Chapter 602

"Director Xia, hello." Zheng Ren answered the phone and said.

After solving several patients for Xiao Hua Nei Ke, Director Xia clearly recognized Zheng Ren's level.

After that, when Director Xia encountered a difficult case, she habitually started to ask Zheng Ren to take a look. Given her temperament, being able to do this is quite difficult.

"Chief Zheng, I have a patient here; could you please take a look?" Director Xia said.

Indeed, that's the case; Zheng Ren didn't mind, just taking a look—what big deal could there be?

Moreover, as Zheng Ren's Skill Tree progressed, he also needed to see more patients and accumulate clinical experience.

He greeted Zhong Min, who was on duty in Jizhenbingfang, and Zheng Ren went off to Xiao Hua Nei Ke.

Emergency consultation requires arrival within five Minutes. But for this kind of consultation where the director uses personal connections, there is essentially no time limit—it's done as a favor. Director Xia's words were No Rush, so Zheng Ren didn't need to rush over.

Upon arriving at Xiao Hua Nei Ke, Zheng Ren glanced at the doctors' office, didn't see Director Xia, so he went straight to the director's office door, knocked, and entered.

"Chief Zheng, you're here." Director Xia was reviewing images on the computer; seeing Zheng Ren enter, she stood up and said.

"Director Xia, what's the matter?" Zheng Ren asked.

"There's a patient whose diagnosis I'm unsure about; I always feel something's off—please take a look." Director Xia then guided Zheng Ren to the desk, pointing at the abdominal CT on the computer and said: "Your image-reading skills are high—what is this?"

Zheng Ren examined the images carefully, while Director Xia said: "The patient's chief complaint is intermittent right upper quadrant colicky pain for 7 months prior to admission. Episodes occur once a week, each lasting 1-3 days. During pain, the patient has no nausea or vomiting, no fever or jaundice. The most recent episode was 1 month ago."

Zheng Ren scrolled the mouse wheel with his right hand, carefully examining the images frame by frame while asking.

"Before admission, there was an ultrasound." Director Xia, whose work is very proficient, also paid special attention to this headache-inducing patient; for auxiliary exams she didn't need to check the slip, she just said: "Abdominal ultrasound suggests a fold in the upper part of the gallbladder, no gallstones, the gallbladder wall slightly rough. Intra- and extrahepatic bile ducts show no dilation, common bile duct diameter about 3mm."

"A fold?" Zheng Ren pondered.

The gallbladder fold shown on ultrasound is not to be taken literally; it's not like folding a piece of paper to bend the gallbladder.

In clinical terms, gallbladder folding refers to the phenomenon of folding of the gallbladder mucosa.

It is commonly seen in patients with chronic cholecystitis, and partly due to congenital developmental abnormalities. When symptomatic, it manifests as some digestive symptoms, such as bloating, etc.

Moreover, the patient's gallbladder wall being slightly rough can be diagnosed as cholecystitis.

After admission, given ceftriaxone anti-inflammatory treatment, after ten days the pain improved significantly, but the abdominal CT showed stones. Director Xia had some doubts, furrowing her brow.

Originally, the patient's symptoms improved, so discharge should have been possible.

Out of caution, Director Xia checked an abdominal CT before the patient's discharge.

Unexpectedly, the CT showed the patient's condition had not improved but worsened! Although inflammation had slightly improved, stones appeared in the gallbladder.

Yet the patient's symptoms hadn't worsened; instead, they were energetic and clamoring for discharge.

Such cases where the patient's self-reported symptoms conflict with clinical auxiliary tests are uncommon; each must be treated with caution.

Zheng Ren flipped through the abdominal CT images frame by frame, no longer asking Director Xia about the patient's condition.

What needed to be said has been said; other things don't matter.

Director Xia noticed Zheng Ren spending a few extra seconds looking at the gallbladder fold, then he continued looking.

Five or six Minutes later, Zheng Ren finished viewing the images and said: "Director Xia, the patient should not be diagnosed with cholecystitis."

"Huh?" Director Xia stared for a moment.

Should we directly overturn the original diagnosis? Is it necessary to be so direct?

However, Director Xia did not refute; she prepared to listen to Zheng Ren's explanation.

But Zheng Ren didn't explain; instead, he stood up, smiled, and said: "Let's do an MRCP."

"Is it necessary?" Director Xia wondered.

"Let's take a look at the patient; if I'm not mistaken, this patient should be a rare case of double gallbladder."

""

"CT images can only speculate; doing an MRCP makes it clear." Zheng Ren suddenly remembered something and asked: "Is the patient's family financially okay?"

"Not bad..." Director Xia said.

"If financial conditions allow… never mind, while doing an MRCP we might as well do an MR 3D reconstruction. The patient currently has no symptoms, but the examination should be thorough to decide how to operate." Zheng Ren said: "MRCP may have artifacts, making it impossible to determine whether the two gallbladder ducts merge and then drain into the common bile duct or drain independently into it"

Once it's clear, according to the Harlaftis classification of gallbladder malformation, being type 1 or type 2 variant helps decide the patient's surgical approach.

Director Xia sweated profusely.

Her purpose in seeking Zheng Ren was to determine why the patient's upper abdominal pain symptoms had eased, yet the examination revealed gallstones.

Unexpectedly, Zheng Ren didn't mention anything related to this at all, but instead brought up double gallbladder malformation?

Director Xia nearly spat out a mouthful of old blood.

But seeing Zheng Ren speak so seriously, she also had some doubts.

But the problem is, double gallbladder malformation…… Director Xia, even as a veteran clinical director, had never seen one.

Zheng Ren saw Director Xia not moving, basically had no intention of going to see the patient with him, a bit Strange, but then he realized.

"Director Xia, gallstones have nothing to do with biliary duplex malformation." Zheng Ren laughed, "The patient's gallbladder indeed has sludge-like stones; stop ceftriaxone, and it will be fine in three to five days."

"Huh?" Director Xia was now confused.

"After using ceftriaxone, reversible cholestasis symptoms occur; the reason is that calcium salts of ceftriaxone metabolites entering the bile easily precipitate in the gallbladder, becoming a 'stone nucleus', inducing gallstones." Zheng Ren said, "If you don't believe me, you can check the ceftriaxone package insert; it lists this complication."

"Well... what exactly is wrong with this patient?" Director Xia puzzled.

"Double gallbladder malformation, that's more serious. Meanwhile, the sludge-like gallstones induced by ceftriaxone can disappear after stopping the drug for a while, and are also called drug-induced gallbladder stones."

"Drug-induced?"

"For example, birth control pills, ceftriaxone, non-steroidal anti-inflammatory analgesics, intravenous high-nutrition drugs, pantoprazole, can all cause drug-induced gallstones." Zheng Ren said.

"How do you know that?" Director Xia asked further.

"In surgery, there have been cases where gallstones were diagnosed, but upon opening the gallbladder, nothing was found inside. Some just brushed it off; others, the family wouldn't let it go, and it became a medical accident. So I have studied this a bit more."

Director Xia knew Zheng Ren's level was not bad, but didn't expect it to be this high.

She picked up the phone and said, "Chief Zheng, wait a moment, I'll ask Director Wang about the Nuclear Magnetic Resonance."