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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 ?

13 responses to “Upper abdominal pain, fever and sub-icteric sclerae”

  1. DJOU TSAPI GÉDÉON avatar

    Wow this wonderful I will like to be part of this page

    1. admin avatar

      You’re welcome. To be a part of the page, we all should subscribe. I noticed you already did.

  2. Bakia Junior avatar

    Awesome presentation. God bless you abundantly

    1. admin avatar

      Thanks. You too. You’re welcome to subscribe ☺️

  3. Calson Ambomatei avatar

    I would go for acute cholecystitis based on the followinig arguments:
    -Low-grade fever
    -Mild jaundice
    -Tenderness on palpation of right hypochondrium
    -absence of abdominal distention
    -Vomitting, which could be caused by the accumulation of bile pigments
    Differential diagnoses:
    -angiocholitis
    -Viral hepatitis
    -occlusion caused by adhesions from the first surgery

    1. admin avatar

      Thanks for the insight Dr.

  4. TetuAl avatar

    Waooh….this is a pretty straight forward case unlike the ones we have had here recently.

    I hope some counselling was done to the mother with regards the frequent use of NSAIDS and the importance of rightly dosing paracetamol.

    1. admin avatar

      Yes Dr., Counseling was initiated and would be intensified.

  5. admin avatar

    Looking at the X-ray, are there aspects, direct or indirect, in favour of acalculous cholecystitis?

  6. Mylène ARLÈNE avatar

    Thanks for the presentation..An interesting one and straight forward…
    We should not forget the counselling to the parents about the effects about the use of NSAID, i think she should catch up too with her vaccinations and better investigations and counselling done about her allergy to dust and pollen after the surgery

    1. admin avatar

      Thanks for going through. As earlier mentioned, counseling has begun and we would see how to add all the other points.

  7. Vanessa Ayafor avatar

    Great presentation and nice comments. I just think malaria should not have figured here again as explanation to jaundice. The diagnosis alone can cause jaundice plus the patient had received 3day treatment for malaria appropriate for age and weight.
    We may always see malaria if we look for it because we live in an endemic zone.
    Again good detailed history

    1. admin avatar

      Thanks for going through and for the insight.
      Acalculous cholecystitis usually has an underlying pathology as a cause. P.falciparum has been previously found as one of the causes…We couldn’t verify if the initial parasitemia was high beyond threshold for an oral treatment…
      I think malaria +gastric ulcer still appears because we generally prefer thinking wide and then narrow down…

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Upper abdominal pain, fever and sub-icteric sclerae