Patient Summary: Mrs. Siuli Khatun, 29F — Lab & USG Report Analysis (23 Jul 2026)

Abnormal Findings at a Glance

Diagnosis

1. Mild Normocytic Anemia with High RDW

• Hb 9.8 g/dL with MCV 93.7 fL (normocytic) and normochromic smear (confirmed on peripheral blood smear - no abnormal cells).
• Elevated RDW 14.8% suggests mixed nutritional deficiency (iron + B12/folate) or early iron deficiency in a normocytic phase, or anemia of chronic inflammation.
• In a 29-year-old woman, the most common causes are:
  • Iron deficiency (early/mixed - can still be normocytic with high RDW before becoming microcytic)
  • Mixed deficiency (iron + folate/B12) - gives normocytic picture with high RDW
  • Anemia of chronic inflammation (normocytic normochromic, as seen here)
• The peripheral smear being normocytic/normochromic without abnormal cells makes hemolysis or hemoglobinopathy less likely.

2. Acalculous Cholecystitis (Primary USG Finding)

• Gallbladder wall 4.3 mm (threshold >4 mm) - thickened
• Pericholecystic edema present
• No intraluminal calculus - making this acalculous

Important caveat from Sleisenger & Fordtran's (p.1279): "Thickened gallbladder wall (>4 mm) in the absence of ascites or hypoalbuminemia" is the US criterion for acalculous cholecystitis. This patient has free fluid in POD and hepatomegaly, so the gallbladder thickening may be secondary (reactive/non-inflammatory) rather than primary acalculous cholecystitis.

3. Hepatomegaly (156.8 mm in oblique axis)

• Normal liver oblique diameter is ~150 mm; 156.8 mm = mild hepatomegaly.
• Normal echo-texture, no focal lesion - suggests a diffuse cause (e.g., viral hepatitis, fatty liver, infiltrative disease, heart failure, lymphoma).
• The radiologist specifically recommended viral markers to rule out viral/infective hepatitis (Hepatitis B, C, E in this region).
• LFTs are completely normal - argues against active hepatitis but does not exclude early infection or non-alcoholic fatty liver disease (NAFLD).

4. Moderate Free Fluid in POD Extending to Both Adnexae (Ascites/Pelvic Collection)

• Ruptured ovarian follicle / physiological - but "moderate" fluid extending to both adnexae is more than expected from follicle rupture alone
• Pelvic inflammatory disease (PID) - very common in reproductive-age women; can also cause reactive gallbladder wall thickening
• Systemic disease with serositis - e.g., SLE, TB peritonitis
• Ovarian pathology - both ovaries show dominant follicles (14.1 mm right, 12.4 mm left); no complex cystic lesion seen; no evidence of ectopic pregnancy noted

5. Elevated A/G Ratio (1.8, reference 1.2–1.5)

• Albumin 4.6 g/dL (normal), Globulin 2.5 g/dL (normal) - but the ratio is 1.8.
• A high A/G ratio can occur with hypogammaglobulinemia, though both values are individually normal. This is a borderline finding, less clinically significant here.

Integrated Clinical Picture - Most Likely Diagnoses

A. Pelvic Inflammatory Disease (PID) with Perihepatitis (Fitz-Hugh-Curtis Syndrome)

• PID can cause peritoneal fluid, reactive gallbladder wall edema, and hepatic capsule inflammation (perihepatitis)
• Should be at top of differential given age and free fluid pattern
• Workup: high vaginal swab, cervical swab for Neisseria gonorrhoeae and Chlamydia, CRP, ESR (ESR here is 5 - very low, argues against active infection)

B. Viral Hepatitis (Hepatitis A, B, C, E)

• Hepatomegaly + reactive gallbladder thickening + pelvic fluid (as part of generalized ascites)
• Radiologist specifically recommended this
• LFTs normal currently, but early hepatitis may not have elevated transaminases yet
• Workup: HBsAg, Anti-HCV, Anti-HAV IgM, Anti-HEV IgM

C. SLE / Autoimmune Disease

• Young woman + anemia + serositis (free fluid) + hepatomegaly fits SLE
• Workup: ANA, Anti-dsDNA, complement C3/C4, CBC for thrombocytopenia/lymphopenia

D. TB Peritonitis

• Common in this region (West Bengal/Murshidabad)
• Can present with peritoneal fluid, hepatomegaly, anemia, and gallbladder wall thickening
• Workup: ascitic fluid ADA, chest X-ray, Mantoux, CBNAAT of fluid

Treatment Recommendations

Immediate / Empirical Management

1. Anemia:
   • Start empirical iron supplementation (ferrous sulfate 200 mg TDS with vitamin C) pending iron studies
   • Add folic acid 5 mg/day given the normocytic picture with high RDW
   • Recheck CBC in 4–6 weeks
   • If ferritin/iron studies confirm deficiency, continue for 3 months minimum
2. Gallbladder:
   • This patient is not critically ill (no sepsis, normal WBC, ESR 5), so emergency cholecystectomy/cholecystostomy is NOT indicated
   • The gallbladder changes are likely secondary/reactive to the pelvic/peritoneal pathology
   • Conservative management: treat the underlying cause; gallbladder should normalize
   • If clinical symptoms of RUQ pain/fever develop, reassess with repeat USG
3. Pelvic free fluid / Hepatomegaly - Urgent workup:

   Investigation	Purpose
   HBsAg, Anti-HCV, Anti-HAV IgM, Anti-HEV IgM	Rule out viral hepatitis
   ANA, Anti-dsDNA, C3, C4	Rule out SLE
   High vaginal swab / cervical swab	Rule out PID / STI
   CRP, Procalcitonin	Assess inflammatory activity
   Serum ferritin, iron, TIBC, B12, folate	Define anemia type
   Chest X-ray, Mantoux	Rule out TB
   CA-125	Rule out ovarian pathology
   Urine pregnancy test (beta-hCG)	Rule out ectopic (if not already done)
   NCCT KUB	As suggested by radiologist, to rule out non-shadowing calculus
   L-S spine X-ray	As suggested by radiologist

4. If PID is clinically suspected (pelvic pain, cervical motion tenderness, fever):
   • Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg BD x 14 days + Metronidazole 400 mg BD x 14 days (BASHH/WHO regimen)
5. If viral hepatitis confirmed:
   • Hepatitis A/E: supportive care (rest, hydration, avoid hepatotoxins)
   • Hepatitis B: Tenofovir if HBV DNA high; refer hepatology
   • Hepatitis C: Refer for DAA (direct-acting antiviral) therapy
6. If SLE confirmed:
   • Hydroxychloroquine 200–400 mg/day (first-line)
   • Low-dose prednisolone for serositis
   • Rheumatology referral

What's Reassuring

• WBC normal (6,060) - no active systemic infection/sepsis markers
• ESR only 5 - very low inflammatory marker
• LFTs entirely normal - no hepatocellular damage
• Platelets normal (1.86 Lac)
• TSH normal (0.80 mIU/L) - thyroid not contributing to anemia
• Uric acid normal (3.3 mg/dL)
• No hydronephrosis, no renal calculi, no adnexal mass
• Endometrial thickness 5.4 mm - normal
• No pleural effusion

Priority Action for the Referring Doctor

Based on Sleisenger and Fordtran's Gastrointestinal and Liver Disease - "thickened gallbladder wall (>4 mm) in the absence of ascites" is the criterion for acalculous cholecystitis; with peritoneal free fluid present in this patient, the gallbladder thickening may be secondary.