Presented by: GAW, Gem Minnie MaeGO, Stephanie M.GONZALES, Alexander II

Case Conference

L.D.L.50/FFilipinoRoman CatholicMarriedHigh school graduateDate of admission: February 1, 2012Informant: patient

General data:

Abdominal pain

Chief complaint:

3 months PTA• Abdominal pain, RUQ radiating to the

back, colicky, associated with bloatedness and not affected by food intake

• No fever; no nausea, no vomiting, no diarrhea; no jaundice; no acholic stools; no tea-colored urine

• Consult: WA UTZ: cholecystolithiases• Advised: for surgery• No medications taken

History of Present Illness

1 month PTA• Increase in intermittence of abdominal

pain, RUQ, colicky, aggravated by food intake

• No fever; no nausea, no vomiting, no diarrhea; no jaundice; no acholic stools; no tea-colored urine

• Consult: EAMC OPD, scheduled for open cholecystectomy

History of Present Illness

1 week PTA• Abdominal pain, RUQ associated

with jaundice, undocumented febrile episodes

• No nausea, no vomiting, no pruritus, no acholic stools, no tea-colored urine

• Consult: EAMC OPD• admission

History of Present Illness

General: no weight loss/gain Skin: no rashes HEENT: no blurring of vision, no itching, no discharge, no changes

in hearing acuity, no tinnitus, no ear pain, no ear discharge, no epistaxis, no nasal discharge, no gum bleeding

Respiratory: No cough, no dyspnea, no hemoptysis Cardiovascular: No chest pain, no orthopnea, no easy fatigability Gastrointestinal: HPI Genitourinary: No dysuria, no incontinence Musculoskeletal: No joint pain, no muscle pain, no weakness Neurological: No headache, no seizures Endocrine: No heat and cold intolerance, no palpitations, no

tremors Psychiatric: No anxiety, no depression, no hallucinations Hematologic: No easy bruising, no prolonged bleeding

Review of Systems

(-) Hypertension(-) Diabetes mellitus(-) bronchial asthma(-) Pulmonary TB(-) allergy(-) blood dyscrasiaNo previous surgeries and blood transfusion

Past Medical History

(+) Hypertension – mother and father(-) Diabetes mellitus(-) bronchial asthma(-) cancer(-) blood dyscrasia(-) gall bladder disease(-) kidney disease(-) heart disease

Family History

Non-smokerNon-alcoholic beverage drinkerMixed diet of chicken and meat (prefers fried

and salty food), occasional vegetables and fish, drinks 3-4 glasses of water a day

Personal and Social History

Menopause: 47 y/oG2P2 (2002)No complicationsNo miscarriagesNo abnormal vaginal dischargeNo history of OCP use

Gynecologic and Obstetrical History

Conscious, coherent, oriented to time, place, and person, ambulatory and not in cardiorespiratory distress

BP 130/80 mmHg PR 92 bpm,regular RR 21 cpm, regular T: 36.9 °C

Height 160.02 cm Weight 64 kg BMI 25 kg/m2 Warm moist skin, no active dermatoses, (+) jaundice Pink palpebral non hyperemic conjunctivae, icteric sclerae,

pupil 3 to 4 mm ERTL, (-) eye discharge No nasoaural discharge, midline septum, (-) mass Moist buccal mucosa, non hyperemic posterior pharyngeal

wall, no tonsillar enlargement No tragal tenderness, non-hyperemic external auditory meatus Supple neck, thyroid not enlarged, no distended neck veins, no

palpable cervical lymphadenopathies

Physical Examination

No chest deformities or asymmetry; no tenderness nor palpable masses, symmetrical chest expansion, equal vocal and tactile fremiti, clear breath sounds

Physical Examination

Adynamic precordium, AB at the 5th LICS MCL, S1 louder than S2 at the apex, S2 louder than S1 at the base, no murmurs

JVP 3cms at 30°

CAP rapid upstroke and gradual downstroke

Physical ExaminationFlabby abdomen,

soft, (+) whitish striae, normoactive bowel sounds, (+) murphy’s sign, (-) CVA tenderness, (-) mass

Physical ExaminationPulses full and equal,

no cyanosis, no edema

No tenderness of joints, no swelling, no limitation in ROM

Mental Status: conscious, coherent, oriented to time place and person, awake, follows commands

GCS 15 (E4V5M6)Cranial nerves: (-) anosmia, pupils 3-4mm ERTL,

OD no visual field cuts, EOM movement intact, OD; V1V2V3 intact, can raise eyebrows, can smile, can frown, intact gross hearing, uvula midline, can shrug shoulders, can turn head side to side against resistance, tongue midline on protrusion

MMT 5/5 on all extremities, can do FTNT and APST(-) Babinski’s sign, (-) Nuchal Rigidity, (-) Kernig’s

sign, (-) Brudzinki’s sign

Neurologic Examination

Obstructive jaundice secondary to cholelithiases

Assessment:

Open cholecystectomy with IOC

Plan:

Ultrasoundinitial investigationnoninvasive, painless, no radiationdependent upon the skills and the experience

of the operator

Diagnostics

Biliary Radionuclide Scanning (HIDA Scan)a noninvasive evaluation of the liver,

gallbladder, bile ducts, and duodenum with both anatomic and functional information

diagnosis of acute cholecystitis, which appears as a nonvisualized gallbladder, with prompt filling of the common bile duct and duodenum

Computed Tomographydifferential diagnosis of obstructive jaundice

Percutaneous Transhepatic CholangiographyAn intrahepatic bile duct is accessed

percutaneously with a small needle under fluoroscopic guidance.

it defines the anatomy of the biliary tree proximal to the affected segment

useful in patients with bile duct strictures and tumors

Magnetic Resonance Imagingprovides accurate anatomic details of the liver,

gallbladder, and pancreas similar to those obtained from CT

Endoscopic Retrograde Cholangiography requires intravenous sedation for the patient include direct visualization of the ampullary

region and direct access to the distal common bile duct, with the pos

the diagnostic and often therapeutic procedure of choicesibility of therapeutic intervention

Complications include pancreatitis and cholangitis, and occur in up to 5% of patients.

Cholecystostomyapplicable if the patient is not fit to tolerate an

abdominal operation

Operative Interventions for Gallstone Disease

Cholecystectomymost common major abdominal procedure

Laparoscopic Cholecystectomyminimally-invasive procedure, minor pain and

scarring, and early return to full activity. treatment of choice for symptomatic gallstones

Open Cholecystectomy safe and effective treatment for both acute and

chronic cholecystitis

Intraoperative CholangiogramThe bile ducts are visualized under fluoroscopy

by injecting contrast through a catheter placed in the cystic duct .

Their size can then be evaluated, the presence or absence of common bile duct stones assessed, and filling defects confirmed, as the dye passes into the duodenum.

Choledochal Drainage Proceduresstones cannot be cleared and/or when the duct

is very dilated (larger than 1.5 cm in diameter)Choledochoduodenostomy

performed by mobilizing the second part of the duodenum (a Kocher maneuver) and anastomosing it side to side with the common bile duct