A 45 year old overweight female, with known gallstones presents to ED complaining of severe right upper quadrant pain. Imaging shows that large gallstones have eroded through the posterior wall of the fundus of the gallbladder to enter the intestine. Which of the following parts of the intestine is most likely to first contain gallstones:
The gallbladder is a pear-shaped sac lying on the visceral surface of the right lobe of the liver in a fossa between the right and quadrate lobes. It is an intraperitoneal structure and lies in the right hypochondrium.
Gallbladder. (Image by OpenStax College [CC BY 3.0 , via Wikimedia Commons)
The gallbladder is located at the junction of the right ninth costal cartilage and the lateral border of the rectus abdominis muscle which is the site of maximal tenderness in the acute inflammation of the gallbladder.
The gallbladder has:
The neck contains a mucosal fold, known as Hartmann's pouch, which is a common site for gallstones to become lodged.
The gallbladder lies:
Inflammation of the gallbladder may present with pain in the right upper quadrant and also in the right shoulder due to irritation of the diaphragmatic peritoneum. N.B. Pain arising from structures supplied by the phrenic nerve is often referred to other somatic regions served by spinal nerves C3 - C5.
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Biochemistry | Normal Value |
---|---|
Sodium | 135 – 145 mmol/l |
Potassium | 3.0 – 4.5 mmol/l |
Urea | 2.5 – 7.5 mmol/l |
Glucose | 3.5 – 5.0 mmol/l |
Creatinine | 35 – 135 μmol/l |
Alanine Aminotransferase (ALT) | 5 – 35 U/l |
Gamma-glutamyl Transferase (GGT) | < 65 U/l |
Alkaline Phosphatase (ALP) | 30 – 135 U/l |
Aspartate Aminotransferase (AST) | < 40 U/l |
Total Protein | 60 – 80 g/l |
Albumin | 35 – 50 g/l |
Globulin | 2.4 – 3.5 g/dl |
Amylase | < 70 U/l |
Total Bilirubin | 3 – 17 μmol/l |
Calcium | 2.1 – 2.5 mmol/l |
Chloride | 95 – 105 mmol/l |
Phosphate | 0.8 – 1.4 mmol/l |
Haematology | Normal Value |
---|---|
Haemoglobin | 11.5 – 16.6 g/dl |
White Blood Cells | 4.0 – 11.0 x 109/l |
Platelets | 150 – 450 x 109/l |
MCV | 80 – 96 fl |
MCHC | 32 – 36 g/dl |
Neutrophils | 2.0 – 7.5 x 109/l |
Lymphocytes | 1.5 – 4.0 x 109/l |
Monocytes | 0.3 – 1.0 x 109/l |
Eosinophils | 0.1 – 0.5 x 109/l |
Basophils | < 0.2 x 109/l |
Reticulocytes | < 2% |
Haematocrit | 0.35 – 0.49 |
Red Cell Distribution Width | 11 – 15% |
Blood Gases | Normal Value |
---|---|
pH | 7.35 – 7.45 |
pO2 | 11 – 14 kPa |
pCO2 | 4.5 – 6.0 kPa |
Base Excess | -2 – +2 mmol/l |
Bicarbonate | 24 – 30 mmol/l |
Lactate | < 2 mmol/l |