Case Presentation

Lump Right Hypochondrium

MODERATOR
Dr. Nandan Rai
Dr. Shabi Ahmad
Junior Resident
MS, FIAGES, FACS,FAIS MLN Medical College
Professor and Head Prayagraj
PG Dept. of Surgery
MLN Medical college
Prayagraj
Mrs.K, 68 yr lady,
Housewife from prayagraj
Socioeconomic status : Lower Middle

Chief complaints :
• On /off pain in right upper abdomen 3 month
• Loss of appetite
Weight loss 1 month
 History of present illness
• Pain in right upper abdomen for 3 months
• -- sudden onset, colicky in nature
– Radiating to back and right shoulder
– Aggravated on taking meal and subsided on its own after
about an hour.
– Pain associated with feeling of fullness in abdomen but not
associated with nausea and vomiting
– From past one month Pain has changed to dull aching pain,
non radiating which doesn’t subside on its own.
• Progressive loss of appetite for 1 month { diet decreased from
4-5 chapattis to 1 chapatti a day }.

• Progressive weight loss ~5-6 kg in past 1 month (not

documented)
• No h/o prodromal symptoms
• No h/o yellowish discoloration of eyes or high colour urine
• No h/o pruritus
• No h/o vomitting / hemetmesis/malena
• No h/o altered bowel habit.
• No h/o abdominal distension
• No h/o chest pain/hemoptysis/bone pain/seizures
 Past History
• No h/o jaundice in past
• No h/o chronic drug intake
• No h/o previous surgeries/blood transfusion
• Not a known case of Diabetes, Hypertension , Pulmonary TB ,
Cardiac or Respiratory disease.
 Family History
• Both her parents died ~20 yrs back likely of natural causes.
• No h/o cancer/cancer related deaths in the family

Obstetric history
• G4P4L4
• All children in good health.
• Menopause attained 16 years back. No h/o post menstrual
bleeding.
 Personal History
• Predominantly Vegetarian diet
• Beedi smoker ~ 30 years ( 1 bundle per day )
• Non alcoholic non tobacco chewer/ No high risk behaviour.
• Normal sleep pattern.
• Normal bladder habits
 General Physical Examination
• After obtaining consent , patient examined in a well lit room
with proper consent, adequate exposure and privacy.
• Conscious, cooperative , well oriented to time place and person.
Lying supine comfortably on bed.
• Performance status : ECOG ~1
• Karnofsky score: 80
• Nutrition : BMI- 17.6 kg/m2 (ht-160cm, wt-45kg)
MAC : 18 cm
• Hydration : adequate
• Vitals
– Temp – Afebrile (98.8 F)
– PR- 80/min, right radial artery , regular rhythm, normal volume
– BP- 110/60 mmHg right arm in Supine Posture
– RR – 18/min thoracoabdominal

• Pallor present
• Icterus absent
• No Cyanosis, clubbing, pedal edema
• No Stigmata of Chronic liver disease
• No Generalised lymphadenopathy
• No Scratch marks present over limbs.
Systemic Examination
(WITH PROPER CONSENT, ADEQUATE EXPOSURE AND PRIVACY)
Inspection
• Symmetrical in shape
• No visible fullness/ no distention of
abdomen
• Umblicus is inverted, centrally
placed ,no nodules
• No visible dilated veins
• No visible peristalsis/pulsations
• No scars/scratch marks/sinuses/visible lump.
• Hernial orifices- normal.
• External Genitilia- normal.
Palpation
• Soft, No tenderness
• Gall bladder lump palpable in right hypochondrium and right
lumbar region measuring 8 *5 cm in size extending 5 cm
below costal margin ,6 cm lateral and 2 cm medial to
midclavicular line.
• Globular shaped, smooth surface, variable consistency, with
defined lateral, medial and lower borders.
• Finger can not be insuminated between lump and costal margin
• No evidence of hepatomegaly or spleenomegaly.
Percussion
• Liver span-11cm (from 5th intercostal space in midclavicular
line)
• No evidence of free fluid in abdomen.
• Tympanic note over rest of abdomen.
• Auscultation
Bowel sounds present.

• PV : Within normal limits.

• PR :
– Perianal skin normal.
–Anal tone normal.
–Gloved finger stained with yellow stools
–No growth felt. No Blumer’s shelf
• Spine examination within normal limits.
 Other systemic examination
• Central nervous system
Higher mental functions normal.
No focal neurological deficit present.
• Respiratory system
Bilateral air entry equal.
No added sounds.
• Cardiovascular system
S1 and S2 sound heard.
No murmur
 Summary
68 yr lady presenting with complaint of right upper abdomen pain
initially episodic colicky which changed to continous dull aching
pain with anorexia and significant unintentional loss of weight
without prodromal symptoms, jaundice or altered bowel habit.
On examination patient anicteric with a palpable gall bladder
lump, and no signs of chronic liver disease or ascites.
PROVISIONAL DIAGNOSIS
Lump gall bladder likely malignant tumor without jaundice,
ascitis or distant metastasis.
DIFFERENTIAL DIAGNOSIS
Carcinoma gall bladder without distant metastasis.
Mucocoele gall bladder
THANK YOU
 Summary
• 68 yr lady presenting with complaint of right upper abdomen
pain initially episodic colicky which changed to continous dull
aching pain with anorexia and significant unintentional loss of
weight without prodromal symptoms, jaundice or altered bowel
habit.