Upper abdominal pain, fever and sub-icteric sclerae

Ten-year-old girl brought by her mother for abdominal pains since 6 days. History reveals fever 8 days earlier treated by Mum as malaria for 3 days with artemether-lumefantrine doses for weight and Paracetamol tablets 1g twice daily.On the third day, abdominal colicky pains started with an estimation of intensity as 3/10, associated to 2 episodes of non-projectile vomiting of food contents and saliva. Mum added to ongoing treatment, diclofenac 400mg suppository once daily for 2 days. The persistence of symptoms led to present consultation. We note a history of laparotomy about 4 years ago for Hirschprung’s disease. No related documents were available at the time of consultation. She is occasionally given non-steroidal anti inflammatory drugs at home for abdominal pains. She has a mild allergy to dust/pollen. Deworming was done in February. Immunisation with vaccines was stopped several years ago.
Clinical exam reveals anorexia, about 2kg weight loss since last year, one episode of loose stool (no blood nor mucus)  the previous day. No other new symptoms.
Temperature at 38 degrees Celsius. Heart rate:74bpm, Respiratory Rate: 27cpm.
Conjunctiva are coloured, Sclerae are subicteric, and there is a 2mm white plaque on left tonsil, and halitosis. Non distended flat abdomen, median longitudinal scar approx 6cm passing through ombilicus(of previous surgery). She has tenderness of the epigastrium and right hypochondrium (right upper quadrant) on superficial and deep palpation, with guarding(pain graded as 7/10). Tenderness on palpation of ombilicus and digital rectal exam.
The rest of physical exam was unremarkable.

STOP, THINK AND DIAGNOSE

Our diagnosis was Peritonitis by gall bladder perforation, gastric perforation or other intra abdominal organ.
As main differential diagnosis, acute cholecystitis or possibly another Cholestasis syndrome. We also thought of acute pancreatitis, and as a last differential an acute crisis of a peptic ulcer and associated malaria responsible for the mild jaundice.
A plain abdomen X-ray and ultrasound were requested. Biological work-ups of interest: Thick Blood smear, Rapid Diagnostic Test for malaria, Full Blood Count, Total and Conjugated Bilirubin, SGOT, SGPT, H. pylori. The X-ray image has been included.
The patient was referred to a pediatric surgeon to present results immediately they were available.
Abdominal ultrasound showed acalculous cholecystitis, and there was a homogeneous hepatomegaly.

Feedback from pediatric surgeon mentioned that enteral feeding was interrupted for the day and the child was placed on broad spectrum antibiotic and analgesics. Follow-up of other results still ongoing.

KEY POINTS:

-Think wide even at this age.

-Keen examination reveals more details as these sub-icteric sclera which had not been noticed by Mum nor child.

Question: Could the surgery done 4 years ago, be the etiology of this acute acalculous cholecystitis or is it linked to a current illness with hemolysis or…what?

Let’s discuss, comment on the frequency or rareness of the diagnosis, ask questions and as well, share your experience on these.
For a quick read on cholecystistis (from etiology to management and prognosis), check https://emedicine.medscape.com/article/171886-overview
and for an African case series on the disease,

https://www.ajol.info/index.php/ecajs/article/view/136499
We are eagerly waiting for YOUR CLINICAL  CASE too. THANKS ?