UNIVERSITY OF THE EAST

Ramon Magsaysay Memorial Medical Center

Aurora Blvd., Quezon City
Department of Surgery

Greg Mikhail B. Hubo August 15, 2021

2023-B
Preceptor: Dr. Napoleon Alcedo

I. Identifying Data
The patient is a 28-year-old Filipino female from Malolos, Bulacan. She is single and practices
Catholicism.

II. Chief Complaint

Right upper quadrant pain of 1-day duration

III. History of Present Illness

Six (6) months prior to admission (PTA): patient noted occasional crampy epigastric pain with a
PS of 3/10. No consultation was done.
Five (5) days PTA: patient noted crampy epigastric pain with a PS of 10/10. Sought consult and
was sent home after being given Omeprazole and Maalox at ER.
During the day of consultation, the patient noted right upper quadrant pain after eating bulalo for
lunch. Hence consult at ER.
Recommendation: A more thorough history of the patient should have been conducted. The
symptoms of the patient must be explored more regarding the timing of the appearance of the
symptom, associated symptoms, and aggravating factors. Pertinent negatives such as fever,
jaundice, and weakness should have been noted.
IV. Past Medical History
The patient has a fish allergy and was diagnosed with Polycystic ovarian syndrome in 2018 for
which she is not taking any medications. The patient has no history of tuberculosis, diabetes
mellitus, hypertension, or heart disease. Patient also has no previous operation.

V. Family History
Family history of hypertension on the maternal side and no family history of cancer, diabetes
mellitus.
VI. Personal/Social History
Patient has a 5 pack year smoking history, is an occasional alcohol drinker, with no history of
illicit drug use. The patient also reported occupational hazards.
VII. OB-GYNE History
No information elicited during interview.

Recommendation: It is prudent to take the OB-GYNE history especially for patients of

child-bearing age and with abdominal complaints. This will help the assessment of the patient and
what should be taken into account when considering pathologies.
VII. Review of Systems
General survey  No anorexia, no fatigue, fever, weakness
Skin No jaundice, dryness, itching, changes in hair and nails, rashes
HEENT  H: No headache, No head injury;
E: No redness, pain, inability to open eye
E: No hearing impairment, otalgia, discharge, swelling of structures
 N: No Nose deformity, no colds, no epistaxis
T: No gum bleeding dental carries dysphagia odynophagia, hoarseness
Respiratory No hemoptysis, wheezing rales, crackles, exertional dyspnea, DOB
Cardiovascular  No chest pain, palpitations, dyspnea orthopnea, syncope
Gastrointestinal No constipation, indigestion, heartburn, fatty food intolerance
Urinary No pain in urination, UTI, hematuria, kidney or flank pain, suprapubic pain,
increase in frequency, weak urinary stream, incomplete emptying, polyuria,
dribbling, hesitancy
Extremities No joint pains, no edema clubbing cyanosis varicosity, claudication
Hematopoietic No excessive bleeding/bruising, PICA, anemia
Nervous No head trauma, sensory perversions, tremors, fainting spells, seizures,
trauma, dizziness
Musculoskeletal No pain on all extremities, swelling
Endocrine No heat/cold intolerance, neck surgery/irradiation, no polydipsia, no
polyphagia, no polyuria, no thyroid problems
Psychiatric No irritation, no agitation, anxiety, depression
IX. Physical Examination
General Survey The patient is awake and conversant, not in pain, not in
cardiorespiratory distress
Vital signs BP: 120/80
HR 91 bpm
RR 17 cpm
Temp 36.2C
O2 Sat 99% at RA
BMI: 27
HEENT anicteric sclerae, pink palpebral conjunctivae, moist lips and oral
mucosa, no tonsillopharyngeal congestion, no palpable cervical
lymphadenopathies
Chest and Lungs Equal chest expansion, clear breath sounds, equal tactile fremitus,
clear breath sounds
Cardiovascular Adynamic precordium, tachycardic, regular rhythm, distinct s1 &
s2, (-) murmurs
Abdomen Flabby abdomen, non tympanitic, non-distended, normoactive, soft,
(+) RUQ tenderness (with inspiratory arrest upon light
palpation)
DRE: Smooth rectal mucosa, no palpable mass, no blood on
examining finger, good sphincter tone
Genitourinary No hematuria, no dysuria, no nocturia, no weak stream, no urgency

Extremities Full equal pulses, no edema, no cyanosis, CRT <2 seconds

Pertinent Subjective Pertinent Objective

Patient Profile BP: 230/80 mmHg
• 28 years old, female Temp: 36.4oC
Chief Complaint RR: 17cpm
• RUQ pain of 1-day duration HR: 91bpm
Personal/Social History:
Abdomen PE:
• Social
• Occasional alcohol drinker
Inspection: Flabby abdomen, non-distended

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• Smoker with 5 pack year Auscultation: Normoactive bowel sounds
History of Present Illness Percussion: Non-tympanitic
• 6 months PTA, Palpation: Soft, (+) RUQ Tenderness
• Occasional crampy (+) Murphy’s Sign (inspiratory arrest upon light and deep
epigastric pain, 3/10
palpation)
• 5 days PTA,
• Crampy epigastric pain,
10/10
• Relieved by Omeprazole
and Maalox
• Day of Consult
• RUQ pain
• After eating bulalo

Initial Assessment
Primary Impression: Acute Cholecystitis with suspected Cholelithiasis

The right upper quadrant (RUQ) pain points to organ systems in the area primarily the
hepatobiliary system. However, the presence of a positive murphy’s sign, which is inspiratory
arrest due to pain, points to a biliary or gallbladder pathology. Among cases of Acute
cholecystitis, which is inflammation of the gallbladder due to cystic duct obstruction, the majority
is caused by gallstones known as cholelithiasis1.

Particularly notable in the patient's history is pain after eating bulalo for lunch.
Postprandial pain from fatty food ingestion is a common history among patients diagnosed with
Acute calculous cholecystitis. Moreover, risk factors for formation of gallstones that may
precipitate inflammation are also present with the patient such as gender, weight, and child
bearing age2.

Cholecystitis can be confirmed if complete blood count tests would show elevated WBC
and especially important is ultrasound imaging to visualize gallbladder wall thickening or edema.
Visualization of the gallstones on ultrasound supports the suspicion of cholelithiasis. In addition,
a liver function test and bleeding parameters, may be requested to rule out other causes of acute
cholecystitis or consider that the pain may be from other causes. The kidney and liver function
tests may be requested to assess possible risks of surgery and management. If suspected, a
pregnancy test for women of childbearing age may also be requested. 1,3.

Differential Diagnosis
Differential Rule in Rule Out
Mirizzi Syndrome4 ● RUQ pain ● Normal biliary system above the neck of
● (+) Murphy’s sign the gallbladder
● (-) jaundice
● (-) elevation of ALP
● (-) stones in gallbladder neck
● (-) change in common bile duct below level
of impacted stone

Choledocholitiasis5 ● (+) RUQ pain ● (-) nausea

● (+) postprandial ● (-) vomiting
pain ● (-) jaundice
● (-) tea-colored urine

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 ● (-) acholic stools
● (-) pruritus
● (-) icterus

Peptic Ulcer Disease ● (+) RUQ pain ● (+) murphy’s sign

● (+) postprandial ● (-) melena
pain ● (-) hematochezia
● smoker

Diagnostic Workup:
● CBC with differentials – to determine if there is anemia and
elevated wbc in cases of infection or inflammatory response.
● Hepatobiliary Ultrasound – non-invasive; diagnostic test of
choice for cholecystitis; Dilated bile ducts may signify
obstruction of biliary tree by gallstones, tumor, strictures,
stenosis; cholecystitis can be confirmed with gallbladder wall
thickening or edema; Gallstones will appear hyperechoic with
strong shadowing
Diagnostic tests ● Hepatic Panel – to rule out liver infection or bile obstruction;
3,4,5,6,7
check levels of liver enzymes.
● Bleeding parameters – to rule out liver inflammation; test for
liver function; assess possible risks during surgery
● Creatinine – checking kidney function for further work-up or
starting medications; assess risks during surgery
● BUN – checking kidney function for further work-up or starting
medications; assess risks during surgery

Laboratory Results
CBC Hemoglobin – 14 gm/dl
Hematocrit – 44%
WBC – 12, 500 (elevated)
Neutrophils – 85% (elevated)
Lymphocytes – 15% (low)
Monocytes – 0%
Eosinophil – 0%
Basophil – 0%
Platelets – 217,000

Elevated WBC and neutrophil count may indicate an inflammatory

process or bacterial infection 6.
Hepatic Panel ALT – 56 U/L
AST – 27 U/L
Alkaline Phosphatase – 18 U/L
Total bilirubin – 0.4 mg/dL
Direct bilirubin – 0.02 mg/dL
Indirect bilirubin – 0.2 mg/dL

Unremarkable results. Liver infection can be ruled out.

Bleeding Parameters Prothrombin time – 11 secs

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 INR – 0.98
APTT – 28 secs
Bleeding Time – 3 mins 10 secs
Clotting time – 4 mins and 30 secs

Bleeding parameters are normal which may imply normal liver function.
Hepatobiliary Multiple hyperechoic shadowing echogenicity in the gallbladder neck,
Ultrasound measuring 0.7-1.2 cm in diameter, gallbladder measuring about 11 cm in
widest diameter, thickened gallbladder wall with pericholecystic fluid;
CBD 0.4 cm in diameter

Normal liver, pancreas spleen

Presence of stones with dark acoustic shadowing; The gallbladder is

distended. with thickened walls and fluid collection or gallbladder
edema that may be interpreted as diagnostic of cholecystitis secondary
to cholelithiasis 2,3.

Assessment
Final Diagnosis: Uncomplicated Acute Cholecystitis secondary to cholelithiasis (Acute
Calculous Cholecystitis)

With the available history, PE findings, and laboratory results, final diagnosis would be
Acute calculous cholecystitis. Hepatobiliary ultrasound revealed gallstones evident with
hyperechoic shadowing with echogenicity in the gallbladder neck.Thickening of gallbladder wall
and accumulation of pericholecystic fluid may be interpreted as acute cholecystitis 1,3.

Absence of elevation of liver enzymes particularly ALP rules out Mirizzi syndrome.
Absence of jaundice and distension in the common bile duct by gallstones rules out
choledocholithiasis.

Management
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Supportive care :
● Intravenous hydration (UTD)
● Correction of electrolyte imbalance, if present
Pain control:
● NSAID/Opioids – Ketorolac (30 to 60mg) adjusted for age and renal
function usually relieves symptoms within 30-60 minutes. If NSAID
is contraindicated to the patient, opioids such as morphine or
meperidine may be used 11.
Initial management2 Prophylactic antibiotics:
● Antibiotics – Empiric antibiotic therapy is recommended.
Uncomplicated cases may use Cefazolin 1g IV every 8 hours or if
with beta-lactam allergy, Fluoroquinolone 400mg IV every 12 hours
+ Metronidazole 500mg every 6 hours. Complicated cases may use
Cefoxitin 2 grams IV every 8 hours or if with beta-lactam allergy,
Fluoroquinolone 400mg IV every 12 hours + Metronidazole 500mg
every 6 hours2.
Surgical:
5
 ● Treatment recommended for patients with gallbladder stones.
Laparoscopic Cholecystectomy [PCS]: Recommended surgical
Definitive Plan 1,2,8 approach for Acute Cholecystitis (other option is open
cholecystectomy)
● Optimal time is within 72 hours of admission
● Indicated for low-risk cholecystitis or Grade I (mild)
Activity:
● Fatigue is common for the first week after surgery.
Post-operative Plan9 ● Limit physical activity and prioritize rest as needed.
● Avoid heavy lifting or any activity that will increase abdominal
pressure for the first 4 weeks.
● Practicing deep breaths and occasional coughing every hour while
awake may reduce the risk of pneumonia during the first week.
Medications and wound care:
● Pain medicine should be taken as needed and is recommended to be
taken with food.
● Follow up for post-op care 1 week after surgery and 3 months after
surgery.
● Empiric antibiotic therapy recommended for both uncomplicated and
complicated cases (duration of therapy depends on clinician’s
assessment post-op)
Diet:
● Avoid fatty or heavy food during the first few days as these may
cause diarrhea or nausea.
● Normal diet may resume after going home and confirming with the
physician.

Precautions (Call or visit a physician when these symptoms are present):

● Fever with or without cough may be a sign of respiratory tract
infection.
● Watery diarrhea with fever may indicate bowel infection.
● Tachycardia may indicate an ongoing infection.
● Dyspnea or difficulty of breathing may indicate cardiovascular
problems such as a pulmonary embolism.
● Leg edema accompanied by pain may be a sign for blood clot
formation.
● Unconsciousness may be a sign of low blood pressure caused by
blood loss or low blood glucose.
● Sudden new stomach pain may indicate leakage around the stomach
or an infection.
● Green/brown wound drainage with foul odor may indicate wound
infection. Redness and irritation may also be considered. Gold
colored wound drainage is normal.

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ALGORITHM:

Figure 1: Primary Impression

Figure 2: Primary Impression and Differential Diagnosis Expected Findings

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Figure 3: Final Diagnosis Classification

Figure 4: Management of Final Diagnosis

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References

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Platinum: Chapter 22: Section 2: The Gallbladder and Biliary System. Top Practice
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2. Greenberger, N. & Paumgartner, G. Harrison's principles of internal medicine: Part
10: Section 3.339: Diseases of the Gallbladder and Bile Ducts. New York: McGraw
Hill Education; 2015.
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=acute cholecystitis management
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e_link
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Gallbladder and the Extrahepatic Biliary System. 10th ed. New York: McGraw-Hill
Education; 2016.
8. Okamoto K, Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I, et al. Tokyo
Guidelines 2018: flowchart for the management of acute cholecystitis. Journal of
Hepato-Biliary-Pancreatic Sciences. 2017;25(1):55–72.
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FMPH268. University of California, San Diego Medical Center; 2008 [cited 2021].
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