CASE PRESENTATIONCEIII-IIPWH IPYu Wing Lam Zoe

PROFILE

M, 56y

C admitted on 6/11/2012 x lap cholecystectomy

Diagnosis: Gall Stone

Open cholecystectomy on 7/11

Chest physio + triflow

Ix: USG abd: gallbladder packed with stones

PMH:BPH with TURP (Transurethral resection of prostate) done 2010AppendicectomyHx of epilepsy

Social Hx: NDNS, unaided outdoor walkerlives with family, retired

GALLSTONE

Crystalline concretion formed within gallbladder

May distally pass into other parts of the biliary tract

May causes acute cholecystitis Gallstones in other parts of the biliary tract can

cause obstruction of the bile ducts e.g. ascending cholangitis Or pancreatitis

GALL STONES

different size and shape Cholesterol stones: light yellow to dark

green or brown and are oval, at least 80% cholesterol

Pigment stones: small and dark, comprise bilirubin and calcium salts, <20%

Mixed stones: 20-80% cholesterol

Other common constituents E.g. caco3

SIGNS & SYMPTOMS

May be asymptomatic “silent stones” don’t require treatment

Symptoms commonly begin, size >8mm “Gallstone attack”: intense pain UR abd,

nausea + vomit, increase for ~30mins to several hrs

May feel referred pain between the shoulder blades or below the right shoulder

often occur after a practically fatty meal / happen at night

PATHOPHYSIOLOGY

Cholesterol GS develop when bile too much cholesterol & not enough bile salts

1. How often & how well gallbladder contracts

2. Incomplete & infrequent emptying of gallbladder

Causes bile over-concentrated

Can be caused by high R to the flow of bile out of gallbladder due to complicated internal geometry of the cystic duct

Eg Increased levels of estrogen Hormonal contraception increase

cholesterol and decreases gallbladder movt

TREATMENT

Medical sometimes GS dissolved by oral

ursodeoxycholic acid, up to 2 yrs, may recur once drug stopped

Endoscopic retrograde sphincterotomy follow by ERCP

Broken up by “lithotripsy” Suitable only by a small no of GS

TREATMENT

Surgical Cholecystectomy 99% chance of eliminate

recurrence Only indicated in symptomatic pt No –ve consequences in many ppl 10-15% postcholecystectomy syndrome causes

GI distress & persistent pain in UR abd, 10% chronic diarrhea

OPEN CHOLECYSTECTOMY

traditional a major abdominal surgery Abdominal incision below lower right ribs Removes the gallbladder through a 5 to 7-

inch incision Remain in hospital at least 2-6 days 4-6 weeks at home

AFTER OPEN CHOLECYSTECTOMY

http://www.drugs.com/cg/open-cholecystectomy-inpatient-care.html

Walk around same day or the day after surgery

Deep breathing and coughing (wound supported)

Drink liquids->soft->solid foods +/-Antibiotics, anti-nausea, pain killer PCA +/-Stool softeners

LAPAROSCOPIC

Laparoscopic: first choice, unless contraindications e.g. technical reason/ safety

Open more prone to infection small (1/4” - ½”) incisions Laparoscope introduced into abd + short Post-OT recovery +rapid return to full f(x)

1ST SESSION D2 9/11/12

C/O: Wound P+++ O/E: Very large GS specimen Off O2 On PCA, Foley Chest: AE fair, coarse crackle’s bil LZ, moist

cough, cough effort fair, decrease basal AE Limbs range full, power 4+ allow to walk around the bed and sit-out

1ST SESSION D2 9/11/12

Treatment Triflow 2balls up 1-2s 5times per half hr Wound supported coughing ex +/-huffing Bed side standing and stepping

10/11 off IV, PCAAXR: prominent SB loopsgeneralized occ wheeze

11/11mild crepitusCXR: LLZ hazziness, mild blunt L CP angleinadequate inspiratory effortAXR: prominent bowel loops

2ND SESSION 12/11/12

Complaint of mild (chest?)abdominal discomfort

ECG: SR 104/min, no ST/T wave changes

Abdominal distension Decrease basal AE, mild crep, moist cough,

fair cough effort (wound supported) Treatment FET->whitish sputum coughed out Deep breathing ex Triflow Walking ex around ward

3RD SESSION 13/11/12

AXR: dilate small bowel, multiple fluid level Contact precaution: diarrhea NG tube inserted: remove gastric secretions and

swallowed air in patients with gastrointestinal obstructions, drain fluids and stomach acidself ambulate in ward

Decrease wound pain Treatment FET->whitish sputum coughed out Deep breathing ex Triflow Walking ex around ward Static bike ex

4TH SESSION 15/11/12

AXR: dilated SB with multiple air-fluid levels, LB gas seen

Off NG tube, keep IV drip Decrease abdominal discomfort Improve AE

16/11 AXR still dilated SB, LB gas seen, air/fluid level seen

Try fluid diet Decrease distension Repeat AXR: dilated SB loops, improving 17/11 abd mod distended, off drip, start soft diet 18/11 soft diet tolerated, abd decrease

distension

5TH SESSION 19/11/12 D12

All stitches removed AE sat, no added sound, moist cough, strong

cough effort, whitish spt coughed out Decrease abd distension Triflow Self ambulate Static bike D/C?

THE ENDThank you!