Ryan Em C.

Dalman

February 11, 2010

MD MBA
- 070070

 Present

a case of Cholelithiasis

History and Physical Exam

Differentials
Diagnostics
Discuss

its basic concepts of management

Patient History

 EI
63-year-old
Female
Born

on May 22, 1947

Roman Catholic
Informant: Patient, good reliability

 Masakit

ang tiyan
(abdominal pain)

Abdominal pain, RUQ

Mostly felt after eating oily/fatty food, took pain

3 years PTA

killers with partial relief

Intermittent and described as crampy
No radiation
Pain 5/10
No yellowing of skin, no nausea, no vomiting, no
fever, no blood in stool, no history of trauma

Sought consult
Diagnosed with cholelithiasis and liver cirrhosis via

ultrasound and CT
Discharged with pain and other unrecalled
medications

Symptoms resolved

No recurrence of symptoms

RUQ pain 10/10

Sudden, episodic, sharp and crampy
After eating oily/fatty food

1 month PTA

Fever, undocumented
Yellowing of skin
Vomiting 1x
Non-projectile, non-bloody, non-bilous

Consult

Tea colored urine

No radiation
Consult at a local clinic, given pain
medications and was discharged
No nausea, no fever, no acholic stool,
no change in bowel movement
Symptoms persisted

General:
Cutaneous:
HEENT:

Cardiovascular:
Respiratory:
Genitourinary:
Endocrine:
Muskuloskeletal:
Hematopoietic:

no weight loss, no change in appetite

no lesions,no pruritus
with occasional headaches
no redness
no aural/nasal discharge
no neck masses
no sore throat
no easy fatigability, fainting spells,
no palpitation
no cough, colds
no pain in urination, no genital discharge
no polyuria, polydypsia, no heat/cold
intolerance
no weakness, numbness on all extremities
no easy bruisability, or
bleeding

No Hypertension No Diabetes, Asthma

No Cancer, Allergies
Liver cirrhosis, probably 2o to
schistosomiasis (2008)
Previously treated for PTB

s/p BTL
Not taking any maintenance medications

 History

hypertension
No heart disease, cancer, stroke, diabetes,
asthma, or allergies

 Owns

a small business
Used to dwell in the rice fields as a kid
Lives with her family
Non-smoker
Occasional alcoholic beverage drinker
No substance abuse

Physical Exam

 Icteric

sclerae

Abdomen
Flabby
Direct tenderness RUQ
No murphys sign
No rebound tenderness

 General

Survey

Awake, coherent, and not in cardiorespiratory

distress
Vital

Signs

febrile at 37.9oC
130/80
RR 20 bpm

HR 71 bpm
Height:162cm weight:53kg BMI: 20.2

 Skin

Jaundiced
No rashes, hemorrhages, scars
Moist

CRT 1-2 seconds

Head
no lesions
Eyes
icteric sclerae, pink palpebral conjunctiva
pupils 2-3mm
Ears
no discharge, tenderness
Nose
septum medline, moist mucosa
Throat
mouth and tongue moist
no TPC

Neck
no cervical lymphadonapathy
no nuchal rigidity
Chest
adynamic precordium
no heaves, thrills, or lifts, PMI at 5th ICS MCL
regular rate, normal rhythm
no murmurs
Lungs
symmetrical chest expansion, no retractions
clear breath sounds

Abdomen
flat, no scars, no lesions
normoactive bowel sounds
tympanitic on all quadrants
direct tenderness on the RUQ
no Murphys sign
no rebound tenderness
no masses, no organomegally
no psoas, obturator, and Rovsings sign

History
63 year old female
Diagnosed with
cholelithiasis and liver
cirrhosis via ultrasound
and CT, 3 years
RUQ pain of 1 month
Vomiting
Fever, undocumented
Tea-colored urine
No history of trauma

Physical Exam
Jaundiced skin
Icteric sclerae
RUQ tenderness
Febrile at 37.9oC

Acute calculous cholecystitis

Liver cirrhosis probably 2o schistosomiasis

 Cholangitis
Malignancy

(biliary, pancreatic, ampullary)

Pancreatitis
Appendicitis
Duodenal

ulcer
Diverticulitis

 Inflammation

of the gallbladder
95% caused by gallbladder stones
Begins suddenly as stones block the cystic
duct

 Presence

of 1 or more calculi in the

gallbladder
1 in 17 (5.88%) or 16 million people in USA
Prevalence lower in Asians
60 years and above: men (12.9%) women (22.4%)

 Cholesterol

stones - > 85%

Black pigment stones
Brown Pigment stones
Mixed

 Female,

Fat, Fertile, Forty

Pregnancy
Oral contraceptives
Hyperlipidemia
Total parenteral nutrition

Imbalance or change in composition of bile!

Supersaturation
crystallization
stone formation

Gallbladder sludge... (acalculous cholecystitis)

Serum
CBC
Liver function test
Bilirubin
Lipase
Amylase

 Plain

abdominal film

10-15% of cholesterol
50% of pigment stones
Ultrasonography

As small as 2mm can be confidently identified

Oral

cholecystography (OCG)

Used to assess patency of cystic duct and

gallbladder emptying function

Replaced by US

 CT scans
Similar findings as in ultrasound
To further characterize complications
Good for detection of intrahepatic stones or

recurrent pyogenic cholangitis

Endoscopic

retrograde
cholangiopancreatography (ERCP)
Common hepatic duct
Common bile duct
Pancreatic duct

Who can undergo surgery?

Symptoms

that affect patients daily

activites
Presence of prior complication of gallstone
disease
Underlying condition predisposing patient
to increased risk of gallstone complication
Prophylactic cholecystectomy
> 3cm stones

Laparoscopic Cholecystectomy
Shortened hospital stay
Complications 4%
Conversion to laparotomy 5%

Death <0.1%
Bile duct injuries 0.2-0.5%

Dissolution of stones
Ursodeoxycholic

acid

Dissolves 80% of cholesterol stones < 0.5cm

Maybe

accompanied by extracorporeal
shock waves

 Elimination

of obesity
Low cholesterol diet
High fiber, high-calcium diet
Ingestion of meals at regular intervals
Vigorous exercise
Ursodeoxycholic acid

Ryan Em C. Dalman

February 11, 2010

MD MBA
- 070070