CASE PRESENTATION CEIII-II PWH IP

Yu 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

unaided outdoor walker lives with family. PMH: BPH with TURP (Transurethral resection of prostate) done 2010 Appendicectomy Hx of epilepsy Social Hx: NDNS. 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  .

caco3  . <20% Mixed stones: 20-80% cholesterol  Other common constituents  E. at least 80% cholesterol   Pigment stones: small and dark.GALL STONES different size and shape  Cholesterol stones: light yellow to dark green or brown and are oval. comprise bilirubin and calcium salts.g.

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  . size >8mm  “Gallstone attack”: intense pain UR abd.SIGNS & SYMPTOMS May be asymptomatic “silent stones” don’t require treatment  Symptoms commonly begin.

PATHOPHYSIOLOGY  Cholesterol GS develop when bile too much cholesterol & not enough bile salts 1. Incomplete & infrequent emptying of gallbladder Causes bile over-concentrated    . How often & how well gallbladder contracts 2.

 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  .

html  Walk around same day or the day after surgery  Deep breathing and coughing (wound supported)  Drink liquids->soft->solid foods  +/-Antibiotics. pain killer  PCA  +/-Stool softeners  .AFTER OPEN CHOLECYSTECTOMY http://www. anti-nausea.drugs.com/cg/open-cholecystectomyinpatient-care.

unless contraindications e.LAPAROSCOPIC Laparoscopic: first choice.½”) incisions  Laparoscope introduced into abd  + short Post-OT recovery  +rapid return to full f(x)  . technical reason/ safety  Open more prone to infection  small (1/4” .g.

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moist cough. coarse crackle’s bil LZ.1ST SESSION  D2 9/11/12 C/O: Wound P+++  O/E:  Very large GS specimen  Off O2  On PCA. Foley  Chest: AE fair. 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 .

PCA AXR: prominent SB loops generalized occ wheeze 11/11mild crepitus CXR: LLZ hazziness. 10/11 off IV. mild blunt L CP angle inadequate inspiratory effort AXR: prominent bowel loops  .

moist cough. mild crep. no ST/T wave changes Abdominal distension  Decrease basal AE. fair cough effort (wound supported)  Treatment  FET->whitish sputum coughed out  Deep breathing ex  Triflow  Walking ex around ward  .2ND SESSION  12/11/12 Complaint of mild (chest?)abdominal discomfort  ECG: SR 104/min.

3RD SESSION    13/11/12        AXR: dilate small bowel. drain fluids and stomach acid self ambulate in ward Decrease wound pain Treatment FET->whitish sputum coughed out Deep breathing ex Triflow Walking ex around ward Static bike ex . multiple fluid level Contact precaution: diarrhea NG tube inserted: remove gastric secretions and swallowed air in patients with gastrointestinal obstructions.

keep IV drip  Decrease abdominal discomfort  Improve AE .4TH SESSION  15/11/12 AXR: dilated SB with multiple air-fluid levels. LB gas seen  Off NG tube.

air/fluid level seen  Try fluid diet  Decrease distension  Repeat AXR: dilated SB loops. off drip. improving  17/11 abd mod distended. LB gas seen. abd decrease distension  .16/11 AXR still dilated SB.  start soft diet  18/11 soft diet tolerated.

whitish spt coughed out  Decrease abd distension  Triflow  Self ambulate  Static bike  D/C? . no added sound. strong cough effort.5TH SESSION  19/11/12 D12 All stitches removed  AE sat. moist cough.

THE END Thank you! .

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