CASE REPORT CHOLELITHIASIS

by: dr.Kartika Iswaranti

PREFACE
This case is an actual case taken from Noongan Public Hospital ward. The reason why this case presented are: Gallstones are a common medical problem that is easily found in every hospital around the world In epidemiological cholelithiasis can be found in areas with high rates of obesity . This is why this case is an interesting case because Noongan General Hospital located in North Minahasa . Minahasa people are famous for their lifestyle . Thus , Minahasa has a high prevalence of cholelithiasis .

Epidemiology
Approximately 10-15 % of the adult population , or more than 20 million people in the United States may have gallstones In 1991 approximately 600,000 patients underwent cholecystectomy in the United States , with a value of 5 billion dollars . In Indonesia, the numbers can vary because the case is relatively new and research is still very limited .

MAIN GOAL
The final goal of the presentation is to widen our knowledge about this disease.

Admistration Data
Name : Ms. J.M Registry number : 054885 Social status : middle-upper

Demographic Data
Name Age Sex Religion Job Education Address : Ms. JM : 65 years old : female : christian : housewife : university graduate : amonggena II

Biological Data
Height Weight Body Type : 159 cm : 75 kg : picnicus

ANAMNESIS
Autoanamnesis was taken on November 27th,2013 Chief Complain : Pain at the upper right abdomen Secondary Complain : Headache, nausea, vomiting, flacid

History of Present Illness

3 days before admission the patient felt pain in the right upper abdomen. Pain was intermittent. Pain was felt especially when the patient was eating fatty foods such as cake or fried food. Pain disappear when the patient rested. The patient had never been to a doctor for treatment or reduce complaints. Initially pain happened since 3 weeks before the patient entered the hospital. But the complaint was not perceived as often and as severe as when the patient comes to the hospital. Urinating (N), defecating (+) Dizziness (+), nausea (+), vomiting (+), weak (+)

History of Past Illnesses

Asthma Hypertension Heart DM Uric acid : Denied : Denied : Denied : Denied :+

History of Family Illness

No family member of the patient who suffered the same illness.

History of Personal Habits

History of smoking : denied History of drinking alcoholic beverages: denied History of eating fatty foods : (+).

Physical Examination

 Skin : effloresency (-) Head : Normocephali Eyes : Conjunctiva anemic (-), sclera icteric (-) Ears: Secret (-) Nose: deviation of the septum (-),secret (-) Mouth: no caries found

 Thorax Pulmo: Inspection Palpation Percussion Auscultation Heart: Inspection Palpation Percussion Auscultation Abdominal: Inspection Palpation Percussion Auscultation Murphy sign Ekstremitas

: Retraction (-),simetric movement of the chest wall : simetric movement of the chest wall(-) : Sonor : Vesiculer, ronchi (-), wheezing (- / -) : Ictus Cordis (-) : Ictus Cordis in SIC IV : dim : Regular, murmur (-) Gallop (-) :abdomen looked flat. : Hepar / lien not palpable, NT (+) epigastrium : Shifting Dulness (-) : Society intestine (+), normal : (-) : warm, pulse adequate, edema -/-

Working diagnosis :
Cholelithiasis

Differential diagnosis :
Dyspepsia Cholecystitits Cholangitis Pancreatitis

cholecystitis Persistent RUQ pain +/- fever, WBC, LFT, +Murphys = inspiratory arrest Cholangitis Charcot triad: RUQ pain, jaundice, fever (seen in 70% of patients), can lead to septic shock Pancreatitis Anamnesis are similar to cholelithiasis. Do the pancreatic enzymes test.

TREATMENT

Laboratory result 27-12-2013

Hemoglobin Malaria Hematokrit Eritrosit Leukosit Granulosit : 11,4 g% :: 36,8 % : 4,18 mm6/ul : 12.500mm3/ul : 82,0 %

Trombosit

: 321.000 mm3/ul

ECG 27-12-2013

USG 30-12-2013

MATERIAL REVIEW

ANATOMY

PHYSIOLOGY

THEORY

Gallstones
The presence of gallstones in the gallbladder is called cholelithiasis.

Definitions
Symptomatic cholelithiasis Acute cholecystitis Chronic cholecystitis Acalculous cholecystitis Choledocholithiasis Cholangitis Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFT Acute GB inflammation due to cystic duct obstruction. Persistent RUQ pain +/- fever, WBC, LFT, +Murphys = inspiratory arrest Recurrent bouts of colic/acute choly leading to chronic GB wall inflamm/fibrosis. No fever/WBC. GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts Gallstone in the common bile duct (primary means originated there, secondary = from GB) Infection within bile ducts usu due to obstrux of CBD. Charcot triad: RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic shock

Etiology / Pathophysiology
Can be caused by an obstruction, gallstone or a tumor.
90% of all cases caused by gallstones. The exact cause of gallstone formation is unknown.

When there is an obstruction, gallstone or tumor it prevents bile from leaving the gallbladder.
Bile gets trapped and acts as an irritant which causes cellular infiltration within 3 4 days.

This infiltration causes an inflammatory process the gallbladder becomes enlarged and edematous. Eventually this occlusion along with bile stasis causes the mucosal lining of the gallbladder to become necrotic. Bacterial growth occurs due to ischemia.

Necrotic Gallbladder

Rupture of the gallbladder becomes a danger, along with spread of infection of the hepatic duct and liver. If the disease is severe and interferes with the blood supply it can cause the gallbladder to become gangrenous.

Gangrenous gallbladder

Gallstones

Those who are most at risk.

These are all adjectives to describe the person most at risk of developing symptomatic gallstones.
FAIR FAT FORTY FEMALE

Something to think about.

Disorders of the biliary system are COMMON in the U.S. INDONESIA? They are responsible for the hospitalization of more than half a million people each year. The two most common conditions are cholecystitis & cholelithiasis.

Signs and Symptoms.

Complaints of indigestion after eating high fat foods. Localized pain in the rightupper quadrant epigastric region. Anorexia, nausea, vomiting and flatulence.

Increased heart and respiratory rate causing patient to become diaphoretic which in turn makes them think they are having a heart attack.

Signs and Symptoms.

Low grade fever. Elevated leukocyte count. Mild jaundice. Stools that contain fat steatorrhea. Clay colored stools caused by a lack of bile in the intestinal tract. Urine may be dark amber- to tea-colored.

Diagnostics.
Fecal studies. Serum bilirubin tests.

Ultrasound of the gallbladder.

Diagnostics.

imaging test used to examine the gallbladder and the ducts leading into and out of the gallbladder - also referred to as cholescintigraphy. the patient takes iodine-containing tablets by mouth iodine is absorbed from the intestine into the bloodstream - removed from the blood by the liver and excreted by the liver into the bile it is concentrated in the gallbladder outlines the gallstones that are radiolucent (x-rays pass through them).

HIDA scan -

Oral cholecystogram -

Operative cholangiography
common bile duct is directly injected with radiopaque dye.

Medical Management.
Lithotripsy
for patients with only a FEW stones.

If the attack of cholelithiasis is mild

bed rest is prescribed. patient is placed on NPO to allow GI tract and gallbladder to rest. an NG tube is placed on low suction. fluids are given IV in order to replace lost fluids from NG tube suction.

Medical Management.

Cholecystectomy or Laparoscopic Cholecystectomy removal of the gallbladder. This is the treatment of choice. The gallbladder along with the cystic duct, vein and artery are ligated.

Medical Management.
If stones are present in the common bile duct, an endoscopic sphincterotomy must be performed to remove them BEFORE a cholecystectomy is done.
A number of various instruments are inserted through the endoscope in order to "cut" or stretch the sphincter. Once this is done, additional instruments are passed that enable the removal of stones and the stretching of narrowed regions of the ducts. Drains (stents) can also be used to prevent a narrowed area from rapidly returning to its previously narrowed state.

Will you survive?

Prognosis is usually excellent with prompt treatment. Laparoscopic surgery has decreased the number of complications.

Prognosis is NOT favorable for those who develop pancreatitis.

Eww!

Thank You