Gallbladder Approach

– History –

  • CC: most likely will present as RUQ pain (or jaundice):
    • Site: where? Does it radiate anywhere else?
    • Onset: first time? When\duration? Sudden\gradual? Continues\intermittent? Getting worse? How frequent?
    • Location: where? Does it radiate anywhere else (right shoulder)?
    • Character: colicky?
    • Aggravating\relieving factors: food (fatty meal)? Movement? Breathing\coughing? Pain killers?
    • Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?
  • Associated sx:
    • Constitutional: fever, chills, wt loss, loss of appetite, night sweats?
    • Hepatobiliary: jaundice, itching, easy bruising, confusion?
    • GI: abdominal pain, abdominal swelling\distension, N\V, diarrhea\constipation?
    • Stool: pale, bloody?
    • Urine: dark, tea-colored, bloody?
  • PMHx:
    • Diseases:
      • Chronic ds (HTN, DM, DLP)
      • Liver diseases
      • Prev biliary colic
      • Malignancy
    • Medications (OCP)
    • Surgery, hospitalization, trauma
    • Blood transfusions, IV drug use, tattoos
    • Allergies
  • FMHx:
    • Similar complaint?
    • Same diseases as in PMHx?
  • Social Hx:
    • Occupation, marital status, children?
    • Smoking, alcohol, recreational drugs?
    • Travel Hx
    • Diet, exercise

 


– Abdominal Physical Exam –

  • WIPE, blah blah 🙂
  • “Take vital signs”
  • Position: flat, arms on the side, pillow below the head
  • Proper exposure: from xiphoid to mid-thigh
  • General inspection of the pt and surroundings (jaundiced?)

1. Inspection: (stand at the end of the bed)

  • Symmetry and contour
  • Abdominal distention + flank fullness
  • Scars, skin changes\discoloration, rashes, straie
  • Obvious masses or swelling
  • Dilated veins\caput medusa
  • Visible pulsations
  • Umbilicus (inverted\everted?)
  • Hernias (ask pt to cough)

2. Palpation + percussion: (ask pt if they have any pain?)

  • Superficial and deep: “abdomen soft and lax, no tenderness, no masses, no peritoneal signs”
  • Liver span (6-12 cm)
  • Gallbladder
    • (Murphy’s sign) -> know how to do it!

3. Auscultation:

  • Bowel sounds
  • Bruits: Aortic, renal, femoral

4. To complete:

  • Digital rectal exam (PR)
  • Genital exam
  • Fecal occult blood test

 

– Investigations –

  • Labs:
    • CBC: to check for leukocytosis
    • LFTs: to check for ALT, AST, ALP, GGT, bilirubin
    • Amylase + lipase: R\O pancreatitis
    • U\A
  • Imaging:
    • First thing -> US: what are you looking for?
      • GB wall thickening
      • Dilated, non-compressible GB
      • Pericholecystic fluid
      • Stones
      • Sonographic Murphy’s sign
      • Dilated CBD or intra-hepatic ducts
    • CT: mainly for complications (ascending cholangitis, gallstone pancreatitis)
    • HIDA scan
    • CXR: lower lobe pneumonia, pancreatic pleural effusion, air under diaphragm
    • AXR: stones

 

– Management –

  1. Analgesia
  2. IVF and electrolytes
  3. Abx
  4. Early cholecystectomy
    • If pt is not fit for surgery: percutaneous drainage
    • If obstructive jaundice: ERCP followed by cholecystectomy

 

– Complications –

  • Perforation: appendicular mass, abscess, peritonitis, sepsis
  • GB empyema (suppurative cholecystitis)
  • GB gangrene (emphysematous cholecystitis)
  • Acute biliary pancreatitis
  • Ascending cholangitis
  • Gallstone ileus (terminal ileum)
  • Cholecystenteric fistula (duodenum)

 


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