57-year-old male with right hypochondrium pain

 

Mr. X, a 57 year-old, presented with pain at the right hypochondrium for 3 days prior to admission. The pain radiated from right hypochondrium to right iliac fossa. The pain was of sudden onset, throbbing in nature and constant. He complained of bloated abdomen, feeling nausea and fever with chills and rigors upon admission. He had no vomiting. His urine was tea-coloured and complained of watery stools. He did not have any chronic illnesses and was not allergic to any drugs or foods. He smokes 20 to 40 sticks per day for 46 years. He doesn’t drink alcohol.

Upon physical examination, he was afebrile with blood pressure of 130/88 mmHg, heart rate of 60 beats/min. and respiratory rate of 12 breaths/min. He was jaundice but not anaemic. His hydration status was fair. The abdomen was distended.T here was tenderness and guarding in the right side of abdomen but no mass palpated. Liver and spleen were not palpable. Bowel sounds were normal. There were no significant findings in the cardiovascular and respiratory examination.

Differential Diagnosis: Acute cholecystitis, acute hepatitis

Investigations: Ultrasound showed liver is homogenous with smooth outline and no focal lesion seen. Gall bladder is well distended and there is a single 1.0cm calculus seen within it.

Final Diagnosis: Acute cholecystitis

Q1) How do gall stones precipitate acute cholecystitis?
Q2) Why is there jaundice in acute cholecystitis? 

Q1) How do gall stones precipitate acute cholecystitis?

Gall stones cause obstruction in gall bladder which leads to increase intraluminal pressure. With the protective glycoprotein mucus layer is disrupted, causing the mucosal layer to be exposed to the bile salts which cause chemical irritation to the gall bladder. Prostaglandins released leads to mucosal and mural inflammation. Bacterial contamination superimposed to the inflammation leading to acute cholecystitis.

Q2) Why is there jaundice in acute cholecystitis?   
In acute cholecystitis, gall bladder is swollen and may press on the common bile duct producing jaundice. This case can happen although there is no stone occluding the common bile duct causing obstructive jaundice.

References:

1.Robbins, & Cotran. (1999). Liver and Biliary Tract. In James M. C. (Eds.), Pathological Basis of Disease (pp. 877-937). Philadelphia: Elsevier Saunders.

2. H. G. Burkitt, Joanna, B. R., & Clive, R. G. Q. (2007). Essential Surgery. Philadelphia: Churchill Livingstone

3. Harold, E., Sir Roy, C., & Christopher, W. (2006). Lecture notes: General Surgery. Australia: Blackwell.