Concluded Case

10 year FEMALE PATIENT PRESENT WITH pain ABDOMEN , vomiting , FEVER, CONVULSION SINCE 3- 4 days . USG ABDOMEN AND STRAIGHT XRAY ABDOMEN ERECT POSTURE REPORT ATTACHED. BLOOD REPORT SUGGESTIVE OF NEUTROPHILIC LEUCOCYTOSIS. BLOOD SUGAR, SGPT, SERUM CREATININE, POTASSIUM, CALCIUM, CHLORIDE, MALARIA TEST, QBC IS WITHIN NORMAL LIMIT. SODIUMIS 128, SRUM BILIRUBIN IS 2.46 TOTAL , DIRECT 1.60, INDIRECT 0.86, SERUM AMYLASE IS 264, SERUM LIPASE IS 123, CRP IS 56. PLATELET COUNT IS NORMAL. PROVISIONAL DIAGNOSIS AND TREATMENT. USG REPORT IS BILATERAL MINIMAL ECHOGENIC KIDNEYS, CONTRACTED AND THICK EDEMATOUS GALL BLADDER, MILD ASCITES AND MINIMAL FLUID IN BILATERAL PLEURAL CAVITY, MILDLY DILATED MAIN PANCREATIC DUCT AND MILDLY DILATED CBD AT PORTA, FEW BORDERLINE DILATED GUT LOOPS IN ABDOMEN.

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Concluded answer

The young lady is having multiple pathological in investigation reports. A. Leukocytosis mainly neutrophilic B slightly raised bilirubin C slightly raised pancreatic enzymes D USG finding thick oedematous gall bladder wall suggestive of acalculus cholecystitis E. Mild ascitis F. Mildly dilated CBDat porta hepatis and mild dilatation of main pancreatic duct. I think acalculus cholecystitis is the main culprit of all intra abdominal pathology. As a calculus cholecystitis is due to several infection it may cause mild bilateral pleural collection and mild collection fluid in peritoneal cavity and peritonitis leading to paralytic ileus with dilatation of guts. Due to septic intra abdominal liver function was deranged leading to jaundice. Slight raised pancreatic enzymes and dilation of the pancreatic due to acalculus cholecystis though dilatation of CBD not explainable .

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This young child is going through a very difficult time However, her Main pathology appears to be intraabdominal 1) Acute cholecystitis- because of thickened gall bladder 2) Acute pancreatitis - Because of raised amylase and raised lipase 3) Obstructive jaundice - because of raised bilirubin and prominent dilated bile duct One theory can be that, she had a stone in CBD which has now passed out. Therefore there is only mild dilatation of CBD and there is NO Intrahepatic biliary dilatation She is in need of appropriate antibiotics, vital support, CT brain and EEG to look for cause of convulsions She may need magnetic resonance cholangiopancreatography if she do not settle - to rule out CBD obstruction causing biliary sepsis She will need cholecystectomy once she is settled Look for hemolytic anemia - they are important cause of biliary calculi at this age

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Really an interesting and complicated case .I would not label it as minimal Ascitis- but peritonitis. Clinical examination to elicit rebound tenderness is most important. Oedematous gall bladder is indicative of acute acalculus cholecystitis. Mild jaundice, dilated main pancreatic duct , CBD mild dilatation only at porta hepatis , minimal pleural effusion- all features are having D/D 1.Septicaemia 2.Peritonitis - X- ray abdomen indicating air fluid levels support peritonitis with secondary subacute intestinal obstruction Amylase and lipase are not significantly raised to diagnose acute pancreatitis but these can be raised any acute abdominal condition 3.Viral hepatitis with secondary complications of Ascitis and minimal pleural effusion and oedematous gall bladder 4.A calculus inGB may have passed causing cholecystitis and pancreatitis

The young lady is having multiple pathological in investigation reports. A. Leukocytosis mainly neutrophilic B slightly raised bilirubin C slightly raised pancreatic enzymes D USG finding thick oedematous gall bladder wall suggestive of acalculus cholecystitis E. Mild ascitis F. Mildly dilated CBDat porta hepatis and mild dilatation of main pancreatic duct. I think acalculus cholecystitis is the main culprit of all intra abdominal pathology. As a calculus cholecystitis is due to several infection it may cause mild bilateral pleural collection and mild collection fluid in peritoneal cavity and peritonitis leading to paralytic ileus with dilatation of guts. Due to septic intra abdominal liver function was deranged leading to jaundice. Slight raised pancreatic enzymes and dilation of the pancreatic due to acalculus cholecystis though dilatation of CBD not explainable .

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history n Reports s/o cholecystis, Pancreatitis, obsructive jaundice So need of CECT ABDOMEN THEN manage accordingly

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