The possibility of diagnostic errors increases if acute cholecystitis develops against a background of heart disease (rheumatic endocarditis, ischemic heart disease, etc.).
Patient F. 48, was taken to the emergency surgery clinic with the diagnosis "Acute cholecystitis." Rheumatism: recurrent rheumatic carditis, latent flow., Stenosis of the left atrioventricular orifice, insufficiency of the mitral valve., Cirrhosis of the liver, portal hypertension. "
Complains of pain in the right upper quadrant, nausea, several times there was vomiting, shortness of breath, palpitations, enlarged abdomen, swelling on the legs.
The condition worsened two days ago, when pains appeared in the right hypochondrium without apparent causes, and the heart rate increased.
In his youth, heart disease was discovered. The last 7 years, sometimes worried about shortness of breath, palpitation, on the legs began to appear swelling. Therapy with cardiac glycosides and diuretics provided a quick effect. 3 years ago, dyspnea became permanent, swelling on my legs did not disappear, ascites appeared. Before admission to the clinic, the patient took the same therapy (cardiac, diuretic drugs), which allowed her to serve herself.
Objectively: the patient's condition is heavy, nervous, restless. Cyanosis of the lips, acrocyanosis. Dyspnea - the number of breaths 26 per minute. In the lungs, vesicular breathing, somewhat weakened in the lower parts, does not wheeze. The boundaries of the heart are widened in all directions. The tones are muffled, a pronounced systolic murmur on the apex and at the Botkin point radiating into the axillary region. Accent 2 tones on the pulmonary artery. AD-110/80 mm. gt; Art. The pulse is arrhythmic, 116 per min, with frequent extrasystoles. The tongue is dryish, coated with a yellowish white coating. The abdomen is enlarged in volume. Fluid fluid in the abdominal cavity is determined. At palpation - diffuse soreness with localization in the right upper quadrant. The liver is dense, the edge of it is sharp, protruding from under the rib margin by 10 cm. Edema on the legs.
Blood test: Er. 4.5 x 10,000,000,000, heme-1,96 mmol / l, leukemia-9,3 X 1,000,000,000, p / am-6, segment-62, lymph. -24, mon. - 8, ESR - 15 mm / hour.
The conclusion of the surgeon - data for an acute surgical pathology is not present. Pain in the right upper quadrant is due to impaired blood circulation.
Therapist is invited to the consultation. After examining the patient, he came to the conclusion that the patient's adequate response to the reception of cardiac glycosides indicates the absence of an overdose of the drug and the vomiting present in the clinic of the disease can not be explained by the cumulation of the cardiac glycoside, and hence the pain in the right subcostal area can not be, are explained by acute enlargement of the liver observed in right ventricular heart failure, as the signs of circulatory disturbances remained the same (from the data of the outpatient card: the dimensions of the liver did not change yalis for a year). The assumption about surgical, a pathology - an acute cholecystitis is made.
The presence of a weakSymptom Shchetkin-Blumberg allowed to make an assumption about peritonitis, the manifestos of which could be hidden (veiled) by circulatory insufficiency.
At the consultation it was decided to observe the patient inconditions of therapeutic hospital. After 6 hours after transfer to the therapeutic department, the patient's condition deteriorated sharply, jaundice appeared. During the following hours of observation, hyperthermia was noted, the patient fell into a coma and died the next day.
Clinical diagnosis: Rheumatism. Recurrent rheumatic carditis, latent flow, stenosis of the left atrioventricular orifice, insufficiency of the mitral valve. Cirrhosis of the liver. Ascites. Hepatic coma.
Pathoanatomical diagnosis: Acute gangrenous cholecystitis. Spilled peritonitis. Rheumatism. Recurrent rheumatic carditis, latent flow. Stenosis of the left atrioventricular orifice, insufficiency of the mitral valve. Cirrhosis of the liver. Ascites. Hepatic coma.
What additional methods of investigation needed to be done to establish the correct diagnosis? Laparoscopy.
On the basis of what data clinic disease could be suspected diagnosis of acute cholecystitis? Acute development of the disease - pain, vomiting, a stable course of the therapeutic disease.
This example shows that the joiningstagnation, including the liver, can mask the inflammatory process in the gallbladder. At the same time, one should not forget that an attack of acute cholecystitis can serve as an impetus to the development of acute cardiovascular insufficiency.
"Acute cholecystitis against a background of heart disease" and other articles from the section Symptoms and Diagnosis of Surgical Diseases