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Abstract: A 50-year-old female patient with epigastric distention and discomfort for six months, which was aggravated after eating fatty food with anorexia and nausea, came to our hospital with a clear diagnosis of gallbladder polyp complicated by cholecystitis. The patient was treated with laparoscopic combined with biliary choledochoscopic cholecystectomy, cholining tablets, ursodeoxycholic acid tablets, vitamin C injection, aminotriol ketorolac injection and famotidine for injection for 1 week, and the patient’s discomfort disappeared and her condition was stable.
Basic information】Female, 50 years old
Disease Type】Gallbladder polyp
Hospital】The First Hospital of China Medical University
Date of consultation】January 2022
Treatment plan】Surgical treatment (laparoscopic combined with choledochoscopic cholecystectomy) + oral medication (cholinergic tablets, ursodeoxycholic acid tablets) + intravenous injection (vitamin C injection, ketorolac aminotriol injection, famotidine for injection)
[Treatment period] 1 week of hospitalization, long-term follow-up
Treatment effect】Abdominal fullness and other symptoms improved, and the condition was stable.
I. Initial consultation
The patient is a 50-year-old female, who started to experience upper abdominal fullness and discomfort with no obvious cause six months ago, especially after eating fatty food, accompanied by anorexia, nausea, no vomiting, no diarrhea, no shortness of breath, no fever, chills, no malaise, and no malaise. The initial diagnosis was gallbladder polyp combined with cholecystitis. In order to seek further treatment, he came to our hospital today and was admitted with gallbladder polyp. Since the onset of the disease, the patient has been able to sleep, poor appetite, yellow urine, no significant abnormal stool, and no significant weight loss.
II. Treatment history
After the completion of all auxiliary examinations and communication with the patient, laparoscopic combined with choledochoscopic cholecystectomy was performed under general anesthesia. A small arc-shaped incision was made under the umbilicus and the corresponding equipment was inserted. After the operation, the patient returned to the ward and the removed polyps were sent for pathological examination as cholesterol polyps, which are benign tissues. Postoperatively, anti-inflammatory and symptomatic treatment was given, and the drugs used were biliary tablets, ursodeoxycholic acid tablets, vitamin C injection, aminotriol ketorolac injection, and famotidine for injection. The stitches were removed 7 days after surgery, and the patient was discharged from the hospital in stable condition.
III. Treatment effect
Before treatment, the patient had no obvious cause of epigastric distension and fullness, which was aggravated after eating fatty food, accompanied by anorexia and nausea. After laparoscopic combined with choledochoscopic cholecystectomy, all gallbladder polyps were removed and anti-inflammatory treatment was given after the operation, and the patient recovered well, with no discomfort of abdominal distention, no anorexia, nausea and other uncomfortable symptoms. 1 week later, the patient’s surgical incision healed well without infection, swelling and so on, and was instructed to remove the stitches, so the patient was discharged from the hospital for recuperation and timely medical treatment if there were uncomfortable symptoms.
IV. Notes
After the patient’s condition was stabilized, I felt happy for her from the bottom of my heart. In order to have a better recovery, I did not forget to emphasize to her that the following points should be noted after treatment.
1, usually should pay more attention to rest, ensure sufficient sleep, if it is difficult to sleep due to the pain of the surgical incision, should promptly inform the doctor.
2, rehabilitation exercises can be carried out gradually, it is recommended to gradually transition to bed activities, early recovery should be accompanied by family members.
3, after discharge from the hospital, strictly follow the doctor’s instructions to take medication, do not increase or decrease the amount of medication because of the improvement or aggravation of symptoms, during the period, if you have abdominal distension, abdominal pain and other uncomfortable symptoms, promptly come to the hospital for medical treatment.
V. Personal insight
The main symptom of the patient in this case is bloating and discomfort in the upper abdomen, which is aggravated after eating fatty food, which is a common manifestation of gallbladder polyps. If the patient in this case chooses to consult a doctor at the first time, it can avoid further development of the disease, prevent the occurrence of cholecystitis and improve the quality of life of the patient.