image1 this is a sag view and patient lie supine
image2 this is a trv view
image3 this is a decube sag view note the location has change
image4 this is a CBD measurement with Doppler
Comment: there were a negative murphy's sign; what do you think this may be? why is the patient asymptomatic? what can be the complication of this finding and what are the treatment
options if patient become symptomatic? add any comment you think may be interesting.
12 comments:
i hope you find this case study interesting even though it is common finding tell us what you think about that
Flore,
This is a Gallstone. The complication of gallstones include inflammation of the GB, blockage of the CBD and pancreatic duct if the stones move to the CBD and PD. If the stone is too big and causes pain to the GB, the GB is removed laparospically.
http://womenshealth.about.com/cs/gallbladder/a/gallstonetreats.htm
This looks like a VERY large gallstone. It is most likely asymptomatic because it is not obstructing the CBD. The patient may only feel slight symptoms immediately after a fatty meal because the GB will shrink around the stone causing friction of the GB walls. If it does end up obstructing the CBD it may become very painful and cause jaundice, pancreatitis,or even sepsis. It has also been proven that large gallstones are associated with gallbladder cancer more than little stones because the large stones are more irritatiing to the GB walls. GB stones can be broken down with a procedure called lithotripsy, or the GB may be removed in a surgery called cholecystectomy.
I agree that this is a large gallstone. "80% of people will not have symptoms for many years if the gallstones stay in the gallbladder." As Tia mentioned, they can block the CBD. They can also block the cystic duct or ampulla or Vater. Blockage of the CBD and ampulla or Vater is more serious than of the cystic duct; acute cholangitis can develop. "Bacteria can spread to the bloodstream and cause serious infections elsewhere in the body. Also, pockets of pus (abscesses) can develop in the liver." "Stones that block the ampulla of Vater also can block the pancreatic duct, causing inflammation of the pancreas (pancreatitis), as well as pain. Inflammation of the gallbladder caused by gallstones can erode the gallbladder wall, sometimes resulting in a hole (perforation). Perforation results in leakage of the gallbladder contents throughout the abdominal cavity, causing severe inflammation (peritonitis). A large gallstone that enters the small intestine can cause intestinal blockage, called a gallstone ileus. Though rare, this complication is more likely to occur in older people."
For gallstones in the gallballder, 90% of cholecystectomies are performed laparascopically. The rest are performed by open abdominal surgery. Stones in the bile ducts are removed during ERCP.
Source: http://www.merck.com/mmhe/sec10/ch140/ch140b.html
It is so funny that I had same case yesterday too. He is 34 years old and men. We got stat order from ER since he had RUQ pain. Eventually, we found out non-shadowing mobile gallstone(>2cm). In addition, he had Murphy's sign and dilatd CBD, given his age. The radiologist end up diagnosed early acute cholecystitis.
The difference between gallstones and polyps is that stones move to the dependent portion of the GB and polyps are immobile. The difference between stones and sludge is that stones shadow and sludge doesn't. Use a high frequency TDR to see if it will shadow (WES sign). There is no way to tell from ultrasound if it is one large gallstone or many small gallstones stuck together. The risk factors for developing gallstones are the "5 Fs"... Forties, Female, Fat, Fertile, and Fair-skinned. Gallstones form when bile salts and cholesterol are out of balance with each other.
Leah
It is interesting the stone is so isolated and appears so large, I haven't seen a gallstone presentation like this. Today we also had a patient come in with general indigestion after eating, and his gallbladder was almost completely impacted with smaller gallstones, but not enough to create a WES sign. But similar to this patient, he didn't have a positive Murphy's sign, which was surprising. Also, his CBD was of normal diameter and there was no pericholecystic fluid.. It's interesting to see variations of the same pathology.
Hi, Flore
I saw one male patient who was 21 years and had a chronic abdominal pain. The patient was very thin and did not have any appetite. In his gallbladder, a small amount of sludge and multiple tiny gallstones without shadowing were seen. Because the gallstones were so small that one or several of them could obstruct the common bile duct. However, the size of the common bile duct was in normal range, strangely.
Hye said.
Patient have a big gallstone in GB.Galstone can block flow of the bile. If the patient is symptomatik and it give him a lot of pain and discomfort then the GB should be removed.
Zouliath said
the patient has a urge gallstone.Many patients do not have any symptoms and the patient can live with that for many years.Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty completely or often enough. The reason these imbalances occur is not known.
The cause of pigment stones is not fully understood. The stones tend to develop in people who have liver cirrhosis, biliary tract infections, or hereditary blood disorders—such as sickle cell anemia—in which the liver makes too much bilirubin.
Gallstones range in size from as small as a grain of sand to as large as a golf ball. Some people develop just one gallstone, while others develop many gallstones at the same time. Gallstones are common in the United States. People who experience symptoms from their gallstones usually require gallbladder removal surgery. Gallstones that don't cause any signs and symptoms typically don't need treatment. Gallstones may cause no signs or symptoms. If a gallstone gets stuck in a duct and causes a blockage, signs and symptoms such as sudden and rapidly intensifying pain in the upper right portion of your abdomen, sudden and rapidly intensifying pain in the center of your abdomen just below your breastbone, back pain between your shoulder blades, or pain in your right shoulder may develop as a result. Gallstone pain may last several minutes to a few hours.
That is a big mamma stone, look at that shadow! A family member of mine has one just like that imagine my surprise when we found it. That gallstone was also asymptomatic, however, this patient may have some mild to moderate digestive issues after a fatty meal but if it is not effecting the patients every day life it is not so bad, they just need to be quick to act if they start experiencing bad pain in that area.
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