Cholecystitis Case Study

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Cholecystitis, cholangitis and Mirizzi's syndrome – A case report

Case Presentation
A 22-year-old male medical student with BMI 22 Kg/m2 presented to the outpatient clinic complaining of severe abdominal pain. The patient gave a history of multiple intermittent episodes of epigastric pain which started during his exams. He reported excessive drinking of caffeine during the last 3 months and these episodes were exacerbated mainly after eating fried food. The primary doctor prescribed omeprazole for a week, but there was no improvement.

Pelvi-abdominal ultrasonography was performed and revealed calcular cholecystitis (Fig. 1). The thickness of the Gall Bladder (GB) wall was normal with multiple echogenic stones seen inside, the largest stone
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He reported that the intervals between the episodes of biliary colic decreased from one time every 10 days until it became daily. Also, the attack of biliary colic was relieved by intramuscular injection of antispasmodics and analgesics at first, but they weren’t effective anymore.

The option of cholecystectomy was discussed and the patient agreed. Pre-operative laboratory investigations revealed normal kidney function, normal blood picture and elevated liver enzymes and elevated bilirubin
(AST=174 u/L), (ALT=399 u/L), (GGT=206 u/L), (Alkaline phosphatase=147 u/L), (Direct bilirubin=2.0 mg/dl) and (Indirect bilirubin= 0.6 mg/dl).
The patient was admitted to gastrointestinal endoscopy unit for Endoscopic retrograde cholangiopancreatography (ERCP). Pre-procedural investigation revealed normal serum amylase. Ultrasonography showed large GB stones measured about 17 mm with caliber 5 mm of the
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Then he was kept for observation for 3 days. The patient developed fever again (39oC) and parenteral paracetamol was able to decrease his temperature temporary for only 2 hours and kept rising again to 39oC. Parenteral antibiotics were started again for a week. However, the fever didn’t decline at all. Abdominal CT scan was performed but revealed nothing except cholelithiasis. A descion of removing the previously inserted plastic stent in CBD was made. The patient underwent ERCP under general anesthesia to remove the stent. The fever started to decline 24 hours after ERCP and was completely gone after 48 hours. The patient was kept on antibiotics for 4 more days and was discharged with instructions of eating only boiled food and weekly

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