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Case Report
PODCAST OF THE WEEK
SHOW ME THE SCIENCE
Doubled over in pain
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SHOW Me the Science is a podcast featuring interviews from frontline doctors and scientists on all things COVID-19 .
The latest episode focuses on the Omicron wave and what makes it different , as well as how vaccines and prior COVID- 19 infections can still provide some immunity as the variant spreads globally .
US immunologist Associate Professor Ali Ellebedy ( PhD ) also discusses how the next stages of the pandemic might play out , along with his hopes for the future when it comes to living with the virus .
Produced by the Washington University School of Medicine , other episodes explore the soaring numbers of hospitalisations from Omicron despite it being known as a ‘ milder ’ form of the virus .
They also address issues familiar to the Australian experience , such as whether children are safer in or out of the classroom ; whether mask mandates are necessary among the vaccinated ; and pandemic resilience among vulnerable groups .
A patient ’ s severe right upper quadrant pain points to a rare congenital anomaly .
Dr Daniel Xu Academic co-ordinator , general practice research and international health , Curtin Medical School , Curtin University , Perth , WA .
Charlotte Dempsey Senior medical student , Curtin Medical School , Curtin University , Perth , WA .
MIGUEL , a 33-year-old male , presents to his GP for a recommended follow-up review and further investigation after an ED presentation with right upper quadrant pain , suspected secondary to biliary colic .
The ED discharge states that , at presentation , Miguel had severe right upper quadrant pain radiating to the back , with no associated fever or vomiting .
In ED , his observations were within normal limits . He was not jaundiced , but he had right upper quadrant tenderness with a positive Murphy ’ s sign but no hepatosplenomegaly .
LFTs showed ALP and GGT were slightly raised . FBC , EUC , CRP and lipase were normal , and urine culture was negative . Miguel ’ s pain settled with tramadol , and he was discharged and advised to follow up with a GP .
On review with his GP later that week , Miguel affirms this account of the presentation . He remains pain free , and his abdominal examination is now unremarkable .
Investigation
The GP refers Miguel for an abdominal ultrasound , which shows a possible duplicated gall bladder .
An abdominal CT is requested , which confirms the finding of a duplicated gall bladder , with two sets of gall bladder necks and sacs . The common bile duct is not dilated , and both the pancreatic duct and pancreas are normal .
There is mild thickening of the gall bladder wall without any gallstones . MR cholangiopancreatography ( MRCP ) is not performed because Miguel cannot afford the cost of this intervention .
Diagnosis
The initial diagnosis is biliary colic with an incidental finding of a duplicated gall bladder .
Management
Miguel is referred to the local outpatient surgical clinic for review regarding further investigation and / or cholecystectomy .
Discussion
A duplicated gall bladder is a rare congenital anomaly , with an incidence of one in 4000 . 1 The anomaly is classified according to the degree of duplication .
Type 1 duplicated gall bladders are either bilobed or septate and share a cystic duct .
Type 2 lesions involve true duplication , with two separate gall bladders and two
separate cystic ducts connecting either to the common bile duct or the cystic duct . 1 , 2 The latter type is more common .
Gall bladder duplication is not typically associated with any specific clinical features and may be difficult to clearly visualise radiologically . 3 Therefore , the duplicated gall bladder is typically detected incidentally — either noted with abdominal imaging or during abdominal surgery . 4
Ultrasound is typically the first-line radiological investigation to assess suspected biliary disease because of its high sensitivity and specificity . However , this modality is limited in its capacity to accurately determine anatomical variations of the biliary tree or to differentiate between forms of gall bladder pathology . 5