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Tamarah P. Cristobal, M.D.
39 year old Female Filipino Single Roman Catholic Pasay City
HISTORY OF PRESENT ILLNESS
7 months prior to admission
Abdominal pain located at the right upper quadrant, aggravated by consumption of oily and fatty foods. Associated with a burning epigastric pain and acid reflux. No associated vomiting nor fever was noted Consulted a private physician and UTZ was done which revealed a 1.5cm stone in her gallbladder She was advised to undergo an operation but the patient did not comply She was prescribed with unrecalled medications to which the patient did not comply as well.
HISTORY OF PRESENT ILLNESS
months prior to admission
Recurrence of the above signs and symptoms. Consulted her private physician and another ultrasound was done which revealed 1 1.4cm stone in her gallbladder. She was again advised to have an operation but the patient declined. No medications were given.
HISTORY OF PRESENT ILLNESS
week prior to admission
Recurrence of the same signs and symptoms. Consulted her private physician who again advised her to have the stone surgically removed. Patient decided to finally comply so she set for the date, hence this admission.
PAST MEDICAL HISTORY
The patient is a known Hypertensive for 6 years Highest BP of 150/100 and a Usual BP of 120/80 Prescribed with Metoprolol 10mg OD as maintenance but the patient is poorly compliant She is a non diabetic and a non asthmatic. No allergy to food nor drugs No other operations prior to this admission
aunt is a known Diabetic. There are no other heredofamilial diseases such as Hypertension, Asthma, Cardiovascular diseases, Respiratory Diseases, Kidney Diseases, nor cancer noted
PERSONAL AND SOCIAL HISTORY
conductor operator Non smoker Non alcoholic beverage drinker.
monthly period 28 day cycle Lasts 3-5 days Consumes 3 pads per day Occasional dysmenorrhea noted Mefenamic Acid 500mg prn
coitus yet No pap smear done
Patient is conscious, coherent, afebrile, and not in cardiorespiratory distress Vital Signs: BP: 130/90mmHg PR: 80 RR: 20 TEMP: 36.7C anicteric sclera, pink palpebral conjunctiva, no nasal discharge, no tonsillopharyngeal congestion, no cervicolymphadenopathies symmetrical chest expansion, no retractions, clear breath sounds adynamic precordium, normal rate regular rhythm, PMI at the 5th LICS, no murmurs Flat abdomen, normoactive bowel sounds, soft, + tenderness on right upper quadrant, (+) Murphy’s sign, no organomegaly full and equal pulses, no edema, no cyanosis
in the bed of the liver in line with that organ's anatomic division into right and left lobes. It is a pear-shaped organ with an average capacity of 50 mL Divided into four anatomic portions: the fundus, the corpus or body, the infundibulum, and the neck.
is the rounded, blind end Normally extends beyond the liver's margin It may be unusually kinked and present the appearance of a “phrygian cap.” It contains most of the smooth muscle of the organ
or body, which is the major storage area and contains most of the elastic tissue. The body tapers into the neck, which is funnel-shaped and connects with the cystic duct. The neck usually follows a gentle curve, the convexity of which may be distended into a dilatation known as the infundibulum, or Hartmann's pouch.
wall of the gallbladder is made up of smooth muscle and fibrous tissue Lumen is lined with a high columnar epithelium that contains cholesterol and fat globules. The mucus secreted into the gallbladder originates in the tubular alveolar glands in the globular cells of the mucosa lining the infundibulum and neck.
GALLBLADDER: BLOOD SUPPLY
The gallbladder is supplied by the cystic artery, which normally originates from the right hepatic artery behind the cystic duct. It is approximately 2 mm in diameter and courses above the cystic duct for a variable distance, until it passes down the peritoneal surface of the gallbladder and branches. Venous return is carried through small veins, which enter directly into the liver from the gallbladder, and a large cystic vein, which carries blood back to the right portal vein.
flows directly from the gallbladder to the liver and drains into several nodes along the surface of the portal vein.
nerves of the gallbladder arise from the celiac plexus and lie along the hepatic artery Motor nerves are made up of vagus fibers mixed with postganglionic fibers from the celiac ganglion.
GALLBLADDER: SENSORY SUPPLY
preganglionic sympathetic level is at T8 and T9 Sensory supply is provided by fibers in the sympathetic nerves coursing to the celiac plexus through the posterior root ganglion at T8 and T9 on the right side.
COMMON DUCT SYSTEM
The gallbladder is connected with the common duct system via the cystic duct, which joins the common hepatic duct at an acute angle. The segment of the cystic duct adjacent to the gallbladder bears a variable number of mucosal folds that have been referred to as the “valves of Heister” but do not have any valvular function. Immediately behind the cystic duct resides the right branch of the hepatic artery. The length of the cystic duct is highly variable, though the average is around 4 cm. Variations of the cystic duct and its point of union with the common hepatic duct are surgically important.
COMMON DUCT SYSTEM
The cystic duct may run parallel to the common hepatic duct and actually be adherent to it. I It may be extremely long and unite with the hepatic duct at the duodenum. It may be absent or very short and have a high (cephalad) union with the hepatic duct, in some cases joining the right hepatic duct instead. The cystic duct may spiral anteriorly or posteriorly in relation to the common hepatic duct and join it on the left side.
UNDERSTANDING THE GALLBLADDER
Understanding the Gallbladder The Gallbladder is a small, pearshaped organ in the abdomen. Its job is to store and release bile, a fluid made by the liver. Bile helps break down fats in the food you eat. Normally, bile moves smoothly through the digestive system. But if stones form in the gallbladder, they can block the release of bile. This can cause pain and lead to serious complications.
Your liver makes bile. Most of the bile is sent through a network of ducts to the duodenum (first part of the small intestine). A small amount of bile is also sent to the gallbladder for storage.
The gallbladder stores some bile. The gallbladder concentrates the bile by removing the water. When bile is needed to digest fats, hormones (chemical messengers) signal the gallbladder to squeeze bile out through the cystic duct.
Bile is sent to the duodenum. The bile moves through the common bile duct to the duodenum. There, it mixes with food. The pancreas adds other digestive juices. Digestion continues in the small intestine
When Gallstones Form Most gallbladder problems are caused by gallstones. These form when substances in the bile crystallize and become solid. In some cases, the stones don't cause any symptoms. In others, they irritate the wall of the gallbladder. Most serious problems occur if the stones move into nearby ducts and cause blockages. This stops the flow of bile and can lead to pain, nausea, and infection. Jaundice ( a buildup of bile chemical in the blood) can also occur. Symptoms include yellowing of the skin and eyes, dark urine, and itching.
obstruction of the neck of the gallbladder or cystic duct caused by stones impacted in Hartmann's pouch
Direct pressure of the calculus on the mucosa
ischemia, necrosis, and ulceration with swelling, edema, and impairment of venous return.
increase and extend the intensity of the inflammation.
Vascular effects of collagen disease Terminal states of hypertensive vascular disease Thrombosis of the main cystic artery
Acute cholecystitis in which the gallbladder is devoid of stones is known as acalculous cholecystitis.
Can occur at any age But the greatest incidence is between the fourth and eighth decades Patients over the age of sixty comprise between one- quarter and one-third of the group Caucasians are afflicted more frequently than blacks Women more than men.
The onset of acute symptoms is frequently related to a vigorous attempt of the gallbladder to empty its contents, usually after a heavy, fatty, or fried meal. Moderate to severe pain is experienced in the right upper quadrant and epigastrium and may radiate to the back in the region of the angle of the scapula or in the interscapular area. The patient is often febrile, and vomiting may be severe. Tenderness, usually along the right costal margin, often associated with rebound tenderness and spasm, is characteristic.
gallbladder may be palpable, or a palpable mass in the region may be the result of omentum wrapped around the gallbladder. Mild icterus may be present and may be caused by calculi within the ampulla and edema encroaching on the common duct.
or penetration of peptic ulcer Appendicitis Pancreatitis Hepatitis Myocardial ischemia or infarction Pneumonia Pleurisy Herpes zoster involving an intercostal nerve.
The hemogram usually demonstrates leukocytosis with a shift to the left. Radiographs of the chest and abdomen are indicated to rule out pneumonia. A radiopaque calculus is noted in less than 20 percent of cases. The serum bilirubin level may determine the presence of common duct obstruction. Although an elevated amylase level is generally regarded as evidence of acute pancreatitis, levels as high as 1000 Somogyi units have been associated with acute cholecystitis uncomplicated by pancreatitis.
rule out myocardial ischemia, an electrocardiogram should be performed on any patient over the age of forty-five being considered for surgical treatment. An ultrasonogram may demonstrate calculi and/or a thickened wall of the gallbladder and is the diagnostic procedure of choice.
There have been conflicting opinions on the management of acute cholecystitis, particularly on the optimal time for surgical intervention. For the purposes of discussion, early operation is defined as one performed within 72 h after the onset of symptoms; intermediate operation is one carried out between 72 h and the cessation of clinical manifestations; Delayed operation permits the acute inflammatory process to subside; and scheduled elective surgery is performed after an interval of 6 weeks to 3 months.
surgeons now favor early operation, i.e., with 24 to 48 h. The mortality rate for emergent cholecystectomy ranges from 0 to 5 percent. In the majority of cases, laparoscopic cholecystectomy is successful, but the incidence of conversion to open cholecystectomy is greater in this group of patients when compared to those without acute inflammation.
Accomplishes decompression and drainage of the distended, hydropic, or purulent gallbladder It is particularly applicable if the patient's general condition is such that it precludes prolonged anesthesia, since the operation may be performed under local anesthesia It is also performed in cases in which marked inflammatory reaction obscures the anatomic relation of critical structures Cholecystostomy may be a definitive procedure, particularly if a postoperative tube cholangiogram is normal.
application of minimally invasive surgical techniques to removal of the gallbladder has emerged as the preferred way of treating symptomatic gallstone disease. Although a subcostal incision is avoided, these operations should be viewed with the same respect for surgical principles as are the open procedures.
A harmless gas inflates the abdomen. The gas lifts the abdominal wall away from the internal organs. This lets your surgeon have a clear view of the gallbladder through the laparoscope.
A cholangiogram catheter may be inserted. The catheter is a thin tube used to inject a special dye into the bile duct. Once the dye has been injected, an x-ray is taken of the duct. This helps show whether any stones have moved from the gallbladder into the duct.
Small clips close off the bile duct and blood vessels. The clips help prevent bleeding and bile leaks. Once the clips are in place, the gallbladder is detached from the liver. The clips are made of metal (titanium) or plastic that does not harm the body. They are left in place.
The gallbladder is lifted for removal. The neck of the gallbladder is raised through an incision. The contents of the gallbladder, including any stones, may be removed. The gallbladder is then carefully lifted out through the incision. Bile will now flow directly from the liver into the small intestine.
If Open Surgery is Needed Your doctor may decide during surgery to switch from a laparoscopic to an open approach. This does NOT mean something has gone wrong. Instead, it is done when your doctor feels it is safer to remove the gallbladder through a larger incision. If you have open surgery, the same methods are used to close off the ducts and blood vessels. The main difference is that you will have a larger incision in your abdomen. Having open surgery also means a longer hospital stay and recovery period after the operation.