A 21-year-old woman was admitted with sudden onset of right upper quadrant pain radiating to the back associated with some nausea. There was no antecedent history. The pain was fluctuating and ongoing. Ultrasound at the referring hospital showed no gallstones, dilatation, wall thickening or pericholecystic fluid. The common duct was normal at 4mm. CT scan at the referring hospital was read as normal. An upper abdominal cut is shown. On admission the patient was afebrile with totally normal laboratory values. She was 3+ tender in the right upper quadrant with a positive Murphy’s sign. Repeat ultrasound was again normal. When the symptoms persisted after overnight observation, HIDA scan was performed. The gallbladder filled promptly, but the ejection fraction was only 19%. The patient was taken to the operating room for laparoscopic cholecystectomy with a diagnosis of biliary dyskinesia.
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On entering the abdomen, there was a massively dilated loop of colon immediately evident. Laparoscopic exploration was undertaken to rule out sigmoid volvulus (see sigmoid volvulus, and cecal bascule, frame 36.)
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