Drips, drains, and dressings

BMJ 2008; 337 doi: (Published 09 July 2008) Cite this as: BMJ 2008;337:a98
  1. Anthony Craighill, GP principal, Shoreham, Sevenoaks
  1. susan.craighill{at}

    After a restless night at home with increasing abdominal pain, followed by bilious vomiting in casualty and an ultrasound scan that showed “a thick-walled gall-bladder with multiple stones, some impacted in the neck,” the diagnosis of cholecystitis was obvious.

    So, my infrequent episodes over 20 years of retrosternal pains and unrelated rigors diagnosed by me as due to oesophageal spasm and viral infections had been nothing of the sort. How unsurprising—doctors who treat themselves have fools as patients.

    With my minimal right upper quadrant tenderness and a neutrophil count of 14 000, treatment was also obvious: intravenous antibiotics and remove the offending organ in six weeks’ time.

    An unpleasant week in hospital followed, largely because of the illness but compounded by poor communication, perfunctory examinations, and a misleadingly normal temperature chart (but then temperature goes up after a rigor and not at the time).

    It was great to go home, but five days later, after hours of rigors, I was back in casualty on a Friday night. This time, a thorough history and examination was conducted by the on-call surgical registrar. My minimal abdominal tenderness and neutrophil count of 21 000 resulted in intravenous antibiotics being recommenced and, in the morning, a visit from the on-call consultant.

    Like his registrar, the consultant had plenty of time to take a full history and make a thorough examination. Some fullness over the gallbladder area was noted, and the first thought was to continue intravenous treatment—but wait. Rigors a few days after antibiotics, a rising neutrophil count, and some abnormality on examination led to a rethink: “Well, you don’t look ill enough and should have more tenderness to have an empyema, but how else to explain the developing picture?” And thank heavens for that time honoured surgical aphorism, “If in doubt, cut it out.”

    The findings: gallbladder stuck to colon and duodenum, thick walled in part, but thin and friable in others, containing multiple stones, some impacted in the neck—and containing 150 ml of pus.

    So perhaps for me, postponement of a failed interview with the heavenly choir. And for all of us; don’t be slavishly led by test results, but allow them to do their job in building up the complete clinical picture. Thank you to the on-call surgeons for taking the time to listen.


    Cite this as: BMJ 2008;337:a98

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