Medicine

1. CASE OF CHRONICCHOLECYSTITIS
QWhatis your case?(Summaryofacase of chroniccholecystitis)
Ans. This 35-year-oldladypresented with history ofrecurrent attack ofpain in right upper half of abdomen for last 1yeat.
The pain startedin theright upper half of the abdomen l year back, which was sudden in onset. The pain was colicky in
nature, severeinintensityandwas relieved by analgesics. The pain radiatedto the backofthe right side ofthe chest and right

2. 102
SECTION 1: Surgical Long Cases
shoulder region. Patient has similar attacks of pain for last lyearinitially at an interval of 3-4 months, but for
lastl month
patient is having dullaching constantpainin right upper half of abdomen. Patient complains of heart
burn,acidity,,Alatulenc,
and sensation offullness after meals for thesame duration. Bowel and bladder habits are normal. There are no
significan,
symptoms suggestive of any systemic disease. There are no significant past family or personal history.
On examination: On general survey patient is conscious and cooperative, no jaundice, anemia, pulse 86 beats/
min. On
abdominal examination, oninspection, the shape and contour of the abdomenis normal. Umbilicus is normal
Abdomen
is moving normally with respiration, no visible peristalsis, no pulsatile movement and skin of the abdomen iss
normal.
palpationthe abdomen has a normal soft elasticfeel. There is nosuperficial or deep tenderness in abdomen. Liver;
spleen are not palpable. No other mass is palpable. On percussion the abdomen is normally tympanitic and there is d
fluidin abdomen. (On auscultation normal bowel sounds are heard. External genitalia are normal. Per rectal and
per vaginal,
examination is not done. Systemicexamination is normal.
Q.What isyourdiagnosis?
Ans. This is a case ofchronic cholecystitis.
(Incase of mucoceleofgallbladder, the history and examination part is the same as chronic cholecystitis, except
abdominal examination on inspection there is aglobular intra-abdominal lump in the right hypochondriac and right lu
region moving up and dowm with respiration. On palpation alump is palpable in the said region, which is intra-abdomi
moving upand down withrespiration, nontender,surface issmooth,lowermargin, medialandlateralmarginsarepalpail.
but the upper margin is passing deep to the costal margin, it is tense cystic in feel. Liver and spleen are not palpable.
QHowwillyou demonstrate Murphy'ssign?
Ans. See abdomen examination (Figs. 3.15A and B, Page No. 70).
Q.When doyoufind Murphy'ssignispositive?
Ans. Murphy'ssignispositive in acute cholecystitis. In chronic cholecystitis Murphy's sign is not positive.
Q.Whatare the other possibilities in this patient?
Ans.
o Chronicduodenal ulcer
$ Chronic gastric ulcer
" Chronicpancreatitis
" Recurrent appendicitis
" Hiatus hernia
" Right-sided renal calculus
" Chronic pyelonephritis.
Q. How will you managethis patient?
Ans. Iwould like to confirm my diagnosis bydoing aUSG ofupper abdomen.
QHow ultrasonography helps in diagnosis ofbiliarytract disease?
Ans. Ultrasonography is areliable investigation for evaluation ofbiliary tract disease.
" Gallbladder:
» Size ofthe gallbladder whether gallbladderis normal sized, contracted or distended
Walls of the gallbladder--normal wall thickness or any thickening of wall
» Intraluminal calculi-intraluminalcalculi may be seen as aechogenic shadow in the gallbladder lumen withDou
anterior and posterior acoustic shadow. Any associated mass in gallbladder mnay be seen.
Common bile duct: The upper end of common bile duct may be seen and its diameter may be measured. Any
intraluminal
o Liver: Liver mnay be seen well and any solid or cysticlesion intheliver may be ascertained. Any dilatation oftheintrahepati
calculi in the bile duct lumen may be seen. However, stone at lower end of bile duct may sometimes be missedl onUSG.
biliary radicles may be seen well.
e Pancreas: The pancreas may be seen and any mass in relation to the pancreas may be seen wel. The diameter
of
the
pancreatic duct may be measured. Any calculus in the pancreatic duct or parenchymal calcification may
beseen.The
arenchymal echotexture may be seen clearly and chronic or acute pancreatitis may be diagnosed.
0. IfUSGshowsstone in gallbladderwhat elsewould you like to do?
Ans. If USG shows stone in gallbladder and common bile duct is normal and there is no history of jaundice
or
cholangits
hen no further investigation is required to confirm diagnosis of gallstone disease.
We would like to dosome more investigation toassess fitness of the patient for general anesthesia.
Complete hemogram: Hb%, TLC, DLCand ESR

3. " Biood for sugar, urea and creatinine
" Liver function test
" Urine for routine examination
" Chest X-ray (posteroanterior view)
" FCG.
0.When will youconsiderdoing an ERCPon MRCP in patient with gallstone disease?
Ans. Ulrasonographyis not always reliable for evaluation of bile duct as it is difficultto studythelower part ofthe bile duct
due tooverlapping bowel gas shadow. So evaluation ofCBD may need to be done in following situations:
" Ifthere is history of jaundice or the patient is having jaundice
Ifthere is suspicion of stonein the common bile duct on USG examination
"IfLFT shows elevation of serumenzymes--ALT, AST and alkaline phosphatase
USGshows dilatation of commonbile duct
* Patient presenting with acute cholecystitis has higher incidence ofCBD stones and hence needs evaluation.
o WhataretheadvantagesanddisadvantagesofMRCPforevaluationofbileduct?
Ans. Magnetic resonance cholangiopancreatography (MRCP) is anewer modality of investigation and it provides virtual
reconstructionofthe whole biliary tree from the slices of MRIofthe hepatobiliary tree and can give verygood picture of the
entire biliarytree. It is anoninvasive investigation,no radiation exposure, no dye is required. The biliary tract dilatation, any
obstruction due to stone or growth may be ascertained.
The limitation ofMRCP is that it has only diagnostic value as no intervention is possible.
Whataretheadvantagesand disadvantagesofERCP?
Ans.Theadvantage of ERCPistherapeuticinterventionlikesphincterotomyandstoneextractionorbiliarystentingis possibie.
Bile aspirated may be used for exfoliative cytology. Biopsyfrom periampullary lesion or brush cytology from the bile duct
mavbe taken.
QHow willyou treatthis patient?
Thisisan invasiveinvestigation. Itrequiresintroduction ofagastroduodenoscope, cannulationofbileand pancreaticduct
and injection ofadye. There is chance ofpostprocedure cholangitis or pancreatitis, which may be life-threatening.
Ans.
Ans. I willtreat this patientbycholecystectomy. Iwould prefer to do laparoscopic cholecystectomy.
Q
Whydoyoupreferlaparoscopiccholecystectomy?
" Laparoscopiccholecystectomyhas been established as gold standard for the treatmentofgallstone diseases
» Surgery is safe in the hands ofa trained surgeon
» Less pain, less hospital stays
» Cosmetic
» EarBy return to work is possible
> More acceptance by the patient.
Whileyoutakeconsentforlaparoscopiccholecystectomywhatconsentshouldbetaken?
Describethesteps of laparoscopiccholecystectomy?
Ans.
Ans. Informed consent ís to be taken. Patient should be explained that if laparoscopic procedure is not safe it may need
Conversion to open cholecystectomy.
Ans. SeeOperative SurgerySection, Page No. 801, Chapter 22.
Whataretheindsionsforopen cholecystectomy?
CHAPTER3: Abdomen
. Right subcostal incision (Kocher's incision)
Right upper paramedianincision
3. Midline incision
Mayo Robson'sincision. Right paramedianwith extension to midline
Upper abdominaltransverse incision (Fig. 3.34).
Wheredoyouplacemopsduringopencholecystectormy?
Ans.Duringopencholecystectomyafteropeningthe peritoneum and confirmation
of diagnosis,three mops are placed properlytoexposethegallbladder area..One mop
103
colon downward. (1) Another mop isinserted to retract the transverse colonand
tirtitFiit
4 3
splacedin the hepatorenal pouch of Morrisontoretract the hepatic flexure of the Fig. 3.34: Incisions for open cholecystec-
tomy (See text for 1, 2, 3, 4, 5).

4. 9
ophageal
reflux
disease.
"
Hiatus
hernia
"
Peptic
ulcer
"
Operative
damage
to
biliary
tree
"
A
stone
in
cystic
duct
stump
4
Missed
stone
in
common
bile
duct
The
important
causes
of
postcholecystectomy
syndrome
are:
postcholecystectomy
syndrome.
Ans.
Q
What
is
postcholecystectomy
syndrome?
»
Intraoperative
cholangiogram
shows
a
stone
in
common
bile
duct.
»
Gallbladder
contains
a
single
facetted
stone
with
cystic
duct
dilatation
»
»
Palpable
stone
in
common
bile
duct
is
t
h
e
absolute
indication
f
o
r
opening
t
h
e
common
bile
duct
*
Intraoperative
criteria:
»
Preoperative
USG/ERCP/MRCP
has
shown
stone
in
common
bile
duct
or
t
h
e
common
bile
duct
is
dilated.
»
LFT
is
abnormal
with
elevation
of
ALT/AST
and
alkaline
phosphatase
»
Patient
is
icteric
or
there
is
history
of
jaundice
or
cholangitis
*
Preoperative
criteria:
Ans.
This
decision
will
depend
on:
Q.
Whi
l
e
doi
n
g
gallbladder
is
oversewn
with
silk
suture.
Gallbladder
removed
leaving
behind
a
sleeve
of
neck
and
t
h
e
neck
of
t
h
e
Ans.
In
such
situation
there
is
risk
of
injury
to
t
h
e
bile
duct
while
dissecting
t
h
e
cystic
duct.
It
is
better
to
open
t
h
e
gallbladder
and
t
h
e
stones
ar
e
removed.
Fi
g
.
3.36:
Boundary
of
Calot'
s
triangle.
do?
Q.
If
t
h
e
Gallbladder
artery
artery
Hepaic
Cystic
bile
duc
comparable
to
laparoscopic
cholecystectomy.
little
postoperative
pain,
shorter
hospital
stay
and
it
has
been
claimed
to
be
about
5
cm
is
called
mini-cholecystectomy.
Thi
s
is
a
good
technique
wi
t
h
very
Ans.
Open
cholecystectomy
done
through
a
small
right
subcostal
Liver
duct
Cystic
Common
Comnon
Q.
What
is
mini-cholecystectomy?
controlled
by
pressure
and
packing
rather
than
by
blind
clamping.
and
divided
avoiding
injury
to
t
h
e
bi
l
e
duct.
If
there
is
bleeding
it
should
be
up
to
t
h
e
neck
of
t
h
e
gallbladder.
Thus
cystic
duct
may
be
identified
and
ligated
is
dissected
first
from
t
h
e
gallbladder
bed
and
t
h
e
gallbladder
is
dissected
of
f
so
it
is
better
to
do
a
fundus
first
cholecystectomy.
The
fundus
of
t
h
e
gallbladder
Ans.
In
such
situation
there
is
risk
of
injury
to
t
h
e
bile
duct
by
blind
dissection
tobe
Right
hepatic
Right
ductLef
lobe
you
do
then?
a
n
d
t
h
e
structures
in
t
h
e
Calot'
s
triangle
ar
e
a
cannot
be
identified
properly
what
do
Q.
Sometime
during
cholecystectomy
Calot'
s
triangle
area
is
found
densely
adherent
cholecystectomy
(See
t
e
xt
f
o
r
1,2,3).
Fi
g
.
artery
and
extends
from
t
h
e
neck
of
t
h
e
gallbladder
to
t
h
e
lesser
omentum.
Ans.
It
is
t
h
e
t
w
o
layers
of
peritoneum
covering
t
h
e
cystic
duct
and
t
h
e
cystic
Q.
What
is
cystic
pedicde?
is
crossed
by
t
h
e
cystic
artery
(Fig.
3.36).
common
hepatic
duct
and
above
by
t
h
e
inferior
surface
of
t
h
e
liver.
The
triangle
Ans.
Calot'
s
triangle
is
bounded
below
by
t
h
e
cystic
duct,
medially
by
t
h
e
.
What
is
t
h
e
boundary
of
Calot'
s
triangle?
Deaver'
s
retractor
(Fig.
3.35).
104
SECTION
1:
Surgical
Long
Cases
In
15%
cases
cholecystectomy
fails
to
which
relieve
t
h
e
symptoms
f
o
r
t
h
e
operation
was
done.
Th
i
s
is
c
a
l
a
Common
bile
duct
is
dilated
more
than
l
cm
cholecystectomy
when
wi
l
l
y
o
u
decide
to
explore
t
h
e
common
bi
l
e
duct?
cystic
duct
is
found
densely
adherent
to
t
h
e
common
bi
l
e
duct
what
wi
l
l
you
incision
of
3.35:
Placement
of
mops
duing
let
hand
of
t
h
e
assistant
and
by
retracting
t
h
e
liver
upwards
by
placement
of
a
(
3
)
The
Calot'
s
triangle
area
is
exposed
by
retracting
these
structures
wi
t
h
t
h
e
t
h
e
duodenum.
(
2
)
The
third
mop
is
placed
medially
to
retract
t
h
e
stomach.

5. lecte
a
dassical
attack
of
f
Aute
"
Gallstone
ileus.
"
Stones
migrated
into
t
h
e
Acut
e
pancreatitis
Recurrent
cholangitis
Obstructive
jaundice
Slones
migrated
into
t
h
e
bile
duct
Carcinoma
of
gallbladder
D
Empyema
of
gallbladder
Mucocele
of
gallbladder
cul
e
cholecystitis
a
n
d
i
t
s
sequelae:
Gangrene/
p
erforat
i
o
n/
l
o
cal
abscess/biliary
peritonitis
Chronic
cholecystitis
Biliary
colic
i
e
nt
stones:
Patient
is
asymptomatic
and
gallstone
detected
in
routine
check-up
St
o
nes
Ans
,
(
i
h
at
n
a
y
be
t
h
e
presentation
of
patients
wi
t
h
gallstones?
ot
answer
to
these
question.
Se
e
Surgical
Pathology
Section,
Gallstones
Diseases,
Page
No.
665,
Chapter
18.
H
o
w
chenodeoxychol
i
c
aci
d
(
C
DCA)
a
n
d
ursodeoxycholic
aci
d
(
U
DCA)
ma
y
prevent
st
o
ne
formation?
#hat
a
r
e
t
h
e
compositions
of
mi
x
ed
stones?
q
Ht
y
i
n
fect
i
o
n
is
important
f
o
r
development
of
gallstones?
Q
Wi
a
t
a
r
e
t
h
e
conditions
causing
reduced
bi
l
e
sal
t
s
concentration
in
bi
l
e
?
Q
Whi
c
h
fact
o
rs
inrease
cholesterol
secretion
in
bi
l
e
?
Q
Whi
c
h
fact
o
s
initiate
cholesterol
precipitation?
Q
Wha
t
is
nudeat
i
o
n?
Qi
n
shi
c
h
f
o
r
m
chol
e
st
e
rol
remai
n
s
in
solution
in
bi
l
e
?
Q
Wh
e
n
bi
l
e
becomes
supersat
u
rat
e
d
wi
t
h
chol
e
st
e
rol
?
a
Mhi
h
fact
o
rs
deternine
solubility
of
chol
e
st
e
rol
in
bi
l
e
?
A
H
o
w
chol
e
st
e
rol
st
o
nes
a
r
e
formed
in
t
h
e
gal
l
b
l
a
dder?
a
Wh
a
t
a
r
e
t
h
e
charact
e
ri
s
t
i
s
of
mi
x
ed
gal
l
s
t
o
nes?
A
Wh
a
t
a
r
e
t
h
e
charact
e
ri
s
t
i
c
Gof
pi
g
ment
gal
l
s
t
o
nes?
Q
Wh
a
t
a
r
e
t
h
e
ch
e
charact
e
ri
s
t
i
c
s
of
Mi
x
e
d
st
o
ne.
"
Pgment
stone
"
Cholesterol
stone
An
s
a
Wh
a
t
a
r
e
t
h
e
di
f
ferent
t
y
pes
of
gal
l
s
t
o
ne?
"
Appropriate
treatmetn
"
Upper
Gi
endos
c
opy
"
Bari
u
m
meal
.
U
S
G
of
upper
abdomen
Lver
funct
i
o
n
t
e
s
t
Ans
.
by
detailed
history
and
physical
examination
a
n
d
relevant
examination
Q
H
o
w
wi
l
l
y
o
u
manage
a
CHAPTER
3:
Abdomen
105
bi
l
i
a
ry
col
i
c
?
bolder
Pain
ma
y
last
l
o
r
f
e
w
inutes
to
several
hours.
Pai
n
is
often
cipitated
by
a
fat
t
y
meal
.
Attacks
of
pai
n
a
r
e
usually
onset
of
pain
n
right
upper
quadrant
of
abdomen,
severe
spasmodic
in
nature,
ma
y
radiate
to
back
of
chest
or
intestine
remaining
in
t
h
e
gallbladder
Patients
wi
t
h
gallstones
may
have
varied
presentations:
cholesterol
galstones?
depending
on
t
h
e
cause.
|
X
-ray
of
esophagus,
stomach
and
duodenum
"
Clinicalevaluation
pat
h
t
i
i
w
ent
postcholecystectomy
syndrone?

6. formation
(Fig.
3.37).
to
as
is
wi
t
h
cholesterol
Fig.3.37:
Cholesterol
solubility
y
i
n
t
h
e
optimumn
concentration.
Thi
s
keeps
percentage
of
bi
l
e
salts
and
lecithin)
Ans.
In
normal
bile
t
h
e
cholesterol,
phospholipids
and
bile
salts
remain
in
Q.
What
is
lithogenic
bi
l
e
?
100
90
80
Percentage
of
bi
l
e
sal
t
60
50
40
30
20
10
70
This
may
be
associated
with
cholesterol
stones
in
gallbladder.
appear
as
yellow
specks
and
t
h
e
interior
of
t
h
e
gallbladder
looks
like
a
strawberry.
Ans.
There
is
deposition
of
cholesterol
crystals
in
t
h
e
submucosa
and
they
may
Micellar
l
i
q
ui
d
0.
What
is
strawbery
gallbladder?
"
Following
"
Critically
i
l
l
patients
in
intensive
therapy
unit
S
Ans.
30
0.
What
P
e
r
c
e
n
t
a
g
e
o
f
c
h
o
l
e
s
t
e
r
o
l
known
as
acalculous
90
100y0
Ans.
Acute
or
chronic
inflammation
of
t
h
e
gallbladder
in
absence
of
gallstone
is
Q.
What
is
acalculous
cholecystitis?
In
50%
cases
t
h
e
contained
pus
is
sterile.
Ans.
Gallbladder
is
filled
with
pus
Q
What
is
empyema
of
gallbladder?
The
content
is
usually
a
clear
sterile
fluid.
Q.
What
is
mucocele
of
gallbladder?
Perforation
into
a
neighboring
viscus
most
commonly
duodenum,
stomach
or
colon.
guard
or
rigidity
in
right
upper
quadrant
of
abdomen
»
Localized:
Localized
abscess
formation
manifested
by
severe
pain,
fever
with
chill
and
rigors,
and
extreme
tendere
*
Perforation
of
gallbladder:
Perforation
may
be
of
rebound
tenderness
"
Gangrene:
Infection
may
lead
to
gangrenous
change
in
gallbladder
manifested
by
increasing
pain,
toxemia
a
n
d
appeare
"
Resolution:
Inflammation
subsides
and
patient
recovers
Ans.
Q
What
a
r
e
t
h
e
sequelae
of
acut
e
cholecystitis?
»
USG
examination
may
diagnose
acute
»
Liver
function
test:
There
may
be
mild
rise
of
serum
bilirubin
»
Leukocytosis
is
usually
a
feature
*
Investigation
»
A
vague
mass
may
be
palpable
»
Murphy'
s
si
g
n
wi
l
l
be
positive
»
Abdominal
examination
may
reveal
marked
tenderness
in
right
upper
quadrant
of
abdomen
»
*
Examination
»
>
Marked
nausea
and
vomiting
shoulder.
Later
on
pai
n
becomes
dull
aching
and
constant
and
usually
lasts
longer
than
24
hours
"
History
Ans.
»
Acute
onset
pai
n
in
right
upper
quadrant
of
abdomen.
Severe
spasmodic
in
nature
wi
t
h
radiation
back
or
he
tg
Q
What
a
r
e
t
h
e
or
rarely
in
t
h
e
l
e
f
t
upper
quadrant
of
t
h
e
abdomen
(
i
n
4%
cases).
106
self-limiting,
but
SECTION
1:
Surgical
Long
Cases
known
lithogenic
bi
l
e
this
as
predisposes
gallstone
cdenote
normal
solubility
r
a
n
ge
of
c
h
o
l
e
s
t
e
r
a
cholesterol
in
solution.
Bi
l
e
supersaturated
b
i
l
e
s
a
l
t
major
surgery,
trauma
or
burns.
a
r
e
t
h
e
predisposing
factors
f
o
r
development
of
acal<ulous
cholecystitis?
cholecystitis.
and
may
follow
as
a
consequence
of
acute
cholecystitis
or
as
result
of
infection
of
amucoc
in
t
h
e
gallbladder
is
absorbed
by
t
h
e
gallbladder
epithelium
and
is
replaced
by
mucus
secreted
by
t
h
e
gallbladder
epithel.
Ans.
When
there
is
obstruction
to
t
h
e
cystic
duct
or
t
h
e
neckof
t
h
e
gallbladder
by
a
stone
or
a
growth
then
t
h
e
containedb|
and
extreme
tenderness
al
l
over
abdomen
»
Generalized
perforation:
Leading
to
generalized
biliary
peritonitis
manifested
by
generalized
pai
n
abdomen,
musi
cholecystitis,
wal
l
thickerning,
pericholecystic
fluid
collection.
Tachycardia
and
jaundice
may
be
present
Fever
features
of
acute
cholecystitis?
recur
in
an
unpredictable
manner.
Fever
and
leukocytosis
ar
e
uncommon.
Pain
may
in
Occur
i
the
epgat

7. LFT,
sis,
en
er
and
ted
on
bile
uct.
unrelated
dition,
vided
t
h
e
osure
is
quate
and
narcotics
Ans.
Diferent
series
has
reported
high
incidence
of
biliary
symptoms
following
abdominal
surgery
with
incidental
finding
Q
Wh
a
t
is
incidental
cholecystectomy?
"
Mul
t
i
p
l
e
smal
l
gallstones
Porcelain
"
Lar
g
e
gallstones
(>2.
5
c
m
)
Candidates
f
o
r
renal
transplant
+
Patients
on
immunosuppressive
therapy
*
Diabetic
patients
i
n
di
c
at
e
d.
in
population
at
hi
g
h
J
o
ng
f
o
l
l
o
w-
u
p
it
per
1%
is
is
of
established
that
t
h
e
chance
h
a
v
e
t
h
e
chance
of
developing
symptoms
over
20
years.
Q
Wh
e
n
do
y
o
u
consi
d
er
An
s
.
Ther
e
is
hi
g
h
Q
Wh
a
t
is
t
h
e
n
nat
u
r
a
l
history
of
silent
gallstones?
An
s
.
In
west
e
rn
popul
a
t
i
o
n,
1
0
%
of
Q
Wh
a
t
is
t
h
e
i
n
ci
d
ence
o
f
s
s
J
m
p
t
o
m
s
,
a
r
e
cal
l
e
d
silent
gallstones.
a
Wh
a
t
do
y
o
u
me
a
n
by
silent
galistone?
An
s
.
I
n
c
i
d
e
n
t
a
l
l
y
or
in
routine
health
check-upt
during
examination
f
o
r
other
yfound
gallstones
f
silent
gallstones?
CHAPTER
3:
Abdomen
107
there
ar
e
no
iated
liary
risk
ctors,
e-g.,
rmal
Simple
stectomy
is
now
widely
mended
as
a
comitant
rocedure
during
t
h
e
course
of
arotomy
f
o
r
and
associated
gallstones.
of
gallstones.
Increased
incidence
of
cholecystitis
in
t
h
e
postoperative
period
is
due
to
bile
stasis,
dehydration,
fasting,
use
of
gallbladder
in
vieWof
increased
risk
of
carcinoma
of
gallbladder.
Datfents
living
in
high-risk
areas
where
there
is
increased
incidence
of
gallbladder
carcinoma
developing
ri
s
k
of
complications.
Thi
s
includes:
An
s
.
Prophylactic
in
al
l
patients
cholecystectomy
wi
t
h
silent
gallstones.
Prophylactic
is
not
cholecystectomy
indicated
is
developing
synptoms
approximately
year.
So
,
onl
y
20%
patients
r
prophylactic
in
silent
cholecystectomy
gallstones?
incidence
of
silent
gallstones
in
t
h
e
community.
However,
al
l
t
h
e
patients
do
not
develop
synptoms.
In
men
and
2
0
%
of
women
have
silent
gallstones.
pathology
that
does
not
produce