Patient’s identification

Name: Golovacheva Natalia Alexivna

Age: 25
Date of Birth: 19th Feb 1981
Address: Kursk, Russia
Profession: Teacher
Nationality: Russian
Date of hospitalization: 9th March 2006

Complaints:
- pain in the right hypochondrium.
- Nausea and vomiting
- Disorder in appetite
- Frequent burping

Anamnesis morbi:
- suffered from right hypochondriac pain for almost 1 year
- nausea after eating (appetite disturbances)
- pain in the right hypochondrium
- fetal oris
- stronger pain attack 2 days ago which made the patient come to the physician
- ultrasound examination found stone in the gallbladder

Anamnesis vitae:
- no allergies
- no congenital disorders
- no significant diseases running in the family

Local status:
- moist tongue
- furry tongue
- normal form of abdomen
- abdominal respiration
- no distention of abdomen
- palpation of abdomen: soft
no tenderness
no muscle guarding
pain at right hypochondrium
no palpable liver and gallbladder
- special signs:
o negative Murphy’s sign
o negative Ker’s sign
o negative Orthner’s sign
- presence of bowel sound
- no irritation of peritoneum
System Review
General condition
Patient is able to tell her name, age and where is she, time, date and season properly
without any problem. Her condition is satisfactory. Her face is adequate according to her
age. Consciousness is alert, she can respond quickly and accurately. Her posture is active.
Her face shows normal expression. Her constitution is normosthenic. Nutrition is slightly
poor. Skin is normal without cyanosis and normal tugor. No presence of edema.

Musculoskeletal system
Normal muscular development and symmetrical muscles. No clonic and tonic spasms.
Palpation of muscles of extremities is painless. Muscle tension is also normal. Muscle
strength is normal and strength is symmetrical. Inspection of bones proved no deformities
or shortening. No finger clubbing. Palpation at supraclavicular, at forearm, sternum show
no signs of pain. Percussions are also painless. Normal shape and size of joints. No
change of skin color. No fluctuation, no crackles and volume of active movement is full.

Respiratory system
The patient has normal and easy breathing through nose without any difficulty. She has
no cough or flu. She has abdominal type of respiration. Surface palpation of the chest is
painless with normal vocal fremitus. Comperative percussion shows clear pulmonary
sound on both sides of the lungs.
Topographic percussion is shown below:
- Altitude of apex- 3.2 cm above from the upper border of clavicle. 4.3cm laterally
from the 7th cervical vertebra posteriorly.
- Kronig's isthmus- 4cm in right and 5cm in left.
- Lower borders of lungs:
Line Right lung Left lung
th
Parasternal 5 interspaces -
th
Midclavicular 6 rib -
Anterior axillary 7th rib 7th rib
Mid axillary 8th rib 8th rib
th
Posterior axillary 9 rib 9th rib
Scapular 10th rib 10th rib
Paravertibral T11-spinous process T11- spinous process

Auscultation of the breath sounds is normal.

Cardiovascular system
The patient has no cardiac humpback. Apex beat is visible, but cardiac beat, pulsations of
aorta and pulmonary trunk are not visible. Carotid shudder is not visible. Jugular venous
pulse is negative. Worms sign and Quince’s sign are negative. No varicose veins. Apex
beat when palpated, is at the 5th intercostals space 2cm laterally to left margin of sternum.
Its strength and intensity are normal. It is diffused. Aortic, pulmonary trunk and epigastric
pulsations are not palpable. Peripheral arterial pulsation of radial artery shows 73 per
minute.
Percussion is shown below:
Relative dullness Absolute dullness
Right border 1cm right to the right margin of the Left margin of the sternum
sternum
Left border 0.5cm medially from midclavicular 1cm medially from
line midclavicular line
Upper margin 3rd rib 4th rib

In auscultation, S1 is louder than S2. No additional murmur or gallop rhythm is heard.

Digestive system
Fetor oris of the oral cavity. She has a single artificial tooth. Her gums are pink and
healthy. The tongue is furry and moist. Mucous membrane of the throat is normal. Tonsils
are not enlarged. No distention of abdomen. The patient is quite plump with weight of
95kg. Surface palpation of the abdomen is painful at the right hypochondrium, but the
palpation reveals no tenderness or muscle guarding.
Lower border of the stomach in the normal position. No appearance of any pain during
intestinal palpation. Localization of the sigmoid colon, caecum, ileum, asending colon,
desending colon and transverse colon are in normal position. Absent of any hemorrhoid
in the anus region.
In liver palpation, upper border of the liver is in the upper border of the 7th rib, and lower
border is in the lower border of the 10th rib. No hepatic displacement. Palpable swellings
are not observed in liver. The borders of liver are soft and surface is smooth.
In gallbladder palpation, it is not palpable.
No enlargement or displacement of the spleen.

Urinary system
Normal urination (2-3 times a day), micturation is often (4 to 5 times a day) without any
difficulty. She is excreting normal volume of urine. Color of the urine is normal.
Primary diagnosis:
Stone in gallbladder
Exacerbation of chronic cholecystitis

Plan of Instrumental and laboratory investigation:

1. biochemical analysis
2. blood analysis
3. urine analysis
4. analysis of common protein level
5. analysis of bilirubin level
6. ultrasound of gallbladder
7. cholecystoendoscopy
8. electrocardiogram
9. therapy consultation
10. plain chest and abdominal x-ray

Result of Instrumental and laboratory investigation:

1. biochemical analysis
a. serum creatinin: 0.088 mmol/L
b. residual nitrogen: 0.3 g/L
c. alanin aminotransferase: 0.56 mmol/L
d. aspartate amonitransferase: 0.42 mmol/L

2. blood analysis
a. anemia is excluded
b. leucocytosis
c. shift to the left

3. urine analysis
a. amylase level: 162.0 gU/L

4. analysis of common protein level

a. total protein: 86 g/L
b. albumin: 50 g/L
c. globulin: 36 g/L

5. analysis of bilirubin level

a. bilirubin level: 10.2 mmol/L

6. ultrasound of gallbladder
a. size of gallbladder: 7.2 * 3.8 cm
b. thickened gallbladder wall: 0.4mm
c. one acoustic shadow of stone in lumen of gallbladder
d. size of stone: 2cm * 1.7cm
e. normal pancreas
 f. no anomalies of common bile duct
7. cholecystoendoscopy
a. present sign of chronic gastroduodenitis

8. electrocardiogram

9. therapy consultation
a. no endocrinal disorder thus no contraindication for operation

10. plain chest and abdominal x-ray

a. shadow is seen suspicion of stone in the gallbladder with help of
cholecystography

b. Cholelithiasis can be seen on a cholangiogram. Radio-opaque dye is used

to enhance the x-ray. Multiple stones are present in the gallbladder.
 11. CT scan
a. CT scan of the upper abdomen showing multiple gallstones.

Plan of the treatment

The treatment for the patient is cholecystectomy. She is operated for cholecystitis
secondary to cholelithiasis. She is prescribed with preoperative antibiotics
(Cephalosporin) and analgesics (Papaverin). She is indicated for surgery when her
condition fails to improve on medical treatment.

Differential diagnosis
- perforated or penetrating peptic ulcer
- myocardial infarction
- pancreatitis
- hiatal hernia
- right lower lobe pneumonia
- appendicitis
- hepatitis
- herpes zoster

Clinical diagnosis and ground for it

Clinical diagnosis: Cholelithiasis
Complication: none
Coexisting disorder: Chronic cholecystitis

Diagnosis is determined based on

a. Patient’s complaint
- Pain in the right hypochondrium.
- Nausea and vomiting
- Disorder in appetite
- Frequent burping
b. Local status:
 - moist tongue
- furry tongue
- normal form of abdomen
- abdominal respiration
- no distention of abdomen
- palpation of abdomen: soft
no tenderness
no muscle guarding
pain at right hypochondrium
no palpable liver and gallbladder
- special signs:
o negative Murphy’s sign
o negative Ker’s sign
o negative Orthner’s sign
- presence of bowel sound
- no irritation of peritoneum

Aetiology and Pathogenesis of Gallstone and Chronic

Cholecystitis
The full story of how the common cholesterol-predominant stones are formed has not yet
been elucidated but several clues are available. The main factors are changes in
concentration of the different constituents of bile, biliary stasis and infection. It is likely
that several subtle abnormalities combine to bring about precipitation of bile constituents.

Bile salts and lecithin are responsible for maintaining cholesterol in a stable micelle
formation. The normal micellar structure of bile supports a greater concentration of
cholesterol than could normally be held in solution and it is therefore inherently unstable.
An excess of cholesterol in relation to bile salts and lecithin is probably one of the main
factors in stone formation. This is supported by the observation that patients in whom the
terminal ileum has been resected or who have chronic distal ileal disease have a threefold
risk of developing cholesterol-rich stones. The terminal ileum is the main site for
reabsorption of bile salts. When this is removed or diseased, reabsorption falls off,
leading to loss of bile salts via the bowel and a consequent reduction in the bile salt pool.
Bile salts are then insufficient to maintain the micellar structure of cholesterol
suspension.

Precipitation is enhanced by biliary stasis. This occurs if the gallbladder becomes

obstructed or its contractility becomes defective. It is not known whether obstruction of
the gallbladder outlet is primary event is formation of gallstone but it is believed to play a
part in their continued accretion. Obstruction could be caused by dysfunction of the spiral
valve in the cystic duct, by reflux of duodenal contents or by small stones already
formed. The muscular gallbladder wall is damaged by longstanding inflammation or
infection which interferes with its ability to empty.

Abnormalities of bile composition may cause chemical inflammation of the gallbladder,

resulting in inflammatory exudation and perhaps accumulation of inflammatory debris.
Thus the gallbladder becomes chemically inflamed causing cholecystitis. This features
include intact but often atrophic mucosa, submucosal and subserosal fibrosis,
hypertrophy of muscular wall and mucosal diverticula.

Treatment
Medical Care: Medical care of the patient with acute cholecystitis centers around
stabilization of the patient and preparation for surgery if the patient is a candidate.
Administer IV fluids to correct any dehydration and continue as maintenance therapy.
Standard regimens include 5% dextrose in 0.2% sodium chloride solution or 5% dextrose
in 0.45% sodium chloride solution with 20 mEq of potassium chloride (KCl) per liter at a
rate determined by standard pediatric calculations.

Patients who are at risk for vaso-occlusion, including those with sickle
hemoglobinopathies, should receive hydration at 1.5 times maintenance dose. The patient
should receive nothing by mouth (NPO), and a nasogastric tube should be placed to low-
intermittent wall suction for evacuation of gastric contents. This step minimizes
stimulation to the inflamed gallbladder and prepares the patient for general anesthesia.
Administer pain medications; however, avoid morphine because of its spasmodic effects
on the sphincter of Oddi.

Antibiotics with biliary excretion covering enteric pathogens may be administered to

control infection. The combination of ampicillin, gentamicin, and clindamycin is a
common and well-accepted regimen. In addition, cefoperazone has a broad spectrum of
coverage and good biliary excretion. The use of antibiotics remains controversial. Some
authors assert that antibiotics are not necessary in simple cases and should be reserved for
persistent fever or worsening condition; however, Agrawal found a significant reduction
in postoperative infection with the use of prophylactic preoperative antibiotic
administration in elective cholecystectomy. Because of the high percentage of cases of
acute cholecystitis that are complicated by bacterial colonization, clinicians should
maintain a low threshold for the use of antibiotic therapy.

Removal of the gallbladder is the standard of care in patients with symptomatic gallstone
disease, although some exceptions exist. Critically ill children with acute acalculous
cholecystitis may not tolerate anesthesia and operative conditions. These children should
receive antibiotic therapy, hyperalimentation, and gastric decompression until their
conditions improve. These patients may then undergo surgery if symptoms persist;
however, many cases resolve with medical therapy alone. One author reported a 75%
resolution of acute acalculous cholecystitis with the use of antibiotics, nasogastric
suction, and hyperalimentation. Therefore, antibiotics may be sufficient in critically ill
patients who do not tolerate anesthesia and who may be assisted by other procedures,
such as cholecystotomy, if gallbladder drainage is necessary.

Observation is also recommended in infants with gallstone disease, especially those with
hyperalimentation-associated gallstones. These gallstones often dissolve with maturation
of the hepatobiliary system. The gallbladder should be removed with any sign of common
duct obstruction, pancreatitis, or cholecystitis. Cholecystectomy should also be performed
if gallstones persist longer than 1 year or if long-term hyperalimentation is anticipated, as
in Crohn disease, pseudo-obstruction, or short-bowel syndrome. Medical care in chronic
cholecystitis or other gallbladder disease is also supportive. Cholecystectomy is
recommended in most patients with gallstone disease. Treatment should be aimed at
control of any underlying conditions and preparation for surgery.

Children with sickle cell disease present a unique challenge because their
hemoglobinopathy may cause perioperative and postoperative complications. These
patients are susceptible to vaso-occlusive crises, pneumonia, sepsis, and pulmonary
infarct, most likely secondary to hypoxia, dehydration, and acidosis in response to
anesthesia.

Ware et al observed no complications when preoperative transfusion of RBCs were

performed to obtain a hemoglobin A (Hgb A) ratio greater than 2:1 while the hematocrit
level was maintained at 35-45%. This required 2 transfusions 2 weeks apart in most
patients with partial volume exchange employed for those with hemoglobin sickle cell
(Hgb SC) or sickle beta-thalassemia (SB thalassemia) disease. The preparation involved
with such improved outcomes suggests that planned elective surgery is beneficial to
patients with sickle hemoglobinopathies.

Other medical management strategies include contact dissolution and biliary lithotripsy.
Percutaneous transhepatic cholecystolitholysis involves the injection of a cholesterol
solubilizer, such as methyl-tert-butyl ether, directly into the gallbladder.

The time between instillation and aspiration must be conscientiously limited to avoid
leakage into the bile duct, causing abdominal pain and duodenitis. This method has been
successful in a few children. Biliary lithotripsy has also been used with limited success.
Similar to lithotripsy for nephrolithiasis, biliary lithotripsy uses shock waves to pulverize
gallstones. Biliary lithotripsy causes fragmentation in most patients but rarely causes
complete dissolution. Because fragments may still cause biliary colic and cholecystitis,
additional oral therapy may be necessary. All management techniques that involve
leaving the gallbladder in situ have 1-year recurrence rates of approximately 10% and 5-
year recurrence rates of approximately 50%.

Surgical Care: The surgical options available are OC and LC. Although OC was
considered the criterion standard, the laparoscopic approach is quickly becoming the
preferred procedure and now is used in 75-80% of cases. Advantages are reduced pain
and hospital stay and improved cosmetic results and patient satisfaction. Some concern
remains regarding the slightly higher risk of bile duct injury and the increased difficulty
of the procedure in cases of acute inflammation and in infants and children younger than
2 years. However, many authors now agree that acute cholecystitis is not a
contraindication, although the surgeon must be experienced and well skilled with
laparoscopic tricks. In addition, conversion to OC can be used in the face of extreme
difficulty.
Some authors assert that LC is ideal in infants and children and should be the procedure
of choice. In this case, surgical experience with laparoscopy and with infants is a must.
Wide spacing of cannulas is helpful in small children to allow for visualization and
adequate working distance. Also, with conscientious surgical technique, some authors
believe that bile duct injury can be minimized. In general, OC is reserved for conversion
and cases of prior major abdominal surgery. OC is accomplished through a right
subcostal incision or a transverse abdominal incision if a splenectomy is also indicated.
Laparoscopic entry involves 4 ports: 2 subcostal, 1 subxiphoid, and 1 umbilical.

The surgical course is usually routine. Patients can be admitted to the hospital the day of
surgery and discharged within 48-72 hours. The average postsurgical hospital stay after
LC is 36 hours, whereas patients undergoing OC typically need to stay in the hospital for
3 days. Continue hydration until the patient can tolerate a regular diet, usually the
morning after LC. In either procedure, observe the patient postoperatively for
complications, including fever, jaundice, ileus, pancreatitis, bile leak, or urinary retention.
Jaundice or continued right upper quadrant pain may signify a retained common duct
stone or biliary injury and should be investigated using ERCP or HIDA scanning as soon
as possible.

Daily examination
Date: 9th March 2006
Dairy: The patient is in full consciousness and in satisfactory condition. She feels pain in
the right hypochondrium. She has no appetite for food. She has had an episode of
vomiting. All palpation and percussion signs contribute to the diagnosis. The patient is to
be operated on this same day. The patient is going to undergo laparoscopic
cholecystectomy. Her present general condition makes her a good candidate for the
operation.

Preopearative epicrisis:
The patient is admitted to hospital with the diagnosis. The diagnosis is supported by
present complications, anamnesis and investigations done. Thus, an operation is indicated
upon diagnosis. Consent of operation is to be signed by the patient. The procedure of
indicated operation is laparoscopic cholecystectomy with elastic bandaging of the lower
extremities pre- and postoperation.

Plan of Operation:
Laparoscopic cholecystectomy
Absolute contraindications to laparoscopic cholecystectomy include generalized
abdominal infection, the late stages of pregnancy and major bleeding disorders. Relative
contraindications for less experienced surgical teams include morbid obesity, acute
cholecystitis, untreated bile duct stones including obstructive jaundice, acute gallstone
pancreatitis, previous abdominal surgery(adhesions)and intra-abdominal malignancy.

Patients undergoing laparoscopic surgery should be prepared for and have consented to
open surgery in case conversion proves necessary. In most centres, 5-10% of elective
patients require conversion. If bile duct stones are suspected, a preoperative ERCP(or
equivalent magnetic resonance investigation) is advisable and stone extraction is carried
out if necessary as laparoscopic exploration of the bile duct has not yet proved its value.
With experience, at least 95% of stones can be successfully extracted by endotherapy.
Some surgeons favour operative cholangiography in every case to give a “road map” of
the duct anatomy, to exclude bile duct stones and to provide experience for when
cholangiography is essential.

Operative technique
The patient is anaesthetized and prepared as for open cholecystectomy but with the
addition of a nasogastric tube and a urinary catheter; this decompresses the stomach and
bladder respectively and minimizes the risk or trocar injury. A pneumoperitoneum is
established via an open Hassan procedure(a safer technique, gradually superseding the
subumbilical Verress needle) using an automatic gas insufflator. A 10mm cannula is then
placed for a video laparoscope. The abdominal cavity is inspected for other pathology
and the feasibility of endoscopic cholecystectomy is then determined.

Three additional abdominal punctures are usually made to introduce operating

instruments. The cystic duct and artery are identified and an operative cholangiogram
performed if desired via the most lateral cannula or percutaneously through the
abdominal wall. It is extremely important to be certain of the ductal anatomy before
cutting anything because of the lack of depth perception, the distortion introduced by
retraction of gall bladder and the limitations of the two-dimensional imaging system.

The cystic duct is doubly ligated with metal clips or ligatures, the gallbladder is dissected
from the liver bed using diathermy or laser probes; haemostasis is secured. The now free
gall bladder is usually removed via the umbilical port. To achieve this, the laparoscope is
moved to the upper midline port and forceps inserted through the umbilical cannula. The
neck of the gall bladder is grasped and pulled into the cannula and the entire cannula and
gall bladder neck withdrawn through the abdominal wall. If large stones prevent its
passage, the incision is enlarged. The umbilical fascial defect should be sutured to
prevent herniation but the upper midline puncture is usually left unsutured along with the
lateral punctures. The nasogastric tube and urinary catheter are removed before the
patient leaves theatre.
Results of laparoscopic cholecystectomy
Most patients are able to walk and tolerate food within 6 hours of operation and up to
80% can be discharged within 24 hours. The time to return to work and other normal
activities appears to be reduced compared with open cholecystectomy.

The risk of bile duct injuries is undoubtedly related to the experience of the operating
team but overall it is twice as high in laparoscopic as in open surgery. Bile duct injuries
probably occur in 0.3-1% of patients. The consequences of bile duct injury can be
catastrophic; patients have died with multi-organ failure resulting from unrecognized
biliary peritonitis whilst others have required open operations to repair bile ducts and
have risked the consequences of long term bile duct strictures.

Postoperative period. Daily examination

Date: 10th March 2006
Dairy: The patient’s condition is satisfactory. She feels slight pain at the incisional
wound. She feels very weak and does not want to get off her bed. She has to take only
clear fluid. A drainage tube is placed to detect any fluid accumulation.
Signs: BP 135/85
Temperature 37.5
Respiratory rate 24/min
Pulse rate 75/min

Date: 11th March 2006

Dairy: Condition of the patient improves much today. She doesn’t feel pain at the present
moment. Wound dressing is done early in the morning. She is more active. Drainage tube
is to be removed later in the day.
Signs: BP 120/80
Temperature 37
Respiratory rate 25/min
Pulse rate 70/min

Date: 12th March 2006

Dairy: The condition of the patient is fit to be discharged. Wound dressing is changed.

Prognosis of disease
The patient’s prognosis is good. Recurrence rate of the same disease is reduced to 3%.
She is prescribed antibiotics for 5 days. She is advised against fatty food till full recovery.