Case No 2

76-year old woman with four-day history of low-grade fever and right upper quadrant pain

Medical History

Present Illness: Not feeling well for five days, chill, mild rising temperature, right upper quadrant pain. The pain persists mainly on empty stomach. Nausea, but did not vomit. Regular stool, now slightly soft. GP examined her, high CRP determined by a POCT.

FHx: Parents died at old age, younger brother is healthy
EHx: She has had no sick contacts. 4 days ago she had mayonnaise sandwich
WHx: Pensioner
PMHx: Arterial hypertension on therapy
PSHx: s/p surgery of left breast cyst
GHx: Postmenopause
Allergies: NKDA
Medications: Prestarium Neo 1-0-0 tabl, Detralex 2-0-0 tabl
Abuse: : Non-smoker, no alcohol drinking

Physical Examination

TT 36,5 °C, alert and oriented, cooperating, quiet breathing, eutrophic, no skin icterus. Head: NAD. Eyes: PERRL (Pupils Equal, Round, Reactive to Light), EOMI (Extra Ocular Muscles Intact), no scleral icterus. Ears, nose without any discharge. Throat clear with no erythema, tongue a little drier, with whitish coating. Neck supple with no LAD or masses. Breath sounds normal, RRR (Regular Rate and Rhythm), heart sounds normal, no m/g/r. Pulses 2+ equal on both sides. BP 110/60. Abdomen soft, non-distended. Liver not palpable, liver span approximately 10 cm, spleen not palpable. No masses. Murphy’s sign positive, no peritoneal signs. Normoactive bowel sounds. Rectal: Deferred. Extremities: Mild soft perimalleolar edemas, no tender to palpation, Homans and plantar sign negative. Meningeal signs negative.

Laboratory Tests

Hematologic examination:

Biochemical lab tests:

Microbiological examinations:

Imaging Studies


Nativní snímek břicha   Fig 1 Abdominal XR: Small bowel loops of adequate width, without dilatation, no air-fluid levels, air is only present in a small bowel loop in the left mesogastrium, no free intraperitoneal air. No evident calcification shadows in the presumed site of the urinary and biliary tract. No structural changes on the visualized skeleton, right-sided coxarthrosis, one phlebolith in the pelvis. Conclusion: No signs of neither ileus nor pneumoperitoneum.


CT břicha   Fig 2 Abdominal CT scan (transverse image): No hepatomegaly, liver parenchyma of natively slightly reduced density, around 33 HU. Gallbladder very large 100 × 65 × 69 mm with layered wall thickening of the fundus, hypodense content. The gallbladder is deeply immersed in the liver parenchyma. Fatty tissue of the gallbladder bed is mild infiltrated. Pancreas lipomatous, not enlarged, without focal changes in the parenchyma, major pancreatic duct not dilated.


Case study 2   Fig 3 CT scan of the abdomen and pelvis (reformatted coronal image): Liver not enlarged, cyst in the left lobe of the liver, size 40 × 23 mm, hepatic parenchyma of natively reduced density, about 33 HU. Intrahepatic bile ducts not dilated. Gallbladder very large 100 × 65 × 69 mm with a layered wall of the fundus, hypodense content, significantly immersed in the liver parenchyma. Fatty tissue of the gallbladder bed is mildly infiltrated. Pancreas lipomatous, not enlarged, without focal changes in the parenchyma, major pancreatic duct not dilated.


Other Paraclinical Examinations

Electrophysiologic examinations:

Endoscopic methods:

Diagnostic Conclusion

Make a diagnosis


Determine for yourself


76-year old woman with high blood pressure, admitted with acute cholecystitis with high inflammatory parameters, hypokalemia, CT showed pericholecystitis. Finding on CT scan confirmed it. Parenteral antibiotic therapy [what antibiotic was prescribed], rehydrated, potassium supplemented, symptomatic therapy administered. ATB therapy caused drop of inflammatory parameters, but after a week bilirubin and hepatic test values are rising, especially those of obstructive enzymes, and subsequently progress of acute pancreatitis. ERCP done, performed papillotomy, extracted concrement, several small stones were removed from common bile duct, bile drain enabled, the presence of pus in the bile indicates cholangitis. ATB therapy was escalated [---- what ATB ? ----], ERCP was performed. After intervention the patient's condition improves, abdominal pain subsides, she does not vomit, oral intake is well tolerated, jaundice regresses, is afebrile, KP is compensated. Inflammatory parameters decrease, liver test values and bilirubin, the activity of serum pancreatic enzymes is normalized. Released in good general condition home.


8 Viral hepatitis and liver infection
Home page

© Feb-28-2021