: 46.
2IU/L, alanine aminotransferase: 59.
2IU/L, calcium: 2.
59mmol/L, magnesium: 0.
53mmol/L, glucose: 8.
68mmol/L, uric acid: 491umol/L, cholesterol: 6mmol/L, blood amylase: 165 IU/L; C-reactive protein : <5.
00mg/L; triple myocardial infarction: normal; new coronavirus nucleic acid test: negative (-); electrocardiogram: 1.
Sinus tachycardia, 2.
Incomplete right bundle branch block
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When Xiao Jiang and I came to the ward, the patient's expression was in pain and felt like she was on pins and needles.
She had already squatted on the ground and asked for painkillers
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On admission, abdominal CT showed: gallstones and acute cholecystitis
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After anti-inflammatory, antispasmodic and other symptomatic treatment, why did the abdominal pain not relieve, but became more serious? Figure 1 Abdominal CT at admission: gallbladder stones, acute cholecystitis Xiaojiang looked puzzled and asked: "Will there be other conditions? For example, biliary pancreatitis, gastrointestinal perforation and other diseases
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" It also makes sense, the patient has abdominal pain Severe, requires differential diagnosis! However, acute pancreatitis is often triggered by eating greasy food and drinking alcohol, and manifests as persistent and severe pain in the upper abdomen, nausea, and vomiting, and may be accompanied by fever.
Blood and urine amylase can be significantly increased, and abdominal CT can confirm the diagnosis
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When the patient was admitted to the hospital, abdominal CT showed no pancreatic enlargement and peripancreatic exudation, no free gas under the diaphragm, nor high blood amylase, so pancreatitis and gastrointestinal perforation were not considered for the time being
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Figure 2 Abdominal CT at admission: The patient with no abnormality in the pancreas had unbearable pain.
We still gave her a strong pain medication, but the effect was still not obvious
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Although the abdominal muscles are not tight, the patient is still tossing and turning and moaning loudly from time to time
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The desired effect was not achieved, and the patient expressed dissatisfaction and strongly demanded that he be referred to surgery for cholecystectomy
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The patient had a history of cholecystolithiasis and cholecystitis, and had undergone gallstone preservation
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China's latest edition of "Expert Consensus on Surgical Treatment of Benign Gallbladder Diseases (2021 Edition)" pointed out that cholecystectomy is recommended for patients with gallbladder stones regardless of symptoms; cholecystectomy is the only curative method for benign gallbladder diseases; Benign disease implementation of "biliary preservation surgery"
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The patient's choice is appropriate regardless of personal preference or expert consensus
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So, we sent the patient to the hepatobiliary surgery
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Transfer to a department for treatment: CT re-examination was still undiagnosed, and the patient was followed up the next day with a lot of suspicion.
It happened to be the round of the superior doctor, and the patient still complained of abdominal pain
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But at this time, the pain in the right upper quadrant was relieved than before, but there was obvious pain in the right lower quadrant, and the abdominal muscles were a little tense.
The tenderness and rebound tenderness of McBurney's point were all positive.
It seems that the condition is a bit strange! Everyone spoke and discussed
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"Metastatic right lower quadrant pain, this is likely to be acute appendicitis, peritonitis symptoms have appeared, please consult the gastrointestinal surgery immediately!" "Although the pain has transferred to the right lower quadrant, the patient still has right upper quadrant pain, could it be? Is it caused by inflammatory exudation?" "The possibility of acute appendicitis is still very high, and surgery is unavoidable.
Please transfer to the department after consultation!" The consulting physician was very quick, and arrived at the ward a few minutes later.
After the examination, it was indicated that: gallstones with acute cholecystitis exist objectively, and acute appendicitis cannot be ruled out, but objective evidence is needed, and abdominal CT needs to be reviewed
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At present, the diagnosis is foggy.
Is it cholecystitis or appendicitis, or cholecystitis combined with appendicitis? there is only one truth! Apart from that, the patient immediately performed a full abdominal CT, and the results showed: gallbladder stones, acute cholecystitis, fluid in the abdominal cavity and pelvis, and no abnormality in the appendix
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Figure 3 Review abdominal CT showed: gallbladder stones, acute cholecystitis, abdominal cavity, pelvic effusion Figure 4 Review abdominal CT showed: no abnormality in the appendix The results of the review CT made everyone in trouble again! Is this acute appendicitis? What is the explanation for metastatic right lower quadrant pain? Is abdominal and pelvic effusion just inflammatory exudation? Was it complicated by other conditions, such as a gallbladder perforation? But imaging has not been supported, what should be the next step? You are welcome to express your personal academic opinions in the comment area, and the author's teacher will answer it at that time, and readers who get the teacher's comment will send a New Year's gift~ The answer will be revealed to everyone at 7:30 tomorrow! Welcome everyone to pay attention to the Digestive Liver Disease Channel in the medical community
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