FACULTY OF MEDICINE AND HEALTH SCIENCES

YEAR 5:

2022/2023

MM50210: SURGICAL SENIOR POSTING

ROTATION 4

CASE WRITE UP:

SYMPTOMATIC CHOLELITHIASIS

NAME :SHARVIENRAAJ VELUKUMARAN

MATRIC NUMBER : BM18110030

GROUP : GROUP B

SUPERVISOR : DR TIMOTHY WONG LEONG WEI

 Table of Contents

N Contents Page
o
1 Patient Particulars 3

2 Chief Complaint 3

3 History of Presenting 3-5

Illness
4 Systemic Review 6

5 Past History 7
I. Past Medical History
II. Past Surgical History
III. Drug and Allergy History

7 Family History 8

8 Social 8-9
History
9 Physical Examination 9-11
⮚ General Examination
⮚ Systemic Examination

Provisional Diagnosis 11
10
Differential Diagnosis 12-14
11
Investigations 14-15
12
Management and discussion on course of 15
13 disease

Operative Procedure 16
14
Discussion and Literature Review 17-19
15
References 20
16

PATIENT PARTICULARS
SHARVIENRAAJ VELUKUMARAN 2
 Name : DG Jamilah Binti
AG Sulaiman
Age : 67 years old

Gender : female

Race : Brunei Islam

Religion : Islam

Address : Kg Benoni, Papar

Marital Status : Married

Occupation : Housewife

Date of admission : 11/06/2023

Date of clerking : 11/06/2023

CHIEF COMPLAINT

Patient is presented with epigastric discomfort since 9 years.

HISTORY OF PRESENTING ILLNESS

Ms Dayang was diagnosed with Cholelithiasis with no biliary obstruction 6

months ago on 13/12/2022 at Rafflesia medical centre. She went for an abdominal
ultrasound on her own intention. She was well 9 years ago until when she
mentioned that she was having right upper quadrant pain since early the year of
2014. The pain was a continuous sharp pain. The pain is a non colic pain. The pain
was only relieved on applying pressure. It aggravates sometimes on taking a deep
breath.  The pain was radiating to the back, lasting about twenty to thirty minutes

SHARVIENRAAJ VELUKUMARAN 3
during each attack and she gave a pain score ranging from 10. Taking food doesn’t
really cause any changes to the pain nor relieves the pain.

The pain is not worsen with food intake or movement(Peptitis, PUD) and she
did not take anything to relieve the pain. It is also not associated with nausea and
vomiting(Obstructive Jaundice). Apart from that, there was no yellowish
discoloration of skin and eyes noticed by her family members. During this time, she
also noted that her urine has a normal colour and no tea color and her stool has not
become pale than usual(Obstructive Jaundice). She also has been experiencing
intense itchiness of her skin for two weeks. However, there was no fever or chills
complained. This is the first episode of such symptoms. She also has no associated
fever. She used to go to clinics nearby and she was always treated as Gastritis. She
denied taking traditional medication. Her diet mainly consist of home-cooked
chicken, fish and vegetables and she lead a sedentary lifestyle. There is no history of
recent travelling. 

Her first hospital visit was to Hospital Papar 2021, 2 years ago. An ultrasound
of the abdomen was done and she was told that she was having gallstone. She was
not admitted but she was given a referral to Hospital Queen Elizabeth. She defaulted
it. 13/12/22, 6 months ago she went to Rafflesia medical centre to get an ultrasound
of her abdomen and it was revealed that she was having grade 1 fatty liver,
cholelithiasis with no biliary obstruction and a non-obstructive renal calculi. Patient
mentioned that she has been always scared to seek for a medical attention for her
problem and will jst be enduring the pain throughout this course of 9 years. She also
mentioned that it never really disturbed her very much. But early this year she took
a decision to herself to do something about it and went to HQE1 clinic for a general
visit bringing her reports. She was then referred to general surgery clinic on 13
January 2023, 5 months ago. OGDS was done 4 months ago and was found that she
was having a bile reflux, actoral gastritis. She was treated with proton pump
inhibitors. It was at this visit she was planned for a laparoscopic cholecystectomy on
12/06/2023 and she was asked to come a day prior which was 11/06/2023, and get
admitted.

SHARVIENRAAJ VELUKUMARAN 4
 She has never had loss of appetite. She noticed most of her clothes has
loosen. 3 months ago her weight was 82 kg and her current weight is 77 kg. For her
she mentioned that this loss of weight is not that significant as she mentioned that
her weight was reducing because her food habits were improper and she skips
meals.  There is also pain over her left hip since three weeks ago which she describe
as dull, on and off pain that does not radiate with pain score of 2. It is not
associated with numbness, and there is no history of fall or trauma and she is still
able to walk. Otherwise, there is no change in bowel habit, no vomiting of blood, no
passing of bloody stool, no abdominal swelling, no change in urination and no
shortness of breath. 

She is having multiple comorbidities such as Hypercholesterolemia,

Hypertension and Diabetes Mellitus. She is currently on Table Simvastatin 40mg OD,
Tablet Amlodipine 10 mg OD, Tablet Perindopril 8 mg OD, Tablet MTF 1g OD and
T.Glicazide 160mg BD.  

SHARVIENRAAJ VELUKUMARAN 5
SYSTEMIC REVIEW

Cardiovascular She denies symptoms of chest pain, palpitation, orthopnea,

system and activity intolerance.
Respiratory She denies shortness of breath, cough, hemoptysis, and
system night sweats.
Neurological She did not have headache, body weakness, numbness,
system visual disturbance and loss of hearing
Gastrointestinal She denies any abdominal distension and change in bowel
system habit
Genitourinary She denies urgency, frequency, dysuria, urinary
system incontinence, no haematuria, no pyuria, no genital pain and
genital discharge
Musculoskeletal She does not have joint or muscle pain, no joint deformity
system

SHARVIENRAAJ VELUKUMARAN 6
PAST MEDICAL HISTORY

Ms Dayang is having multiple comorbidities such as Hypercholesterolemia,

Hypertension and Diabetes Mellitus. She is currently on Table Simvastatin 40mg OD,
Tablet Amlodipine 10 mg OD, Tablet Perindopril 8 mg OD, Tablet MTF 1g OD and
T.Glicazide 160mg BD.  She had no other significant past medical history such as
history of malignancy.

PAST SURGICAL HISTORY

No relevant surgical history.

SHARVIENRAAJ VELUKUMARAN 7
DRUG AND ALLERGY HISTORY

She has no known drug allergy, however he was allergy to seafood.

PAST OBSTETRIC AND GYNECOLOGICAL HISTORY 

She attained menarche at the age of 15 years old and had a regular 5 days cycle
with no menorrhagia, dysmenorrhea or intermenstrual bleeding. She has 6 children
all born through spontaneous vaginal delivery with no antenatal, intrapartum and
postpartum complication. She breastfeed her child for up to two years. There is no
history of miscarriage or other gynecological problem. She reached menopause at
the age of 56 years old and there is no post-menopausal bleeding until present time.
She did a pap smear two years ago and the result is normal. 

FAMILY HISTORY

Father Passed away due to Mother

old age Passed away
years ago

Ms DG

SHARVIENRAAJ VELUKUMARAN 8
Both her Mother and Father has passed away due to old age. Her younger sister
recenty passed away due to end stage renal failure as a complication of untreated
Diabetes mellitus type 2. Other than that, there is no history of malignancy running
in the family.

SOCIAL HISTORY

She is married and blessed with six children. Her husband has is an ex police
officer and he has diabetes mellitus type 2 associated with renal failure and soon to
be started on dialysis. She is taking care of her husband as well back at home. They
live in a two storey semi wooden house equipped with electrical supply and clean
water. She is a non-smoker and doesn’t consume alcohol. She denied taking
traditional medication. Her diet mainly consist of home-cooked chicken, fish and
vegetables and she lead a sedentary lifestyle. There is no history of recent travelling.

SUMMARY

Miss DG Jamilah, 67 years old Brunei Muslim lady with history of Right
Hypochondriac pain 9 years ago, with a colicky pain nature, radiating to the back
Aggravated on deep inhalation and relieved on pressure applied was confirmed to
have gall bladder stones 6 months ago and has been on review under hqe 1 general

surgery clinic. Currently has been planned for a laparascopic cholecystectomy.

PHYSICAL EXAMINATION

Blood pressure: 131/62 mmHg

Pulse rate: 67 beats per minute
Respiratory rate: 16 breaths per minute
Temperature: 36.8 degree Celcius
SpO2: 
SHARVIENRAAJ VELUKUMARAN 9
Pain score: 5/10 

On general examination, patient is lying supine on the bed supported with

one pillow. She is alert and conscious to time, place and person, not in pain or
respiratory distress. She has a big built body. There is a cannula inserted on the
dorsum of her right hand. 
On hands examination, there is no digital clubbing, no leukonychia, no
koilonychia, no palmar pallor, and capillary refilling time is less than 2 seconds.
There is no dupuytren contracture, no palmar erythema. Her pulse rate is 67 beats
per minute, regular rhythm, moderate volume, sharp rise followed by gradual fall, no
radio-radial delay. There is no scratch marks noted over the arms. 
On eyes examination, there is no scleral jaundice and no conjunctival pallor.
On mouth inspection, there is good hydration, good oral hygiene, no angular
stomatitis, no glossitis, and no gum bleeding. There is no cervical lymph node,
supraclavicular lymph node or neck swellings noted. On examination of the legs, no
pitting edema.

Abdominal Examination
● Inspection: Abdomen is moving with respiration and not distended. There is
no scars, no dilated veins and no visible pulsation noted. Umbilicus is centrally
located and inverted. Hernia orifices are intact. 
● Palpation: On superficial palpation, the abdomen is soft and non-tender. 
o On deep palpation. Murphy’s sign is negative. 
o The lower edge of liver is non palpable below the left subcostal margin
with upper border located at right 5th intercostal space and liver span
measured at 12cm. It moves with respiration and has firm consistency
with smooth surface, regular margin, non-tender, non-pulsatile, upper
border cannot be insinuated and it is dull on percussion. 
o The spleen cannot be felt over the left subcostal margin and kidneys are
not ballotable. 
● Percussion: No free fluid evidence by shifting dullness negative. 
● Auscultation: Bowel sounds is heard and no bruits noted. 

SHARVIENRAAJ VELUKUMARAN 10
 ● I should completed my examination with digital rectal examination but it is
not done. 

Cardiovascular examination
● Inspection: No surgical scars and no visible apex beat pulsations 
● Palpation: Apex beat is felt at the left 5 th intercostal space, midclavicular line.
It is not displaced. There is no thrills or parasternal heaves. 
● Auscultation: Both heart sounds S1 and S2 heard with no added sounds. No
bibasal crepitation noted. 

Respiratory Examination
● Inspection: The respiratory rate is 20 breaths per minute and no chest
recession or nasal flaring noted.  Hence, patient is not in respiratory distress.
There is no deformities or scars present.
● Palpation: Trachea is centrally located. Chest expansion is symmetrically
equal. Apex beat is not displaced. 
● Percussion: Equal resonance is elicit over bilateral lung fields, anteriorly and
posteriorly. 
● Auscultation: There is vesicular breath sounds heard with equal intensity on
all lung fields with no added sound.  

Neurological Examination
All high functions and cranial nerves were intact. Motor and sensory functions of the
upper and lower limbs were normal. 

Summary
A 67 years old lady with big built. Abdominal examination revealed negative murphy
sign. It is non-tender, no raised in temperature. The gallbladder non palpable but
non-tender and Murphy’s sign is negative. There is no hepatomegaly with liver span

SHARVIENRAAJ VELUKUMARAN 11
of 12cm, no splenomegaly, kidneys are not ballotable and no free fluid. Examination
over other systems are unremarkable. 

PROVISIONAL DIAGNOSIS

Symptomatic Cholelithiasis

Justification:

- Patient present with right upper quadrant pain, continuous sharp pain in
nature.

- Pain relieved on applied pressure on the right upper quadrant.The pain is

radiating to the back.
- The pain is not worsened with food intake or movement.
- It is not associated with nausea or vomitting.

- Urine has a normal colour and stool is not pale but brown.

- Abdominal ultrasound revealed that she has cholelithiasis with no biliary

obstruction.

DIFFERENTIAL DIAGNOSIS

a. Ascending cholangitis

Point to support:

- Patient presented right upper quadrant pain (part of Charcot triad).

SHARVIENRAAJ VELUKUMARAN 12
 Point to against:

- However there is no fever and jaundice. (Charcot triad : fever, jaundice,

right upper quadrant pain)

- Cholangitis is a life-threatening bacterial infection, in which the patient

will be severely ill.

b. Cholangiocarcinoma

Point to support:

- Patient presented right upper quadrant pain

- Patient’s age is 67, its a higher risk for the patient to have
cholangiocarcinoma

Point to against:

- Patient is not jaundiced.

- Patient does not have constitutional symptoms such as loss of weight, loss
of appetite and malaise.

c. Head of Pancreas Carcinoma

Point to support:

- Patient presented right upper quadrant pain and jaundice.

- Age for the patient increase the risk to have cholangiocarcinoma

- Patient had positive family history of malignancy running in the family.

SHARVIENRAAJ VELUKUMARAN 13
 Point to against:

- Patient does not have constitutional symptoms such as loss of weight, loss
of appetite and malaise
- Abdominal pain does not radiate to the back

- No mass palpable during physical examination

d. Acute cholecystitis

Point to support:

- Patient presented right upper quadrant pain.

Point to against:

- Patient does not have jaundice and fever.

- No palpable gallbladder

- Negative Murphy sign

INVESTIGATION

1. Full Blood count (13/06/2023)

PARAMETERS RESULTS NORMAL RANGE INTERPRETATION
Haemoglobin 11.0 11.0-15.2 g/dL Low
Total white cell 8.55 4-10 x10^3/uL Normal
Platelet 198 150-410x10^9/L Normal

SHARVIENRAAJ VELUKUMARAN 14
 2. Liver Function Test (13/06/2023)

PARAMETERS RESULTS UNIT NORMAL RANGE

Total Bilirubin 9.2 Umol/L 3.4- 20.5
Direct Bilirubin 93.2 Umol/L <5.1
ALT 65 U/L 0-55
AST 130 U/L 5-34
ALP 74 U/L 40-150
Total Protein 66 g/L 60-82
Alb/Glo 0.9
The ALT and AST is raised.

3. Coagulation profile (13/06/2023)

PARAMETERS RESULTS UNIT NORMAL RANGE

PT 10.1 seconds 9.3 -10.8
APTT 20.2 seconds 22.2- 31.6
INR 0.98
APTT is prolonged.

4. Ultrasound Hepatobiliary (13/06/2023)

-Grade 1 fatty liver with cholelithiasis with no biliary obstruction.

Management and Discussion on course of disease

General Management

SHARVIENRAAJ VELUKUMARAN 15
 1. Pain Management: Cholelithiasis can cause severe abdominal pain, which
should be managed by painkillers such as acetaminophen, ibuprofen, or
opioids.
2. Infection control: The stones can cause infection in the bile duct which
antibiotics is needed to treat the infection.
3. Hydration status: To prevent dehydration or improve hydration, intravenous
fluid should be prescribed.
4. Medical management: To dissolve small stones in the bile duct,
ursodeoxycholic acid can be prescribed. Its mechanism is to change the
composition of the bile and prevent the new stones formations in the duct.

Operative Procedure

Laparascopic cholecystectomy was done for the patient on 12/06/2023. The gall
bladder was found to be Fibrotic and distended. There were dense adhesions up to
fundus. The neck of gallbladder was impactedwith stone at the Hartmans pouch.
The duct of Luschka was ligated.

SHARVIENRAAJ VELUKUMARAN 16
Discussion and Literature Review

Cholelithiasis or gallstones are solidified stores of stomach related liquid that can
shape in your gallbladder. The gallbladder is a little organ found just underneath the
liver. The gallbladder holds a stomach related liquid known as bile that is delivered
into your small digestive tract. Asymptomatic gallbladder stones found in an ordinary
gallbladder and typical biliary tree don’t require treatment except if they foster side
effects. In any case, roughly 20% of these asymptomatic gallstones will foster side
effects more than 15 years of follow-up. These gallstones might continue further to
foster difficulties like cholecystitis, cholangitis, choledocholithiasis, gallstone
pancreatitis, and seldom cholangiocarcinoma. This action audits the etiology, show,
assessment, and the board of cholelithiasis, and surveys the job of the
interprofessional group in assessing, diagnosing, and dealing with the condition.

There are three primary pathways in the arrangement of gallstones:

Cholesterol supersaturation: Typically, bile can disintegrate how much

cholesterol discharged by the liver. Be that as it may, in the event that the liver
delivers more cholesterol than bile can break down, the abundance cholesterol might
hasten as precious stones. Gems are caught in gallbladder bodily fluid, delivering
gallbladder muck. With time, the gems might develop to frame stones and impede
the pipes which at last produce the gallstone sickness.

Overabundance bilirubin: Bilirubin, a yellow shade got from the breakdown of

red platelets, is discharged into bile by liver cells. Certain hematologic circumstances
make the liver make a lot of bilirubin through the handling of breakdown of
hemoglobin. This abundance bilirubin may likewise cause gallstone development.

Gallbladder hypomotility or disabled contractility: In the event that the

gallbladder doesn’t void really, bile might become focused and structure gallstones.

SHARVIENRAAJ VELUKUMARAN 17
Contingent upon the etiology, gallstones have various organizations. The three most
normal sorts are cholesterol gallstones, dark shade gallstones, and earthy colored
color gallstones. A lot of gallstones are cholesterol gallstones.

Each stone has an interesting arrangement of hazard factors. Some gamble

factors for the improvement of cholesterol gallstones are stoutness, age, female
orientation, pregnancy, hereditary qualities, absolute parenteral sustenance, quick
weight reduction, and certain prescriptions (oral contraceptives, clofibrate, and
somatostatin analogs).

Around 2% of all gallstones are dark and earthy colored shade stones. These
can be tracked down in people with high hemoglobin turnover. The color comprises
of generally bilirubin. Patients with cirrhosis, ileal infections, sickle cell frailty, and
cystic fibrosis are in danger of creating dark shade stones. Earthy colored shades are
essentially tracked down in the Southeast Asian populace and are not normal in the
US. Risk factors for earthy colored shade stones are intraductal balance and ongoing
colonization of bile with microbes.

Patients with Crohn illness and those with ileum infection (or resection) can’t
reabsorb bile salts and this expands the gamble of gallstones.

Cholesterol gallstones are framed mostly because of over discharge of

cholesterol by liver cells and hypomotility or impeded purging of the gallbladder. In
pigmented gallstones, conditions with high heme turnover, bilirubin might be
available in bile at higher than ordinary fixations. Bilirubin may then take shape and
ultimately structure stones.

Side effects and confusions of cholelithiasis result when stones deter the
cystic pipe, bile channels or both. Transitory hindrance of the cystic pipe (as when a
stone hotels in cystic channel before the conduit widens and the stone re-visitations
of gallbladder) brings about biliary torment yet is generally brief. This is known as

SHARVIENRAAJ VELUKUMARAN 18
cholelithiasis. More relentless deterrent of cystic channel (as when a huge stone gets
forever stopped in the neck of the gallbladder) can prompt intense cholecystitis. In
some cases a gallstone might help go through the cystic conduit and get stopped
and affected the normal bile channel, and causes impediment and jaundice. This
entanglement is known as choledocholithiasis.

On the off chance that gallstones go through the cystic conduit, normal bile
channel and get unstuck at the ampulla of the distal part of the bile pipe, intense
gallstone pancreatitis might come about because of upholding of liquid and
increment strain in pancreatic conduits and in situ actuation of pancreatic chemicals.
Every so often, huge gallstones really do puncture the gallbladder wall and make a
fistula between the gallbladder and little or enormous entrail, creating gut hindrance
or ileus.

Asymptomatic gallstones require the patient to be advised in regards to side

effects of biliary colic and when to look for clinical consideration. Cholelithiasis
without entanglements can be dealt with intensely with oral or parenteral absense of
pain in the crisis division or earnest consideration place once the determination has
been laid out and elective analyses avoided. Patients ought to likewise be offered
dietary counsel to decrease the opportunity of repetitive episodes and alluded to an
overall specialist for elective laparoscopic cholecystectomy. Today, laparoscopic
cholecystectomy is the norm of care and most patients are overseen as short term
patients.

Patients with side effects and workup steady with intense cholecystitis will
expect admission to medical clinic, careful counsel and intravenous anti-toxins.
Patients with choledocholithiasis or gallstone pancreatitis will likewise expect
admission to clinic, gastrointestinal (GI) counsel and ERCP or MRCP. Patients with
intense climbing cholangitis are normally sick showing up and septic. They
frequently likewise require forceful revival and ICU-level consideration
notwithstanding careful mediation to deplete a disease in the biliary lot.

SHARVIENRAAJ VELUKUMARAN 19
REFERENCES

Ana Dudelj Gracanin, Milan Kujundzic, Mladen Petrovecki, Zeljko Romic, Dario
Rahelic, (2013). Etiology and epidemiology of obstructive jaundice in
Continental Croatia, National Library of Medicine.

Bailey H. Love R. J. M. N. Mann C. V. & Russell R. C. G. (1992). Bailey and

love's short practice of surgery (21st ed.). Chapman & Hall Medical.

Christopher F. Mc Nicoli, Alyssa Pasrtorino, (2023), Choledocholithiasis, National

Library of Medicine.

Lin, C. C., Li, T. C., Li, C. I., Liu, C. S., Lin, C. C., Yang, S. Y., & Lee, Y. C.
(2014). Obstructive jaundice and risk of long-term liver disease mortality--a
population-based cohort study in Taiwan. Journal of hepatology,

Shenoy, K. R., & Shenoy, A. (2020). Manipal Manual of Surgery. CBS Publishers
& Distributors, Pvt Ltd.

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