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Mrs Murphy, a 48 year old woman, was referred by her GP to the hospital with new-onset yellow discolouration of her skin.

History

Presenting complaint

“Well, I went to my GP because I’ve noticed that over the last week or two that my skin is getting more and more yellow. I didn’t think it was too bad, but my husband said that I was very yellow especially the whites of my eyes. I’m also getting a lot of abdominal pain, which has been getting much worse!”

What questions might be useful to elicit further details surrounding the presenting complaint?
           

When did you or your husband first notice you were yellow?

“My husband said he first noticed something was wrong about 12 days ago”

 

Have you been unwell recently? 

“No I’ve been pretty well for a while now.”

 

Have you noticed any other associated symptoms?

“Well I’ve had some on and off pain in my abdomen and my bowels have been a bit off, but other than that I’ve been ok, no fevers or anything like that.”

 

What’s changed with your bowels? 

Well they just seem a weird colour, pale I’d say, weird right?”

 

Have you had any urinary symptoms?

“My urine is definitely a lot darker, but other than that, no other changes”

Abdominal pain questions

Site – Where is this pain specifically?

“Here, on my side” (*she indicates her right hypochondrium*)

 

Onset – When did you first start experiencing the abdominal pain?

“It’s been on and off for a few months”

 

Character – What kind of pain is it? Is it sharp or a dull ache?

“It can be quite sharp actually, when it’s bad it can just completely stop me in my tracks.”

 

Radiation – Does it move anywhere else?

“It used to give me some back pain behind my right shoulder, but, now it’s only sore in the same place on my side.”

 

Associated symptoms – Do you experience any other symptoms when you have the abdominal pain?

“I often feel a bit nauseated when it’s happening, but that’s about it.”

 

Timing – How frequently are you experiencing the abdominal pain? 

“Well when it started a few months ago, I’d get the pain every week or so, but now I’m getting at least one or two bouts of pain a day.”

 

Exacerbating / Relieving factors – Does anything seem to trigger the pain or make it better?

“I know that if I eat a big dinner it will get more painful. I don’t eat much at all now because it makes me sore and a bit nauseous.”

 

Severity  – If you were to rate the pain out of 10, how bad would you say it is?

“Right now? I’d say 7 out of 10.”

What other parts of the history would be important to cover?

Past medical / surgical history:

  • Any medical conditions?
  • Have you ever had any previous hospital admissions?
  • Have you ever had surgery?
  • Have you ever had a blood transfusion?

“The only times I was ever in hospital were for the birth of my two children and for appendix surgery when I was a teenager. I never had a blood transfusion to my knowledge.”

 

Drug history:

  • Do you take any regular medication?
  • Have you started any new medication recently?
  • Do you take any over the counter medication?
  • Do you have any allergies?

“I just take a blood pressure tablet, can’t remember the name, but I’ve taken it for years. Other than that I don’t take anything. I don’t have any allergies.”

 

Social history:

  • How much alcohol would you drink in an average week?
  • Do you smoke? How much?
  • Have you ever taken recreational drugs? For example, drugs administered using needles?
  • Have you done any recent foreign travel?

“I would usually have a glass of wine each day with dinner. I’ve never smoked nor did recreational drugs. I was on holiday last summer but it wasn’t abroad.”

 

Family history:

  • Any illnesses in the family?

“Nothing really.”

What drugs might cause jaundice?

Flucloxacillin and co-amoxiclav are the most common causes of drug-induced jaundice. 

Others include paracetamol (in overdose), nitrofurantoin, steroids, oral contraceptive pill, tuberculosis drugs and malaria drugs.

Examination

What signs would you look for on examination?

General inspection 

  • Mrs Murphy is sitting on the bed. She is clearly jaundiced and looks uncomfortable.
  • She has a normal respiratory rate and is fully alert.
  • There are no adjuncts around the bed. She is overweight.

Abdominal examination

Eyes – Jaundice is noted in the sclera

Neck – No palpable lymph nodes

 

Abdomen:

  • Inspect: No significant distension
  • Palpation:
    • No organomegaly
    • No masses
    • Tenderness in the right upper quadrant
    • Murphy’s sign is +ve.
  • Percussion: Percussion tenderness over the RUQ
  • Auscultation: Bowel sounds present
What is Murphy’s sign? How do you elicit it on examination?

It is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the patient stops breathing in and winces with a ‘catch’ in breath, the test is considered positive. In order for the test to be considered positive, the same maneuver must not elicit pain when performed on the left side.¹

What is Courvoisier’s law? Why is it significant?

Courvoisier’s law states if a patient presents with jaundice and they have a non-tender, palpable gallbladder on examination, the cause is unlikely to be due gallstones. This is because gallstones form over a prolonged period, which results in a shrunken fibrotic gallbladder which does not distend easily. As a result the presence of jaundice and a palpable gallbladder should raise suspicion of malignant obstruction of the biliary tree (e.g. pancreatic).

What are Cullen’s and Grey Turner’s signs? What do they indicate?

Cullen’s sign is periumbilical bruising.

Grey Turner’s sign is bruising at the flank.

Both are visible on inspection.

They indicate retroperitoneal haemorrhage as a result a number of pathologies such as acute pancreatitis.

What is Mirizzi’s syndrome?

Mirizzi’s syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct, resulting in obstruction and jaundice. The obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis (inflammation).²

What is gallstone ileus?

This is when a cholecystoenteric fistula forms and a gallstone passes into the small intestine and obstructs the terminal ileum.

Differential diagnosis

What is your differential diagnosis?
  • Cholecystitis
  • Choledocholithiasis
  • Pancreatitis

Investigations

What blood tests would you perform?

Bloods:

  • Full blood count – Hb / Platelets / WCC
  • Serum lipase and amylase – rule out pancreatitis
  • LFTs
  • Coagulation screen – helpful to assess the liver’s synthetic function
  • U&Es – baseline renal function

Mrs Murphy’s blood results:

  • Hb 14 (13-18.5g/dL)
  • Platelets 175 (150 – 450 x109/L)
  • WCC 13 (4-11 x109/L) ↑
  • Na+ 136 (135-145mmol/L)
  • K+ 4.1 (3.5-5mmol/L)
  • Urea 5 (3-7mmol/L)
  • Creatinine 100 (62-106mmol/L)
  • Albumin 44 (35-50g/L)
  • PT and APTT: normal
  • Bilirubin 75 (<17µmol/L) ↑
  • ALT 29 (7-35 IU/L)
  • AST 26 (8-48 IU/L)
  • ALP 137 (45-115 IU/L) ↑
  • γGT 83 (<60 IU/L) ↑
  • Lipase 150 (114-286IU/L)
  • Amylase 80 (25-115 IU/L)
What imaging would you perform?

USS gallbladder – the gold standard

Abdominal x-ray -> not that useful as only 10% of gallstones are calcified are therefore visible.

CT abdomen with contrast – can be useful if other modalities fail however some gallstones are isodense to bile and therefore may be missed by CT.

MRCP – provides detailed imaging of the biliary tree – often used for pre-operative planning of surgery 

Gall bladder USS

USS Gallbladder6

Radiology report

“Large obstructing stone found within gallbladder neck. Thick hypoechoic gallbladder wall. Common bile duct dilated at 8mm.”

Diagnosis

What is the diagnosis?

Acute cholecystitis

Management

How would you manage this patient?

Initially acute cholecystitis is managed conservatively with:

  • Bed-rest
  • Gut-rest (nil by mouth)
  • Analgesia with NSAIDs and opiates
  • Antiemetics
  • IV fluids
  • Antibiotics (broad spectrum)

After initial treatment patients may either undergo an elective laparoscopic cholecystectomy, or an early cholecystectomy during their emergency admission.

References

Click to reveal

1. Murphy’s sign definition – https://en.wikipedia.org/wiki/Murphy%27s_sign

2. Mirizzi syndrome definition – https://en.wikipedia.org/wiki/Mirizzi%27s_syndrome

3. Greg McLatchie, Neil Borley, Joanna Chikwe (2013). Oxford Handbook Of Clinical Surgery. 4th ed. Oxford, UK: Oxford University Press. P311-321.

4. J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):1-7. doi: 10.1007/s00534-012-0566-y. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. Takada T1, Strasberg SM, et al.

5. Alasdair K.B. Ruthven (2010). Essential Examination. 2nd ed. Oxfordshire, UK: Scion Publishing Limited. p14-17.

6. USS image –  http://www.slideshare.net/shaffar75/ultrasound-of-acute-chronic-cholecystitis

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