By Tedler D. Depaynos, MD
The patient is a well known elderly in their town who is easily recognized by his long white hair and beard. Recently, he was observed to be bending down from time to time holding his anterior abdomen as he walks around. It was several days after when he finally complained of severe abdominal pain and requested to be brought to a hospital. Learning that a neighbor was recently operated by a town mate MD, he requested that he will also be under his care.
At the Emergency Room, he complained of abdominal pain which appeared to be localized at the right upper quadrant (RUQ) where the liver and gallbladder (GB) are located. Initial impression was an inflamed GB or simply Acute Cholecystitis, so that an ultrasound (UTZ) was immediately done to confirm the impression.
While the UTZ technician was asking if the RUQ was painful while she was sliding the instrument, the patient softly responded “yes” in the dialect. To get a more accurate vision, the technician gently pressed the instrument and was suddenly shocked when the patient shouted in pain “aray ngarod!”. The adjacent medical personnel who heard the shout rushed in to see what was wrong.
The patient was 82 years old and must have been tolerating his pain for quite some time already. The UTZ revealed that his GB was severely enlarged and the walls were thickened implying inflammation. This confirmed the diagnosis so that he was referred to a cardiac MD to clear him for surgery the soonest possible time.
With his age, other concomitant diseases were expected of the patient so that an extensive work-up and treatment was done before surgery. The cardiac MD was even obligated to be in the operating room (OR) to closely monitor the patient. Fortunately, no medical complications occurred during the surgical procedure.
The surgery done was to remove the GB and explore the abdominal surroundings for any abnormality. Because of bile leakage, the surrounding tissues were extremely edematous and inflamed so that the surgery took a longer time than usual. It was however uneventful. There was a gangrenous part of the GB that perforated causing the localized “bile peritonitis”. Multiple stones were also noted inside the GB so that probably they blocked the exit of the bile from inside leading to its enlargement and inflammation.
In cases like this, when the diagnosis is “acute”, prevention of possible complications is the rule of thumb. If the infected GB is not removed the soonest, the infection may spread into the abdominal cavity causing peritonitis. The infection may be absorbed into the blood stream resulting into sepsis. Hence, even if the patient is a high surgical risk, the surgery is a must. Of course the relatives are always informed in detail of the procedure and the risk the patient may undergo during and after surgery before they are made to sign the consent for surgery.
Pain due to inflamed GB is usually very severe so that in a scale of 10, it may be described as 10/10 or even 11/10 because of its severity. In this patient the pain may already be present for quite some time because it would take several days for gangrene to occur and more days before rupture occurs. This complication is seldom encountered because patients usually seek consultation early due to the severity of the pain. This patient probably has been trying to tolerate the severe pain for days until he can no longer bear it. This is sometimes expected in the elderlies like in this patient. They keep hoping that it would disappear spontaneously! Still, the patient is lucky because he did not develop any serious complications.
After surgery, continuous intensive monitoring was done. He was even placed at the Intensive Care Unit (ICU). The patient eventually recovered and upon discharge he went directly to his native town where a thanksgiving native celebration awaited him. He promised himself to let his white beard grow again because it was shaved before surgery.