Question
A 47-year-old obese woman presented with on and off epigastric pain for 4 months. The pain was dull in nature and aggravated by fatty meals. Physical examination was essentially normal. Laboratory investigations showed normal liver function and white cell count. An abdominal x-ray was performed as a routine initial investigation.What can be the most possible diagnosis?
| A. | Gall Stone |
| B. |
Kidney Stone |
| C. |
Hepatic Calcification |
| D. |
Renal Tuberculosis |
Show Answer
|
Correct Answer � A Explanation |
 |
Ans:A.)Gall Stone
Image shows:Abdominal radiograph showing faceted calcification in the right upper quadrant suggestive of gallstone (arrow).
CHOLELITHIASIS
PATHOGENESIS:
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Stasis
|
PREDISPOSING FACTOR:
|
Cholesterol stones |
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Pigment stones
| Black pigment | Brown pigment |
|
|
Clinical Features:
- 5 Fs: Flat, Fertile, Flatulent, Female, Forty
- Commonest type of gall stone is mixed
- Childhood cholelithiasis is seen in Neimann Pick’s disease
-
Illeo cecal junction is the most common site of intestinal obstruction caused by a gall stone
- Biliary colic with periodicity, severe within hours after meal (commonest presentation)
- The Gall stone pain is referred to the shoulder through C3-05
- Dyspepsia is a common symptom
- Cholesterol stones are mostly radio-lucent
- Gall stones contains Cholestrol, Phosphate, Carbonate
- Pigment stones are mostly radio opaque
- No resolution of symptoms, fever and leucocytosis Acute cholecystitis
- The commonest site of obstruction in Gall stone ileus is Distal ileum
- Centre of the stone may contain radiolucent gas which is either triradiate (Mercedes Benz sign) or biradiate (Seagull sign)
- GB may be filled with toothpaste like material(calcium carbonate + phosphate) – limey gall bladder
- Bouveret’s syndrome or gallstone ileus- a large stone may erode directly into an adjacent loop of small bowel causing intestinal obstruction.
Management:
Management
- Investigation of choice – USG
- Best investigation for diagnosis of ampullary gall stone with obstructive jaundice is ERCP
- 10% Percent of gall stones are radio opaque
- Prophylactic cholecystectomy can be considered in
- Diabetic patients
- Congenital haemolytic anemia
- Patients undergoing Bariatric surgery
- The treatment priority should focus on relief of obstruction and not on gall bladder and its fistulous communication
- Multiple Gall stones & 8 mm dilation with 4 stones in CBD, best treatment modalities are Cholecystectomy with choledocholithotomy at same setting
- Elective open cholecystectomy for cholelithiasis is the surgical procedures is considered to have a clean-contaminated wound
- Cholecystectomy if it is asymptomatic but develops biliary colic
- Symptomatic gallstones are the main indication for cholecystectomy.
- Absolute contraindications for the procedure are uncontrolled coagulopathy and end-stage liver disease.
- Medical therapy for gall stone dissolution utilizes two bile acids
- Ursodeoxycholic acid (UDCA)
- Chenodeoxycholic acid (CDCA)
- For patients with serious comorbid conditions not responding to conservative treatment – percutaneous cholecystostomy is performed under USG control, which will rapidly relieve the symptoms. A subsequent cholecystectomy is usually required
- Recurrent attacks of cholelithiasis, U/S examination shows a dilated CBD of 1 cm is best treated with ERCP
- Surgery: lap cholecystectomy or open cholecystectomy through right subcostal Kocher’s incision
- Open cholecystectomy for cholelithiasis is considered a clean contaminated wound
- Indication for medical treatment in gall stone is stone
- size less than 15mm,
- Radioluscent stones,
- Functioning gall bladder,
- Non acute symptoms
