The Gallbladder on the Wrong Side
Dr. Hammad Ali came into the research room with his phone already unlocked.
“Sir, you will not believe this. Yesterday, in a routine laparoscopic cholecystectomy, the gallbladder was not under the right lobe. It was on the left of the falciform ligament. No situs inversus. The heart, the spleen, everything else in the normal place. My consultant said he had seen it once in twenty years.” He held up a photograph from the laparoscope. “I want to write it up tonight. A case report. That is a publication, no?”
Dr. Junaid Rashid smiled from his corner. “My only paper is a case report, Hammad. A senior added my name to it fifteen years ago. To this day I could not tell you what was in the discussion.”
“Then tonight both of you will learn what a case report really is,” I said. “And Hassan, stay alert. Before the session ends, you will discover that your own synopsis is closer to this topic than you think.”
Dr. Hassan Raza looked up from his phone. “Sir, my study is a descriptive case series. I already wrote it on the title page.”
“I know,” I said. “That is exactly why.”
What Makes a Case Worth Reporting
“A case report is a detailed description of one patient, sometimes two or three, written so that other doctors can learn something they could not learn from their own practice,” I said. “The key words are ‘could not learn’. An interesting patient is not automatically a reportable patient.”
I wrote the usual reasons on the board.
- A rare disease, or a common disease in a rare place, age or form
- An unusual presentation that delayed or misled the diagnosis
- An unexpected adverse effect of a drug, device or procedure
- An unexpected association between two conditions
- A new or modified technique for managing a difficult situation
- A diagnostic mistake from which others can learn
“So my gallbladder qualifies,” said Hammad.
“It is rare, yes. But search PubMed first. You will find that a left-sided gallbladder has been reported many times. An editor will ask you one question: what does your report add? Perhaps it is how your consultant changed the port positions, or how the cystic duct entered the bile duct from the left, or how it might have been suspected on the preoperative scan. Your case report is not about the gallbladder. It is about the lesson.”
Dr. Bushra Fatima raised the question I was waiting for. “Sir, honestly, is it worth the effort? Does a case report even count?”
“It counts for less than an original article,” I said. “Some induction criteria, such as the Punjab second fellowship scoring, give a case report about half the marks of an original article, and promotion committees look mainly for original research. Never build a career on case reports alone. But a good case report teaches you how a manuscript is built, how to search the literature, and how to deal with an editor, all with one patient instead of three hundred. For a beginner, that is excellent training.”
When One Patient Changed Medicine
“In the evidence pyramid,” Dr. Zunaira Malik said quietly, “case reports are near the bottom. Why do journals still publish them?”
“Because the bottom of the pyramid is where many discoveries are first noticed. In June 1981, a short report described five previously healthy young men in Los Angeles with Pneumocystis pneumonia, an infection seen almost only in severely immunosuppressed patients [1]. Five patients. No control group, no p-value. That report was the first published description of what the world would come to know as AIDS.”
“So a case report can raise a signal,” said Zunaira, “but it cannot prove anything.”
“Exactly. A case report or case series can tell you that something happened. It cannot tell you how often it happens, and it cannot tell you why. If one patient developed a rash after a new antibiotic, the drug may have caused it, or the viral illness may have caused it, or it may have been a coincidence. Answering that needs one of the designs you have already learnt. Murad and colleagues suggest using evidence from case reports and case series for decisions only when nothing better is available [2].”
Writing It: The CARE Checklist
“So how do I write it?” Hammad asked. “Introduction, case, discussion?”
“That is the skeleton. The flesh comes from the CARE guidelines, which an international group of clinicians, researchers and editors developed so that case reports would stop missing the same details again and again [3]. Most journals now ask you to upload a completed CARE checklist with the manuscript. The explanation document gives a published example for each item, and it is worth reading once [4].”
| CARE section | What it means for Hammad’s case |
|---|---|
| Title | The words “case report” plus the main point: left-sided gallbladder found during laparoscopic cholecystectomy |
| Keywords | Two to five words that a reader would type into PubMed |
| Abstract | Short: background, case, lesson; no references |
| Introduction | One or two paragraphs on why this case matters, with a few key references |
| Patient information | Age, sex, main complaint, relevant history, without any identifying detail |
| Clinical findings | Examination findings relevant to the case |
| Timeline | The sequence of events from presentation to follow-up, often as a small table |
| Diagnostic assessment | The ultrasound report, what it showed and what it missed |
| Therapeutic intervention | How the operation was adapted: port sites, dissection, any change in technique |
| Follow-up and outcomes | Recovery, histopathology, complications, outcome at the last visit |
| Discussion | How this case compares with earlier reports, its limitations, and the one take-away lesson |
| Patient perspective | If possible, the patient’s own experience, in a few lines |
| Informed consent | A statement that written consent for publication was obtained |
“For a surgical case, many surgery journals also expect the SCARE checklist, which adds details about the operator, the setting and the procedure itself [5]. Read the instructions for authors before you write a single word. Case reports have strict limits on words, figures and references, and those limits differ from journal to journal.”
Junaid laughed. “Mine had a two-page discussion that reviewed everything ever written about the disease. The editor cut it to four paragraphs.”
“That is the commonest mistake,” I said. “The discussion of a case report is not a textbook chapter. It answers three questions: how does this case compare with what has been reported, what are its limitations, and what should the reader do differently on Monday morning.”
Consent and the Photograph
Zunaira had been looking at Hammad’s phone. “Sir, in oral pathology our case reports are mostly photographs: the mouth, the face, the lesion. Is the patient’s consent for surgery enough?”
“No. Consent for treatment is not consent for publication. The ICMJE recommendations say that identifying information, in the text or in photographs, should not be published unless it is essential and the patient has given written informed consent for publication [6]. Most journals now ask for that written consent even when the report looks anonymous, because a rare condition in a named hospital can identify a patient by itself. Take consent on a separate form, in a language the patient understands, and keep it in your file. Many journals have their own form.”
“And a black bar across the eyes?” asked Bushra.
“It does not make a face anonymous. Crop the picture to the lesion. Remove names, MR numbers and dates from scans and reports before you take the screenshot, not after. And Hammad, the photograph on your phone should leave your phone once it is in the case file. Patient pictures do not belong in WhatsApp groups.”
“Do I need ethics committee approval for one patient?” Hammad asked.
“Policies differ. Many ethics committees do not review a single retrospective case report, but some hospitals and many journals still want a letter from the committee, either an approval or a statement that review was not required. Ask your ERC before you submit, and keep the letter. We will discuss ethics committees in detail later in the series.”
From One Patient to Many: The Case Series
I turned to Hassan. “Now your descriptive case series. Tell the group about your study.”
“Functional outcome after open reduction and internal fixation of distal radius fractures. I take patients who have ORIF in our unit and check their wrist function at follow-up.”
“A case series in its simplest form is a group of patients with the same condition, or the same treatment, described together,” I said. “If Hammad found five left-sided gallbladders over ten years and described all five, that would be a case series. But the term is used loosely, and it causes confusion.”
I drew two boxes on the board, and explained the distinction made by Dekkers and colleagues [7].
| Case series | Cohort (it may have only one group) | |
|---|---|---|
| How patients are selected | Because they already have the outcome (for example, all patients with a left-sided gallbladder, or all patients who developed a complication) | Because they have the exposure or treatment, before the outcome is known (for example, all patients who had ORIF) |
| Direction | Looks at patients who already have the outcome | Follows patients forward to see who develops the outcome |
| Can it give a rate or risk? | No, because there is no denominator of people at risk | Yes, for example the proportion with a good functional outcome at 12 weeks |
Hassan read the table twice. “Sir, then my study is a cohort. I select patients because they had ORIF, and I follow them to see their outcome.”
“By this definition, it is a single-group cohort, yes. In Pakistan, CPSP and university synopsis templates have long called this kind of study a ‘descriptive case series’, and supervisors expect that label. So here is the practical advice. In your UHS synopsis, use the label your supervisor and the university expect. In the methods, describe the design exactly as it is: consecutive patients selected on the treatment, followed for a fixed period, with outcome measured at a fixed time. When you write the paper, a journal may ask you to call it a prospective cohort. Neither label changes what you actually did, and what you did is what the reviewer judges.”
“And what can I conclude from it?”
“You can say how many patients had a good functional outcome after ORIF in your unit, with a confidence interval. You cannot say that ORIF is better than a plaster cast, because you have no plaster-cast group. That sentence appears in the discussion of half the case series I review. Kempen calls this the main misuse of uncontrolled case series: drawing comparative conclusions from a study that has nothing to compare [8].”
Making a Case Series Credible
“So how does a reviewer decide whether a case series is good or weak?” asked Dr. Sumaira Talib.
“Murad’s tool asks about four things: selection, ascertainment, causality and reporting [2]. In plain language, it looks like this.”
| Question the reviewer asks | What Hassan should write |
|---|---|
| Were these all the patients, or only the best ones? | All consecutive patients who had ORIF for a distal radius fracture in the unit during the study period, with dates |
| Was the outcome measured the same way for everyone? | A validated wrist function score at a fixed time after surgery, defined in the operational definitions |
| Who measured it? | Ideally someone other than the operating surgeon, using the same method every time |
| What happened to patients who did not come back? | Numbers lost to follow-up, with reasons where known |
| Is the treatment described well enough to repeat? | Implant, approach, immobilisation and physiotherapy protocol |
| Could something else explain the outcome? | Age, fracture type and hand dominance reported, and the limitation of having no comparison group stated honestly |
Hassan was quiet for a moment. “Sir, the operating surgeon in my unit is me.”
“Then ask a colleague or the physiotherapist to score the wrists, and train him to do it the same way each time. A surgeon scoring his own patients tends to see what he hopes to see. You learnt that lesson with Hammad’s trial.”
Two Drafts by Morning
By the end of the session, Hammad had made a timeline table for his patient, from the first clinic visit to the histopathology report, and listed the three earlier reports he would compare his case with. He had also deleted the photograph from his gallery after copying it to the unit’s case file.
Junaid stayed behind. “Sir, last month I saw a young patient in OPD with malignant hypertension that turned out to be a phaeochromocytoma. I never thought of writing it up. If I take consent and follow CARE, can I write that one myself? Properly, this time?”
“Search PubMed first and find what your case adds,” I said. “If it adds something, yes. It will not be the paper that gets you promoted. That will be your adherence study. But it will be the first paper you understand from title to reference list. Research is not rocket science. It is a skill, and skills can be taught, and sometimes the first lesson is one patient long.”
Key Takeaways
- A case report describes one patient (or a few) from whom other doctors can learn something new: a rare presentation, an unexpected adverse effect, an unusual association or a new technique. Search PubMed first and know exactly what your case adds.
- Case reports and case series can raise a signal, but they cannot measure how often something happens or prove what caused it.
- Write case reports with the CARE checklist (and SCARE for surgical cases), keep the discussion short, and follow the journal’s limits on words, figures and references.
- Consent for treatment is not consent for publication. Take separate written consent, crop photographs to the lesion and remove all identifiers. Ask your ERC whether a letter is needed.
- A true case series selects patients by the outcome; a study that selects patients by treatment and follows them forward is a single-group cohort, even when a synopsis template calls it a “descriptive case series”. Use the expected label, but describe the design exactly.
- A case series without a comparison group cannot show that one treatment is better than another. Make it credible with consecutive patients, a fixed follow-up time, a validated outcome measured by someone other than the surgeon, and honest reporting of losses.
References:
- Centers for Disease Control (CDC). Pneumocystis pneumonia: Los Angeles. MMWR Morb Mortal Wkly Rep. 1981;30(21):250-2.
- Murad MH, Sultan S, Haffar S, Bazerbachi F. Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med. 2018;23(2):60-3.
- Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D, et al. The CARE guidelines: consensus-based clinical case reporting guideline development. J Med Case Rep. 2013;7:223.
- Riley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017;89:218-35.
- Sohrabi C, Mathew G, Maria N, Kerwan A, Franchi T, Agha RA, et al. The SCARE 2023 guideline: updating consensus Surgical CAse REport (SCARE) guidelines. Int J Surg. 2023;109(5):1136-40.
- International Committee of Medical Journal Editors. Recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals: protection of research participants [Internet]. ICMJE; [cited 2026 Oct 14]. Available from: https://www.icmje.org/recommendations/
- Dekkers OM, Egger M, Altman DG, Vandenbroucke JP. Distinguishing case series from cohort studies. Ann Intern Med. 2012;156(1 Pt 1):37-40.
- Kempen JH. Appropriate use and reporting of uncontrolled case series in the medical literature. Am J Ophthalmol. 2011;151(1):7-10.