Have you guessed what the disease is?
"Dr. Yang, come and see the 3-bed patient admitted to the hospital today, the epigastric pain is very severe!"
Dr. Xiao Jiang of the department trotted into the office and said hurriedly.
Case review: Eerie abdominal pain
This is a newly admitted patient with gallbladder stones and cholecystitis, a 58-year-old female, who was admitted to the hospital for "12 hours of right upper abdominal distention pain".
After 12 hours of eating greasy food, there is continuous swelling and pain in the right upper quadrant, paroxysmal exacerbation, no radiation pain, accompanied by nausea and vomiting; fearless cold, fever, no chest tightness, chest pain, no cough, sputum, no diarrhea, frequent urination, urgency and other symptoms.
He has a history of "gallbladder stones and cholecystitis" for many years, and has performed gallstone preservation surgery. Denial of history of "hypertension, coronary heart disease, diabetes".
Admission to the hospital for physical examination: body temperature 36.2 °C, pulse 74 beats / min, breathing 20 times / min, blood pressure 140 / 90 mmHg, clear consciousness, no yellow staining of the whole body skin sclera, no rales in both lungs, heart rate 74 beats / min, rhythm, no murmur. Flat abdomen, no gastrointestinal type and peristalsis waves, soft abdominal muscles, positive right upper quadrant tenderness, no rebound pain, untouched under the liver and spleen, positive Murphy sign, normal bowel sounds.
At this point, some of the patient's test reports have been reported:
Blood routine: white blood cells: 11.72 * 109 / L, neutral cell ratio: 90.9%; blood biochemistry: glutamyl transpeptidase: 46.2 IU / L, alanine aminotransferase: 59.2 IU / L, calcium: 2.59 mmol / L, magnesium: 0.53 mmol / L, glucose: 8.68 mmol / L, uric acid: 491umol / L, cholesterol: 6 mmol / L, blood amylase: 165 IU / L; C reactive protein: <5.00 mg / L Myocardial infarction triptych: normal; nucleic acid test for novel coronavirus: negative (-); ECG: 1. Sinus tachycardia, 2. Incomplete right bundle branch block.
When Xiao Jiang and I came to the ward, the patient's expression was painful, like sitting on a needle felt, she was already half squatting on the ground, and asked for pain injections.
Abdominal CT at admission: gallbladder stones, acute cholecystitis. After anti-inflammatory, antispasmodic and other symptomatic treatment, why is the abdominal pain not alleviated, but more serious?
Fig. 1 Abdominal CT at admission: gallbladder stones, acute cholecystitis
Xiao Jiang looked puzzled and asked, "Will it merge other situations?" For example, biliary pancreatitis, digestive tract perforation and other diseases. ”
It also makes sense that the patient has severe abdominal pain and needs to be diagnosed differentially!
However, acute pancreatitis often has the inducement to eat greasy food and drink alcohol, manifested by persistent and severe pain in the mid-upper abdomen, nausea, vomiting, and may be accompanied by fever, blood amylase can be significantly elevated, and abdominal CT can be confirmed. When the patient was admitted to the hospital, there was no pancreatic enlargement and peripanius peripalapancreatic exudation in the abdomen CT, no free gas in the subdiaphragm, and no high blood amylase, so pancreatitis and gastrointestinal perforation were not considered for the time being.
Fig. 2 Abdominal CT at admission: no abnormalities were seen in the pancreas
The patient's pain is unbearable, we still gave her a strong pain, but the effect is still not obvious. Although the abs are not tight, the patient is still tossing and turning, moaning loudly from time to time. The desired effect was not achieved, and the patient expressed dissatisfaction and strongly demanded to be transferred to surgery for cholecystectomy.
The patient has a history of gallbladder stones and cholecystitis, and has undergone gallstone preservation. The latest edition of the Mainland's "Expert Consensus on the Surgical Treatment of Benign Diseases of the Gallbladder (2021 Edition)" points out that gallbladder stone patients, regardless of whether they have symptoms or not, gallbladder resection is recommended; cholecystectomy is the only cure for benign diseases of the gallbladder; and opposes the implementation of "gallbladder preservation surgery" for benign diseases of the gallbladder.
Whether from individual wishes or expert consensus, the patient's choice is appropriate. So we sent the patient to hepatobiliary surgery.
Transfer:
CT review is still undiagnosed and there is a lot of suspicion
The patient was followed up the next day, coinciding with the superior physician's rounds, and the patient still complained of abdominal pain. But at this time, the right upper abdominal pain is relieved than before, the right lower abdomen has obvious pain, and the abdominal muscles are somewhat tense, Mai's point tenderness, rebound pain are positive, it seems that the condition is a bit strange!
Everyone spoke and discussed.
"Metastatic right lower quadrant pain, this is likely to be acute appendicitis, ah, there are already symptoms of peritonitis, immediately ask the gastrointestinal surgery consultation!"
"Although the pain has metastasized to the right lower quadrant, but the patient still has right upper quadrant pain, will it be caused by inflammatory exudation?"
"The possibility of acute appendicitis is still very large, surgery is inevitable, and then transfer after consultation!"
The consultant moved quickly, rushed to the ward a few minutes later, and after a simple medical history inquiry and physical examination, he said: Gallbladder stones with acute cholecystitis objectively exist, acute appendicitis can not be ruled out, but objective evidence is needed, and abdominal CT needs to be reviewed.
The diagnosis is currently foggy, is it cholecystitis or appendicitis, or cholecystitis with appendicitis?
There is only one truth!
Without saying a word, the patient immediately did a full abdominal CT, and the results showed: gallbladder stones, acute cholecystitis, abdominal cavity, pelvic effusion, and no abnormalities in the appendix.
Fig. 3 Re-examination of abdominal CT shows: gallbladder stones, acute cholecystitis, abdominal cavity and pelvic effusion
Figure 4 Re-examination of abdominal CT shows that no abnormalities are seen in the appendix
The results of the review CT put everyone in trouble again!
Is there any acute appendicitis? What is the explanation for metastatic right lower quadrant pain? Is the abdominal and pelvic effusion just inflammatory exudations? Are there other complications, such as perforation of the gallbladder? But imaging is not supported, what's next?
Traceability:
Start with imaging to solve the mystery of abdominal pain
Materialistic dialectics tells us that things are always in constant motion, change and development. After much deliberation, we decided to start with the imaging data, hoping to find some clues to the diagnosis.
After careful comparison and reading, it was found that the morphology of the second abdominal CT gallbladder had changed significantly, and the original fullness had become the current collapse, and the tension had also been reduced. It takes less than 24 hours, so why is that?
This suggests a perforation of the gallbladder! However, this is only an imaging diagnosis and needs to be combined with clinical practice.
Fig. 5 Comparison of two abdominal CT gallbladders
How can it be further confirmed before surgery?
Therefore, we carefully examined the patient's previous medical history and found that the patient's abdominal CT suggested abdominal effusion and pelvic effusion during the patient's re-examination.
Why not make a puncture?
We gave the patient a posterior vault puncture and pulled out 10 ml of yellow effusion, yes, this is bile! The gallbladder is indeed perforated! It seems that the so-called acute appendicitis is nothing more than a smoke bomb!
Fig. 6 Puncture of the posterior vault punctures the extracted bile
Surgery is urgent and preoperative examination is perfect. Intraoperative see: a large amount of biliary fluid can be seen in the abdominal cavity and pelvis, the size of the gallbladder is about 10 cm * 8 cm, the adhesion to the surrounding omentum is obvious, the scabies lesion and local perforation can be seen at the bottom of the gallbladder, and multiple granular stones can be touched in the gallbladder.
Intraoperative diagnosis: multiple gallbladder stones, acute gangrenous cholecystitis with perforation, laparoscopic cholecystectomy + abdominal adhesion + laparoscopic exploration.
Postoperative pathology: acute onset of chronic cholecystitis, cholelithiasis; cell infiltration of mucosal laminatitis, sinus formation of "R-A", necrosis of focal lesions.
The patient recovered after surgery and was discharged from the hospital after 1 week.
At this point, this case of rapid abdomen with three twists and turns has finally been diagnosed and treated in time.
Information Inquiry: Understanding Gallbladder Perforation
Gallbladder perforation is one of the serious complications of acute cholecystitis, clinically about 3% to 10% of acute cholecystitis can occur gallbladder perforation, mostly occurs with gallbladder stone incarceration, and the elderly with arteriosclerosis or diabetes are more likely to occur. Perforations are common at the base of the gallbladder, followed by the neck. The cause of gallbladder perforation is mainly due to various obstructive factors (most often gallbladder stones) causing gallbladder/biliary blockage, resulting in increased pressure in the gallbladder and ischemia necrosis of the gallbladder wall, which triggers perforation.
There are three forms of gallbladder perforation:
(1) Acute perforation: perforation of the free margin of the gallbladder breaks into the abdominal cavity, causing acute biliary diffuse peritonitis;
(2) Subacute perforation: during perforation, there are adjacent organs and tissues around the gallbladder, and after perforation, it is wrapped by the surrounding tissues to form a peri-gallbladder abscess;
(3) Chronic perforation: penetration with adjacent organs to form an internal fistula, with gallbladder duodenal fistula being the most common, followed by gallbladder colon fistula.
Gallbladder perforation is mainly based on abdominal ultrasound or CT, which can clearly show signs of fluid effusion around the gallbladder, enlargement of the gallbladder, and thickening of the gallbladder wall.
In this case, two abdominal CT scans did not show gallbladder perforation, considering: 1) the continuous interruption of the gallbladder wall after perforation is relatively subtle and atypical, and it is easy to ignore; 2) the tension is reduced and the volume is reduced after the perforation of the gallbladder, the sac wall is shrunk, and the fracture site of the gallbladder wall is not clear and easy to miss.
Enhanced CT is more likely to show continuity of the gallbladder wall, and discontinuities in gallbladder wall strengthening are highly specific. Therefore, when the infection progresses rapidly and there is a high suspicion of gallbladder perforation, it is recommended to use enhanced CT examination to observe the continuity of the gallbladder wall in multiple directions and multiple sections, observe the relationship between liver abscess and gallbladder, and make an accurate diagnosis in combination with the medical history, providing a favorable basis for clinical treatment.
Fig. 7 Important signs of enhanced CT findings: disruption of gallbladder wall continuity and hyper-strengthening of the hepatic surface envelope suggesting gallbladder perforation and peritonitis (image from network)
Acute perforation of the gallbladder requires urgent surgical treatment, according to the operation to choose the appropriate surgery, and as far as possible to remove the gallbladder together, the key to the success or failure of treatment is whether the correct diagnosis can be made in an early and timely manner.
Experience: Details come from the heart
The abdominal pain of the patient in this case seems to be ordinary, but the condition is ups and downs, the sinuses are full of doubts, and the truth is not revealed until the critical moment, which can be described as breaking through the clouds and seeing the moon.
Patients first present with right upper quadrant pain, which gradually worsens, and after perforation of the gallbladder, gallbladder tone decreases and right upper quadrant pain is relieved. However, bile flowed to the right lower quadrant, causing localized biliary peritonitis in the right lower quadrant, which was clinically manifested as metastatic right lower quadrant pain, resembling acute appendicitis, and once confused many doctors. When we were at a loss, we returned to the objective basis, extracted the image information by stripping the cocoon for comparative analysis, decisively performed pelvic puncture, and finally found the clue and was confirmed during the operation.
Pay attention to learning everywhere! In clinical work, only by grasping the details of those that do not conform to normal logic, repeatedly deliberating, and tracing back to the source, can we find the crux of the problem and continuously broaden our clinical thinking.
Acknowledgements: Thank you to Director Hu Renjian and Director Lin Wenyin of the Imaging Department for guiding the reading of the film!
Resources:
[1] Biliary Surgery Group of The Surgery Branch of the Chinese Medical Association, Biliary Surgery Committee of the Surgeons Branch of the Chinese Medical Doctor Association. Expert Consensus on surgical treatment of gallbladder disease (2021 edition)[J]. Chinese Journal of Surgery,2021,59(11):881-886.
Guo Zijian,Fei Zhou. Surgery[M].1st Edition, Beijing: China Medical Science and Technology Press, 2017:454-455.
Biliary Surgery Group, Surgery Branch of Chinese Medical Association. Guidelines for the diagnosis and treatment of acute biliary system infection (2021 edition)[J].Chinese Journal of Surgery,2021,59(06):422-429.
Zhu Jun,Wang Junqing. Signs of multilayer spiral CT perforation of acute and subacute gallbladder[J].Chinese Journal of Hepatobiliary Surgery,2018,24(2):128-129.
Xie Haiyan,Wang Guodong,Li Mingjian. Diagnostic analysis of spiral CT for gallbladder perforation[J].Henan Journal of Surgery,2016,22(04):131-132.
This article was first published: Digestive Liver Disease Channel of the Medical Community
The author of this article: The Second People's Hospital of Jingdezhen City, Hong Siqin, Yang Health
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