a case of upper abdo pain joanna wykes, fy2. you are an fy2 in general practice o a 45 year old...
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A case of upper abdo painJoanna Wykes, FY2
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You are an FY2 in general practice
O 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.
O What do you want to ask in your history?
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HPCO Site: RUQO Onset: Built up graduallyO Character: squeezingO Radiation: noneO Associations: Mild nausea, no vomitingO Timing: lasted about 4 hours both timesO Exacerbating factors: occurred after
eating fatty food both timesO Severity: 6/10
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PMHO HypercholesterolaemiaO ObesityO Gastric band, Dec 2013O T2DMO Hypertension
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DHO Microgynon ODO NKDA
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FHO Mother was told she had gallstones
though they never seemed to trouble her
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SHO Smoker 20/dayO Alcohol 10 units/ weekO Works as a receptionist
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Examination…O Is completely normal
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What is the diagnosis?
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What is the diagnosisO Biliary colic
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What will you do for the patient?
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What will you do for the patient?
O OP USS
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USSO A solitary 2cm stone is found in the
gallbladder. The gallbladder wall is
not thickened. All other imaged
organs are normal.
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You phone the patient to tell her the news
O It’s now 3 months since she came in to see you
O She’s not had any pain since the last episode she told you about
O What do you suggest?
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Surgery/ watch and wait
O What does the patient want?
O She’s not very keen on the idea of surgery and would prefer to see how things go
O Other options could be smoking cessation advice, statins or weight loss
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You have moved on to your next rotation in A+E
O You pick up the next patient to clerk and it’s Mary. She has upper abdominal pain again.
O None of her PMH, DH, FH or SH have changed
O You take a HPC
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HPCO Site: RUQO Onset: Occurred graduallyO Characteristic: gripping painO Radiations: To the backO Associations: vomited, feels hot and
stickyO Timing: 4 hours nowO Exacerbating factors: nilO Severity: 8/10
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You move on to examination
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Abdo examO SoftO Tender in the RUQO Murphey’s sign positiveO No masses
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ObsO Temp:38.0O Pulse: 105O BP: 130/78O RR: 16O Sats: 99% on air
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What investigations do you do?
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What investigations do you do?
O Urine dipO Bloods: FBC, U+Es, LFTs, G+S, bone,
amylaseO AXRO Erect CXRO Ultrasound (after senior review)
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What do we expect on the bloods?
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BloodsO WCC: 13.5O Billirubin: NADO ALP: 145O AST: NADO ALT: NADO Amylase: NAD
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Where do these blood test results suggest the stone is?
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The cystic duct
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So where are all these ducts?
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(Aside) If the AST/ALT and billirubin were deranged, what would this suggest?
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(Aside)O The stone would be in the common
bile duct
O And if this were the case, what additional symptom would we see?
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(Aside)O Jaundice
O An what procedure might we be able to use to remove the stone?
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(Aside)O ERCP
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Back to MaryO We get the AXR and erect CXR back
O What do we expect to see?
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AXR and errect CXRO NAD
O Why havn’t we seen the gallstones?
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USSO 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.
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Treatment (as a junior doctor)
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Treatment (as a junior doctor)
O Pain reliefO AntiemeticsO NBMO IV fluids
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Treatment (as a surgeon)
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Treatment (as a surgeon)
O Laparoscopic cholecystectomy
O When?
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O In a few days time, when the inflammation has begun to settle
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Everything goes very well for Mary but some patients aren’t so lucky…
O What complications can occur?
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ComplicationsO PancreatitisO EmpyemaO Gallstone ileusO MucocoeleO Ascending cholangitis
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SummaryO Gallstones are usually asymptomatic
but can produce pain (biliary colic) or infection (cholecystitis)
O Risk factors for gallstones include being a female, being overweight, hypercholesterolaemia and T2DM
O Laparaoscopic or open cholecstectomy or ERCP can be used in management