INFORMATION FOR CANDIDATE:

Your next patient in general practice is a 56 year old Mr.

Lukas who has suffered from a bloated feeling in his
abdomen, usually after meals. He also noticed an increase in
his girth but has not put on weight.
YOUR TASK IS TO:
Take a history
Examine the patient
Discuss the most likey diagnosis with the examiner
Organise appropriate investigations
Discuss the management with the examiner

HOPC: Mr. Lucas noticed a bloated feeling after meals for the last few months, usually after meals
almost every day and it lasts for a couple of hours. Mainly in the epigastrium and not radiating
anywhere. Nothing really which makes it worse or better. You have not had any relief with panadol,
Mylanta or ranitidine. No nausea or vomiting. Regular bowel action.
Mr. Lucas is rather concerned that he could have gallstones.
PHx.: unremarkable
FHx.: mother had gallstones and needed an operation in her fiftees, still alive, father in good health in
his eighties.
SHx: married police man, no children, quite a bit of stress at work, non smoker, little alcohol, no
recreational drugs, NKA, no medications.
EXAMINATION: Patient looks quite well, normal BMI, vital signs normal.
The physical examination is quite normal.
INVESTIGATIONS:
All blood tests are normal
Urinalysis normal
U/S: see provided image
DIAGNOSIS: INCIDENTAL GALL STONES
About 70% of people with gallstones (cholesterol or bilirubin pigment) are asymptomatic but become
symptomatic over the years at a rate of 1% per year. That means that a 30 year old with asymptomatic
stones who lived to 80 years would have a 50% chance of requiring their gall bladder to be removed
and a laparoscopic cholecystectomy would be advisable, while for a 60 year old there would only be a
20% chance if he lived till 80. Unless it is clear from the history that any symptom the patient has can
be attributed to the gallstone, then the gall bladder should be left untreated, particularly if there are
serious co-morbid factors. A major possible complication from a cholecystectomy in a patient who did
not need it in the first place is the biggest disaster! Prophylactic cholecystectomy might be considered
in patients with diabetes because they tend to develop more serious cholecystitis!
However, the incidental gallstone at laparotomy should be removed because for unknown reasons they
have a higher rate of developing future symptoms up to 75% within 12 months!
COMPLICATIONS:
Acute cholecystitis
Obstructive jaundice (gallstones can pass into the common duct, causing obstruction)
Cholangitis
Pancreatitis
Septicaemia
Cancer

MANAGEMENT:
1.
Wait and see in this situation!
2.
Gall stone dissolution
3.
Operation:
a) laparoscopic
b) open laparotomy
c) lithotripsy