# Clinical Cases: Liver, Gallbladder, and Pancreas ## Case 1: Acute Cholecystitis ### Clinical Presentation A 45-year-old obese female presents with severe right upper quadrant pain that began after a fatty meal 12 hours ago. The pain is constant, radiates to her right shoulder and infrascapular region, and is associated with nausea and vomiting. She has had similar but milder episodes in the past that resolved within a few hours. On examination, temperature is 38.5C, blood pressure is 140/90 mmHg, and heart rate is 100 beats per minute. Abdominal examination reveals tenderness in the right upper quadrant with guarding. Murphy's sign is positive - the patient catches her breath when the examiner's fingers palpate deeply at the gallbladder point during inspiration. Laboratory studies show leukocytosis of 14,000/mm3 and mildly elevated liver enzymes. Right upper quadrant ultrasound demonstrates multiple gallstones with gallbladder wall thickening to 5 mm, pericholecystic fluid, and a positive sonographic Murphy's sign. She undergoes laparoscopic cholecystectomy the following day with identification of the critical view of safety within Calot's triangle. ### Radiographic Findings ![Gallstones](case_01_image.jpg) *Image: Gallstones removed from the gallbladder. Calculous cholecystitis is caused by impaction of a stone in the cystic duct or gallbladder neck. Source: Wikimedia Commons, Public Domain.* ### Key Anatomical Points - The gallbladder lies in the gallbladder fossa on the visceral surface of the liver between the right and quadrate lobes - The cystic duct joins the common hepatic duct to form the common bile duct - Calot's triangle is bounded by the cystic duct inferiorly, common hepatic duct medially, and liver superiorly - The cystic artery typically arises from the right hepatic artery and crosses within Calot's triangle ### Key Learning Points - The "critical view of safety" requires visualization of only two structures (cystic duct and cystic artery) entering the gallbladder - Murphy's sign indicates gallbladder inflammation when the inflamed organ contacts the examining hand during inspiration - Referred pain to the right shoulder occurs via visceral afferents traveling with the greater splanchnic nerve to T7-T9 - Gallbladder pain may also be referred to the infrascapular region through the same dermatomal distribution --- ## Case 2: Acute Pancreatitis ### Clinical Presentation A 52-year-old male with a history of heavy alcohol use presents with severe epigastric pain that began 8 hours ago after a drinking binge. The pain radiates straight through to his back and is partially relieved by leaning forward. He has had multiple episodes of vomiting. On examination, he is tachycardic at 115 beats per minute with blood pressure of 100/60 mmHg. He appears uncomfortable and diaphoretic. Abdominal examination reveals epigastric tenderness with voluntary guarding but no rigidity. Bowel sounds are hypoactive. There is faint periumbilical ecchymosis (Cullen sign). Laboratory studies show lipase elevated at 1,850 U/L (normal <160), amylase 980 U/L, and mildly elevated liver enzymes. CT scan reveals an edematous pancreas with surrounding fat stranding and a small peripancreatic fluid collection. He is admitted for aggressive IV fluid resuscitation, pain control, and bowel rest with gradual improvement over 5 days. ### Key Anatomical Points - The pancreas is a retroperitoneal organ extending from the duodenal C-loop to the splenic hilum - The pancreatic head lies within the duodenal curve; the neck overlies the portal vein formation site - The splenic vein runs along the posterior surface of the pancreatic body and tail - The pancreas lacks a complete capsule, allowing inflammatory exudate to spread into the retroperitoneum ### Key Learning Points - Pain radiating to the back reflects the retroperitoneal position of the pancreas against the vertebral column - Cullen sign (periumbilical ecchymosis) and Grey-Turner sign (flank ecchymosis) indicate hemorrhagic pancreatitis - The two most common causes are gallstones and alcohol, accounting for 80% of cases - The main pancreatic duct joins the common bile duct at the ampulla of Vater - a stone impacted here can cause biliary and pancreatic obstruction --- ## Case 3: Pancreatic Head Adenocarcinoma ### Clinical Presentation A 68-year-old male presents with progressive jaundice over 3 weeks. His wife noticed yellow discoloration of his eyes, and he reports dark urine and pale stools. He has lost 8 kg over 2 months and describes vague epigastric discomfort. He has no history of gallstones, alcohol abuse, or liver disease. On examination, he is deeply jaundiced with scleral icterus. The abdomen is soft with a non-tender, palpable gallbladder (Courvoisier sign - a palpable, non-tender gallbladder in a jaundiced patient suggests malignant biliary obstruction rather than stones). Total bilirubin is 12 mg/dL with elevated direct fraction. CA 19-9 tumor marker is elevated at 850 U/mL. CT scan reveals a 3 cm mass in the pancreatic head encasing the superior mesenteric vein with biliary dilation. ERCP with biliary stent placement provides symptomatic relief. Staging evaluation shows no distant metastases, and he undergoes neoadjuvant chemotherapy followed by Whipple procedure (pancreaticoduodenectomy). ### Key Anatomical Points - The common bile duct passes through or behind the pancreatic head before entering the duodenum - Tumors of the pancreatic head obstruct the bile duct, causing painless jaundice - The superior mesenteric vein and artery lie immediately behind the pancreatic neck - The Whipple procedure removes the pancreatic head, duodenum, distal common bile duct, gallbladder, and often distal stomach ### Key Learning Points - Courvoisier's law: painless jaundice with palpable gallbladder suggests malignant obstruction; gallstone obstruction causes a contracted, scarred gallbladder - The portal vein forms behind the pancreatic neck from the junction of the SMV and splenic vein - Vascular involvement (SMA, SMV, portal vein) often determines surgical resectability - The head of the pancreas receives blood from the pancreaticoduodenal arcades, sharing supply with the duodenum