A 59-year-old female Noida resident presented to us in the surgery OPD of Sharda Hospital with complaints of chronic right sided hypochondriac region pain and heaviness which was insidious in in onset, episodic in nature, mild in intensity, dull aching type of pain., with associated occasional nausea and vomiting more after heavy meals. No other significant positive history was obtained.
Patient was taking regular medication for hypertension from outside for last 15 years since she was diagnosed to be hypertensive. She has had blood pressure within normal limits on examination. Patient has had no history of any chronic illnesses like tuberculosis diabetes, jaundice in the past. Patient has undergone lower segment caesarean section twice in the past with 2 alive children. Also, patient has undergone laparoscopic tubal ligation done more than 20 years back outside.
There was no pallor, icterus, clubbing or any lymphadenopathy.
On abdominal examination, there was old well healed surgical scars with soft protuberant abdomen, but no palpable lump, no organomegaly.
Patient was admitted and investigated.
Whole abdomen Ultrasound revealed multiple Gall bladder calculi largest ~12.5 mm, thickened gall bladder wall, with normal Common Bile Duct diameter and multiple small renal calculi ~4 mm. Rest scan was unremarkable.
Blood investigations done were essentially unremarkable except for the renal functions which were impaired with levels of Serum Creatinine-2 mg % and Blood Urea- 76 mg%.
So, in view of left renal calculus and deranged renal parameters along with a history of long-standing hypertension, patient was advised to undergo Diethyl Triamine Pentacetic Acid (DTPA) scan for assessment of renal functions.
DTPA revealed bilateral kidneys having mildly reduced function with non-obstructed disease.
With the given history, clinical presentation, ultrasonography and DTPA findings, the diagnosis of chronic calculous cholecystitis with poor pre-existing renal functions (chronic kidney disease CKD) with hypertension was made.
She was suggested for stenting surgery for renal problem to which the patient was unwilling as poor renal functions were well tolerated by the patient and therefore only gall bladder problem was addressed on patient request. After thorough workup and informed consent, patient was posted for elective laparoscopic cholecystectomy (Fig. 1).
Per op. -Gall bladder distended, thick walled, dense Calot's adhesions, between omentum and Gall bladder body. Multiple small discrete white patches seen on bowel surfaces. Dilated Hartmann pouch with impacted stones seen (Fig. 2a).
Laparoscopic cholecystectomy was therefore converted to open cholecystectomy due to adhesions and to prevent any iatrogenic injury to the biliary tree.
Post-operative period was uneventful. Patient was allowed liquids orally, the evening following surgery. Patient tolerated the surgery well and has had satisfactory progression in improvement. Drain was removed on 2rd post-operative day. Patient was discharged on 3rd post-operative day with sutures in situ and alternate day dressing with antibiotics and symptomatic treatment was advised.
Biopsy revealed apart from chronic calculus cholecystitis, a chronic schistosomal infestation of gall bladder. Gall bladder shows atrophic mucosa with dense chronic inflammation with wall showing calcific deposits and numerous basophilic ova entrapped in the fibrous tissue. Few of the ova were calcified (Fig. 2b).
Patient fared well with Anti helminthic (Tablet Praziquental) treatment and related symptomatic medication in the follow-up. At 12 months post-operative period patient has no new symptoms or any evidence suggestive of urinary bladder or digestive tract involvement.