This document discusses four clinical cases involving gallstones and bile duct issues. Case 1 involves a 40-year-old woman with acute gallstone pancreatitis who underwent medical treatment and may require surgery if symptoms recur. Case 2 is a 53-year-old woman with vague upper abdominal symptoms who was managed medically with follow up. Case 3 is a 67-year-old woman with jaundice, weight loss, and elevated tumor marker found to have a hilar mass requiring further investigation and management. Case 4 is a 41-year-old woman with acute gallstone pancreatitis and CBD stones seen on ultrasound who requires further evaluation and treatment.

1. Clinical cases
Hossam Ghoneim, MD

2. Case 1
• Female patient , 40 yrs, married with 2
children
• Presented with acute upper rt quadrant pain
referred to the back and rt shoulder, and fever.
• On examination the ebdomen was markedly
tender but no rigidity

3. Investigations
• Abdominal U/S
• Labs:
– Bil 2.1
– ALT, AST, 2 folds
– CBC Tlc 12000
– CRP 26

4. Treatment
1. Medical only
2. Surgical immediately
3. Antibiotics then surgery
4. Medical and surgery in case of recurrence

5. Bile acid therapy
• Small stone size (<0.5 to 1 cm)
• Mild symptoms
• Good gallbladder function (ie, normal filling
and emptying)
• Minimal calcification and low density on
computed tomographic (CT) imaging

6. Case 2
• Female patient, 53yrs,
• Presented with vague upper abdominal
discomfort, dyspepsia, nausea and occasional
vomiting.
• Clinical examination was unremarkable

7. Investigations
• U/S
• All lab results were
unremarkable

8. Management
• Surgical
• Medical and follow up
• Further investigations

9. Case 3
• Female patient, 67 yrs
• Presented with jaundice, dyspepsia and loss of
weight
• CA 19-9 was significantly raised
• MRCP showed a hilar mass
• ERCP confirmed
• Management?

12. Case 4
• Female patient 41, presented with acute
upper abdominal pain referred to the back
• Clinically the abdomen was very tender but
not rigid
• Ultrasound showed calcular cholecystitis with
few CBD stones and dilatation.
• What next?

13. • Diagnosis of acute gall stone pancreatitis
pancreatitis was established…
• What next?