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It came as a distress call from a colleague with respect to a lady aged 40 years and in severe right upper abdominal pains. The pains were intermittent or rather colicky in nature. The type you’d find in an organ that has a lumen when it is diseased. In addition to this, there was a significant bulge in the right hypochondria area where the liver is situated. It was tender when palpated.
The patient prior to coming to the hospital had bouts of fever. She was adequately treated for malaria at home by a nurse. Of clinical significance was that she not jaundiced at the time of presentation. The severity of the pains was out of proportion to the clinical picture the patient presented with.
The pains had to be taken care of with strong analgesics and anti-spasmodic. This was followed with a barrage of investigations as requested by her. She could afford them. These included abdominal ultrasound scan, X-ray, CT-scan and Magnetic Resonance! Honestly left to this caregiver, Ultrasound scan was enough to make a definitive diagnosis as an option of surgery was already in the pipeline. When the results came in, the findings were no different from the early clinical impression. The lady had stones in the gall bladder, a condition known as Cholelithiasis, which caused the gall bladder being inflamed and infected. This condition is known as Cholecystitis.
Having ascertained the diagnosis, we simply walked away and rescheduled the surgery. There is NO emergency gall surgery and procedures in the gall bladder are NOT LIFE SAVING. In other words, if the surgery is deferred the patient is not likely to die. It is always safe to have a full complement of the surgical team, including the Anaesthetist when doing a gall bladder.
This is simply because the anatomical disposition of the gall bladder varies a lot. There are instances where the gall bladder is completely buried in the liver parenchyma. So it is commonplace for surgical procedure and approaches to be altered along the way.
For our index case, it was relatively simple. The bulge in the anterior abdominal wall just happened to be the FUNDUS of the thickened gall bladder. When explored further, it was observed that the cystic duct was almost non-existent as it had almost fused with the hepatic duct as the COMMON BILE DUCT, as it inserts in the first portion of the small intestine known as the duodenum and opens into the lumen as the ampulla of Vater. The safest surgical option was to perform a cholecystectomy. This basically involved the opening up the gall bladder at the fundus and emptying the content. Bleeding is arrested and a surgical drain is left in the raw bed after removing some part of the gall bladder wall. Some caregivers may use the opportunity to remove the appendix if it is looking suspicious. We didn’t have to do that as it had been previously done.
For a recap, gall stones are classified as cholesterol stone, bilirubin stone or mixed stones. As a rule, gall stones develop when the concentration of cholesterol is far higher than bile salts. Secondly, if the gall bladder does not empty its content frequently due to poor contraction of its muscle, over concentrated bile can contribute to gall stone formation. Again, the molar of cholesterol and bile acid concentration also have been noted as a factor. Ordinarily, the presence of gall stones may be asymptomatic. But when they are enough to clog the ducts they give rise to the crazy pains aptly described as biliary colic. When the gall bladder is infected as a result of bile stasis, this now becomes a serious clinical condition known as Cholecystitis. This could lead to serious complications and needs intervention.
Classically, in clinical practice Benjamin MURPH’S sign is used to differentiate between Cholecystitis and Cholelithiasis. To elicit this sign, the patient is asked to breathe out. The right hand is placed on the right upper side of the abdomen and he is then asked to take a deep breath. If she suddenly stops while doing this as a result of pains, the sign is POSITIVE and the likely clinical impression is Cholecystitis. The diagnosis of Cholelithiasis and Cholecystitis is ultimately made with ultrasound scan. Here the stones that usually contain calcium would be visible on scanning and even the thickness of the gall bladder wall can be measured when inflammation is uppermost in the mind of the caregiver.
Notwithstanding, other laboratory investigations would be necessary to have a holistic clinical picture. These would include Urinalysis to estimate the level of Bilirubin and Urobilinogen, complete liver function test when a hepatic lesion is suspected and blood culture when bacteraemia is suspected. Other tests would depend on the clinical picture the patient presents with. This is even more so if the bile ducts are involved in the infective process, a condition known as Cholangitis. This, as a rule, is regarded as a medical emergency and would require antibiotics and intravenous fluid because of attendant drop n the patient’s blood pressure. Classically the triad of abdominal pain jaundice and fever; the so called CHARCOT’S triad is the hallmark of Cholangitis.
In worsening condition when there is SEPSIS resulting in multi organ affectation and mental disorientation, the phenomenon is described as REYNOLD’S PENTAD. The prognosis in this situation is usually very poor. Luckily, it is becoming uncommon in our environment. In the elderly, the clinical course may be atypical with a collapse without the enumerated features. It must always be remembered that sepsis is a life threatening condition that comes into play when the body’s response to infection leads to collateral injury to self. This manifests clinically as rapid heart rate (TACHYCARDIA), rapid breathing (TACHYPNOEA) fever and confusional state. Aggressive control of the infection is the rule and there is no exception.
For completeness, Cholelithiasis has a lot to do with lifestyle, especially with respect to the food we ingest. Commonly, this condition is found in women in their forties who may be fat and fair. Thus you may hear some caregivers talking about the 4Fs meaning female, forty, fat and fair. Apart from these, other risk factors include the use of contraceptive pills, obesity, diabetes, liver disease, rapid weight loss and a family history of gall stones. Thus it is expedient that to reduce the risk of Cholelithiasis one should eat healthy food, especially those rich in fiber and low in carbohydrate. The concept of weight reduction should not translate into punishing rapid weight reduction programme and unnecessary starvation. By and large, easy does it.
