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Abstract: The patient presented with significant right upper abdominal pain, fever and other symptoms, mostly colic in nature, significant pressure pain on abdominal examination, and positive Murphy’s sign, often aggravated by drinking alcohol or eating fatty food, which is characteristic of gallbladder stones combined with cholecystitis. The patient’s clinical symptoms gradually disappeared after treatment with drugs and retrograde cholangiopancreatography via endoscopy.
Basic information】Male, 70 years old
Disease Type】Gallbladder stones and cholecystitis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】June 2020
Treatment plan】Medication (sodium penicillin for injection, ursodeoxycholic acid tablets, vitamin B complex tablets, polyene-phosphatidylcholine injection) + surgery (transendoscopic retrograde cholangiopancreatography)
Treatment period】7 days of hospitalization and follow-up after 1 month
Treatment effect] The disease was basically controlled and the clinical symptoms disappeared
I. Initial consultation
When we first met the patient, he reported pain and discomfort in the upper abdomen for more than 20 days, which was aggravated for one day, and a history of femoral head replacement surgery. Physical examination of the patient showed a flat abdomen, positive epigastric pressure pain, no rebound pain, mainly in the right upper abdomen, positive Murphy’s sign, no palpable enlargement of the liver and spleen, no mobile turbid sounds, no percussion pain in the liver and kidney area, and normal intestinal sounds, and a preliminary diagnosis of cholecystitis. It is a common disease of the gastrointestinal tract, often aggravated after drinking alcohol and eating more fatty food, and the symptoms will recur.
II. Treatment history
After the patient was admitted to the hospital, all the auxiliary examinations were completed, and a CT scan of the abdomen was given, which showed dilatation of the intrahepatic bile duct, right and left hepatic ducts, common hepatic duct, common bile duct, and an enlarged gallbladder with thick walls and irregular high-density foci. The lower part of the common bile duct showed a high-density foci with a diameter of about 0.9 cm and clear margins. Based on the findings and clinical symptoms, the patient was found to have cholecystitis and gallbladder and lower bile duct stones combined with intrahepatic bile duct and common bile duct dilatation. The patient was first given anti-inflammatory and hepatoprotective medication with injectable penicillin sodium, ursodeoxycholic acid tablets, vitamin B complex tablets, and polyenyl phosphatidylcholine injection. After taking them for 3 days, the inflammation in the patient was controlled, while the blood routine and drug sensitivity test were not abnormal, and then the patient was given retrograde cholangiopancreatography via endoscopy to remove the gallbladder stones. After the operation, a drainage tube was given to drain the gallbladder, and anti-inflammatory drugs, penicillin sodium for injection, were administered for anti-infection treatment, and the condition was stabilized after 7 days of hospitalization and discharged.
III. Treatment effect
The patient was given good anesthesia during the operation, and continued to be given sodium penicillin for injection for anti-inflammatory treatment after the operation. One day after surgery, the drainage fluid in the drainage tube was light red, the patient’s abdominal pain was reduced, and there was no exudation or pressure pain at the wound site. The color of the drainage fluid in the drainage tube gradually became lighter 3 days after surgery, and the patient’s abdominal pain symptoms basically disappeared, and there was no pressure pain in the wound. Six days after surgery, that is, 7 days after hospitalization, the color of drainage fluid in the drainage tube was normal, and the patient’s abdominal pain disappeared completely, and the wound recovery effect was also good. The abdominal wound recovered better and no abdominal pain symptoms appeared in the follow-up examination to the hospital 1 month after the operation.
IV. Precautions
1, patients need to pay attention to avoid drinking alcohol or eating more greasy food, such as fried chicken, after surgery and in daily life, so as not to cause disease recurrence.
2, patients in the process of treatment, if abdominal pain, nausea and other uncomfortable symptoms, need to promptly go to the hospital, and give the corresponding treatment.
3. Patients should pay attention to the color change of the drainage fluid during the drainage tube to drain the residual stone. If the drainage fluid changes to blood color, it may indicate the presence of bleeding, and the doctor should be informed and treated accordingly.
V. Personal insight
Gallbladder stones are a common gastrointestinal disease, mainly characterized by right lower abdominal pain, mostly colic in nature, which may be accompanied by nausea, vomiting and other symptoms, and fever if accompanied by infection. In this case, Mr. Wang did not seek medical attention in time after the abdominal pain appeared, and the disease was aggravated by delaying the disease. Fortunately, after surgery and medication, the treatment result was relatively satisfactory and did not cause serious damage to the body. It is recommended that people with these symptoms actively seek medical attention to avoid delaying the disease, otherwise it will cause serious damage to the body.