CASE HISTORY

The patient, who had had ten pregnancies had suffered from chronic constipation and attacks of flatulent dyspepsia for three years. These were usually relieved by vomiting. On the morning before admission she suddenly developed a severe pain at the lower end of the sternum going through to the back. This persisted and was accompanied by nausea but no vomiting. On admission she was obese and slightly jaundiced.T.100.4; P.80; R.20. There was tenderness in the upper abdomen but very little rigidity. She was treated expectantly and a cholecystography was performed and failed to visualise the gall-bladder. Blood count showed no leucocytosis. Her condition improved greatly and 28 days after admission a  cholecystectomy was performed. The gall-bladder was found to be surround by adhesions. She made a satisfactory recovery and reported fit two months later.

PATHOLOGY

The gall-bladder has been split sagittally and the two halves mounted. It is enlarged and at operation it was still further distended with muco-purulent fluid containing no bile. The lumen is packed with numerous facetted mixed cholesterol stones. The wall is greatly thickened and badly disorganised. The mucous membrane is covered by a mass of blood and fibrinous  exudate. The actual wall is thick and oedematous and its appearance suggests an  inflammatory infiltration. Over the outer surface there is a layer of blood stained fibrin. The absence of bile and the thickness of the wall suggest a long standing lesion whilst the fibrinous exudate and haemorrhage indicate a recent superadded inflammatory process.