MURPHY’S LAW a.k.a. How straight forward is treating cholecystitis ?


This was a 63-year-old gentleman who came for recurrent episodic  right upper quadrant pain of 2 to 3 weeks duration.On examination Murphy’s sign was positive.  The pictures follow.

DR KN  CH_2 DR KN  CH_3 DR KN  CH_4 DR KN  CH_10 DR KN  CH_9

ACUTE CHOLECYSTITIS WITH MULTIPLE SMALL GALLSTONES AND ECHOGENIC SLUDGE WAS SEEN.

The Common Bile Duct is 5.07 mms.

Now a quick question . What is the normal range of measurement of the C.B.D. ?

A reference link is given below.

http://www.jultrasoundmed.org/content/19/11/727.full.pdf

a small although statistically significant increase in the caliber of the common bile duct with increasing
age (60 years old or less, mean diameter 3.6 mm ± 0.2mm, versus over 85 years old, mean diameter 4
mm ± 0.2 mm, P = 0.009). Although the common bile duct did increase in size with aging, 98% of all
ducts remained below 6 to 7 mm, the commonly accepted upper range of normal.

DR KN  CH_12 DR KN  CH_11 DR KN  CH_10

A high definition live rendering is given below.

DR KN  CH_5

The pancreas  appeared to be normal.

DR KN  CH_1

He also had mild prostatomegaly.

DR KN  CH_8 DR KN  CH_7 DR KN  CH_6

He was taken up for laparoscopic cholecystectomy. The procedure was uneventful . He had fever on the 1st post operative day ; but subsequently he recovered well and was discharged 2 days later. He was complaining of a mild right upper quadrant pain occasionally.

He came for a repeat scan   50 days later.

The C.B.D. measured 5.70 mms ( still within the normal range ).There was no evidence of any obstruction .

DR KN POST CH_1

The pancreas appeared to be normal.

DR KN POST CH_2 DR KN POST CH_3

He was reassured by everybody concerned – the sonologist ( yours truly ) and  the surgeons.

Now for the Murphy’s law .  When the patient complains of persistent pain and the investigations are normal , is everything under control ? What has to go wrong , goes wrong anyway. Now for the law number 2 : When the patient happens to be a great friend this is more likely.

Now he had increasing pain over the next few days and developed jaundice. This time MRI scan was ordered by the gastroenterologist and a small gallstone with surrounding edema was found in the C.B.D. just before the sphincter of Oddi. He was taken up for ERCP retrieval . Again the Murphy’s law came into play . What was supposed to be a less than 30 minutes procedure took around 2 hours ,but the stone was retrieved successfully and he was sent home that evening. But the story does not end immediately there. He developed visible gastric peristalsis and pain the next day . But the gastroenterologist felt that was due to duodenal edema due to the prolonged procedure . Over the next few days he recovered well and is asymptomatic now.

6 thoughts on “MURPHY’S LAW a.k.a. How straight forward is treating cholecystitis ?

  1. Hi, first thank you for your wonderful case. For my understanding, the patient younger 40, CBC<6 mm, older 40, every 10 year add 1 mm.
    For example: 60 years patent, CBC<8 mm.

    Sabrina

    Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s