MosaicED Brain Teaser!
It's early morning in ED and you're at the end of a long night shift. You're so tired you haven't noticed that the good looking nurse you've been flirting with for the past hour is actually an US machine. A 40 year old woman presents to ED with RUQ abdo pain coming in waves and right shoulder pain. She has had similar pain like this before and is due for elective surgery in 3 weeks.
Which one of below is not a risk factor for her ailment?
- A-Being a woman
- C-Have multiple kids
- D-Middle aged
Answer:F-Premenopausal. The patient most likely cholelothiasis. The main risk factors for cholelothiasis are Fair (it's more common in white people), Fat (BMI >30), Female, Fertile (multiparous), Forty (>40 years), some people also include Familial or sub it for Forty. In this presentation without fever it is likely uncomplicated. It is important to understand the terminology; gallstones = cholelothiasis, inflamed gall bladder = cholecystitis, infected bile duct = cholangitis or ascending cholangitis, gall stones in the bile duct= choledocolothiasis, gallstones in the gall bladder = colic pain, gallbladder mucocele = mucous filled and distended gall bladder, gallstone ileus = Gallstone blocking the ileum. There are three types of stone; cholesterol stone, pigment stone, and a mixed stone (most common). They are caused by genetic factors, stasis, and/or hypercholesterolaemia. Pathogenesis: bile supersaturated with cholesterol causes accelerated cholesterol crystal nucleation, combined with gallbladder hypomotility. Common opportunistic bacteria: E. Coli ("Coliform”, gram negative enterobacter), Klebsiella (“Coliform”, gram negative enterobacter), Enterococcus faecalis(gram positive). Signs and symptoms: previous episode of biliary pain, RUQ pain, colicy pain (pain comes in waves), positive murphy’s sign (patient breath out, place hand over gallbladder, pain when patient breaths in), abdominal mass. Less common signs and symptoms: right shoulder pain (referred phrenic nerve pain), anorexia, nausea, vomiting, jaundice, fever - rigors suggest pyelonephritis, pneumonia, or ascending cholangitis. Investigations: LFTs (bilirubin >200 - suggests tumour rather than stones), FBE, Abdominal Ultrasound. Differentials: cholecystitis, ascending cholangitis (Charcot's triad: pain, fever, jaundice), Courvoisier’s law (enlarged non tender gallbladder with mild jaundice is unlikely to be gallstones - head of the pancreas cancer), duodenal ulcer, and hepatitis. Complications: pancreatitis, pseudomonas infection (green and smelly). Treatment is a cholecystectomy. Not done on an acutely ill patient unless it's an emergency. Post surgery diarrhoea is common, is usually due to bile salt malabsorption. responds well to cholestyramine (questran). There is a 1% chance that gall bladder is malignant so always check removed gallbladder. Always cholangiogam for choledocolothiais and gall duct safety and check bile duct anatomy to see if everything is okay - stones, leaks and drainage. Calot’s triangle/Cystohepatic triangle: Superior: inferior border of the liver, Lateral: cystic duct, Medial: common hepatic duct, The cystic artery travels through the triangle, Lund’s Node is inside the triangle and is removed in cholecystectomy.