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!