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The Big 5

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Gold and Diamond
黄金 钻石

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 Case Report
Bed No. 5床
Name: 邵云 （Shao Yun)
Diagnosis: Gallstones with Mirizzi Syndrome

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 Personal Information

姓名：邵云 （shao Yun)

性别：女
年龄：36岁
民族：回族 (Han)
职业：Unknown
住址：安徽省淮南市凤台县粮食局2库

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 Personal Information
主诉 Chief complaints：
complaining of abdominal pain for 1 week

现病史 Personal History：

Patients came to the ER complaining of abdominal pain
1week
blood test show increased total bilirubin levels
she was misdiagnosed with CBD stones and treated with
ERCP (endoscopic retrograde cholangiopancreatography),
ENBD (Endoscopic nasal bile drainage) on 2018.11.6,
2018.11.9 the MRI scan in our hospital indicated gallstone,
patients in our department for further diagnosis and
treatment. 8
 Work-up
体格检查 Physical Examination：

Abdomen: NORMAL
flat and symmetrical abdomen, no exposure of abdominal wall
vein, no gastrointestinal type and peristaltic wave, soft abdomen,
no tenderness, no rebound pain, no mass in abdomen. The
subcostal liver and spleen were not touched, but Murphy's sign was
negative. The abdominal percussion was drumming, the upper
hepatic boundary was between the fifth rib of the middle line of
the right clavicle, there was no percussion pain and no moving
murmur in the liver and kidney area. The sound of bowel sounds
is regular, 4 / min. No vascular murmur
ECG and other examinations were all NORMAL

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 Work-up

既往史：Past history:

normal health, denies of history of hepatitis,

tuberculosis, malaria,hypertension, history of heart
disease, diabetes, cerebrovascular disease,mental
illness, history of food, drug allergy, history of
vaccination, 2010.1 caesarean sections, 2013.12
thoracic vertebrae internal fixation due to trauma

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 Blood Results
2018-11-14: Admissions

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 Ultrasound findings:

 the common bile duct was dilated, the inner diameter was about 17 mm, and its
internal scan showed 14*6mm strong echo light mass accompanied by acoustic
shadow.
 liver size, shape normal , capsule smooth, intrahepatic light distribution, vascular
network structure clear, intrahepatic bile duct dilatation, with portal vein type sign.
 The volume reduction of bile was normal, no obvious abnormal echo was found in the
lumen
 The spleen and pancreas was normal
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 MRI Scan
 The upper segment of the common bile duct had a
mixed high density shadow at the opening of the
cholecystic duct about 13.5mm in diameter. The
upper hepatic and extrahepatic bile ducts were
dilated,
 abdomen and pelvis showed that the liver was
normal.
 Pancreas, kidney, spleen and bladder size, shape and
density were normal, There were no ascites. no
obvious abnormal masses in the pelvic cavity,
uniform uterine density, no lymph nodes, obvious
effusion in the pelvic cavity,
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MRCP

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 Differential Diagnosis

1. Extrahepatic cholelithiasis: general asymptomatic, when stone

obstruction and secondary infection, its typical clinical manifestation is
Charcot triple disease, namely abdominal pain, shivering high fever and
jaundice, B ultrasound can be clear, the treatment is to remove
obstruction by surgery, unobstructed drainage mainly

2. Cholangiocarcinoma: some chemical carcinogens, such as liver

cirrhosis, viral hepatitis, aflatoxin, and soil and water-related factors.
Early lack of typical symptoms, common clinical manifestations: liver area
pain, systemic and digestive symptoms, mainly for lack of strength,
wasting, loss of appetite, abdominal distension, and so on; Hepatomegaly
is the most common sign of liver cancer. CT examination and needle
aspiration cytology have definite diagnostic significance. Surgical
resection is the main treatment
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 Diagnosis

2018-11-14 08:11am, Yu Xiaojun's ward rounds were recorded, all

physical examinations were normal. Mirizzi syndrome,
gallbladder stone are considered in the diagnosis.
There are indications for operation, and relevant examinations
should be improved actively. After eliminating the
contraindications of operation, elective surgery should be
performed.

2018-11-14 11: 10am Wang Guobin's deputy chief physician's room

inspection record: the current diagnosis considers the possibility of
Mirizzi syndrome and gallbladder stones.

The patients are scheduled for surgical treatment 2018-11-15.

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 Diagnosis

Diagnosis and treatment plan:

actively improve the relevant examination, remove

surgical taboos after the limited period of operation.

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 Mirizzi Syndrome

Mirizzi syndrome is defined as common hepatic duct

obstruction caused by an extrinsic compression from
an impacted stone in the cystic duct or Hartmann's
pouch of the gallbladder. Patients with Mirizzi
syndrome can present with jaundice, fever, and
right upper quadrant pain.

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 Surgery

 Preoperative diagnosis: Gallstones with Mirizzi

Syndrome
 There is no obvious contraindication of
operation
 name: cholecystectomy, choledochus
exploration, external drainage of T tube

 Surgery was preformed.

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 
Gallbladder

Gallbladder stone

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 Blood Results
2018-11- 24 : Post operation

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 Summary
Name: 邵云 （Shao Yun)
Chief complaints：
complaining of abdominal pain for 1 week
Personal History
Patients came to the ER complaining of abdominal pain 1 week, blood
test show increased bilirubin, she was misdiagnosed and treated with
ERCP (endoscopic retrograde cholangiopancreatography) IDUS ENBD
(Endoscopic nasal bile drainage) on 2018.11.6
2018.11.9 the MRI scan in our hospital indicated that gallstone
Physical Examination: NORMAL
ECG and other examinations: NORMAL
Blood Results:
Pre-op: total bilirubin 41.5umol/L
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Post-op: total bilirubin 18.5umol/L
 Summary
Ultrasound findings:
the common bile duct dilated, the inner diameter was
about 17 mm, and its internal scan showed 14*6mm
strong echo light mass accompanied by acoustic shadow.
MRI Scan
 The upper segment of the common bile duct had a
mixed high density shadow at the opening of the
cholecystic duct about 13.5mm in diameter. The upper
hepatic and extrahepatic bile ducts were dilated,
Diagnosis:
Mirizzi syndrome and gallbladder stones
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 Summary

Surgery:
Cholecystectomy, choledochus exploration,
external drainage of T tube

Evaluation of the patient's condition:

the patient is now stable, actively improve the

relevant examination, removed surgical taboos, the
patient is younger, prognosis is fair, actively
communicate with the patient's family, follow up.
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 谢谢你的关注。

THANK YOU
FOR YOUR ATTENTION!

Shivar Sewpersad 谢瓦
6th year Student
MBBS Major 29