by: dr.Kartika Iswaranti

This case is an actual case taken from Noongan Public Hospital ward. The reason why this case presented are:  Gallstones are a common medical problem that is easily found in every hospital around the world  In epidemiological cholelithiasis can be found in areas with high rates of obesity .  This is why this case is an interesting case because Noongan General Hospital located in North Minahasa .  Minahasa people are famous for their lifestyle . Thus , Minahasa has a high prevalence of cholelithiasis .

 Approximately 10-15 % of the adult population , or more than 20 million people in the United States may have gallstones  In 1991 approximately 600,000 patients underwent cholecystectomy in the United States , with a value of 5 billion dollars . In Indonesia, the numbers can vary because the case is relatively new and research is still very limited .

 The final goal of the presentation is to widen our knowledge about this disease.

M  Registry number : 054885  Social status : middle-upper .Admistration Data  Name : Ms. J.

Demographic Data  Name  Age  Sex  Religion  Job  Education  Address : Ms. JM : 65 years old : female : christian : housewife : university graduate : amonggena II .

Biological Data  Height  Weight  Body Type : 159 cm : 75 kg : picnicus .

flacid .ANAMNESIS Autoanamnesis was taken on November 27th. nausea. vomiting.2013 Chief Complain : Pain at the upper right abdomen Secondary Complain : Headache.

nausea (+). But the complaint was not perceived as often and as severe as when the patient comes to the hospital. The patient had never been to a doctor for treatment or reduce complaints. Pain was felt especially when the patient was eating fatty foods such as cake or fried food.  Initially pain happened since 3 weeks before the patient entered the hospital.  Urinating (N). defecating (+)  Dizziness (+). Pain was intermittent.History of Present Illness  ± 3 days before admission the patient felt pain in the right upper abdomen. weak (+) . Pain disappear when the patient rested. vomiting (+).

History of Past Illnesses      Asthma Hypertension Heart DM Uric acid : Denied : Denied : Denied : Denied :+ .

.History of Family Illness No family member of the patient who suffered the same illness.

.History of Personal Habits  History of smoking : denied  History of drinking alcoholic beverages: denied  History of eating fatty foods : (+).

Physical Examination  .

secret (-)  Mouth: no caries found . sclera icteric (-)  Ears: Secret (-)  Nose: deviation of the septum (-). Skin : effloresency (-)  Head : Normocephali  Eyes : Conjunctiva anemic (-).

 Thorax Pulmo:  Inspection  Palpation  Percussion  Auscultation Heart:  Inspection  Palpation  Percussion  Auscultation Abdominal:  Inspection  Palpation  Percussion  Auscultation  Murphy sign Ekstremitas : Retraction (-). wheezing (. normal : (-) : warm. NT (+) epigastrium : Shifting Dulness (-) : Society intestine (+)./ -) : Ictus Cordis (-) : Ictus Cordis in SIC IV : dim : Regular. ronchi (-). edema -/- . : Hepar / lien not palpable.simetric movement of the chest wall : simetric movement of the chest wall(-) : Sonor : Vesiculer. pulse adequate. murmur (-) Gallop (-) :abdomen looked flat.

Working diagnosis : • Cholelithiasis Differential diagnosis : • Dyspepsia • Cholecystitits • Cholangitis • Pancreatitis .

jaundice. .cholecystitis • Persistent RUQ pain +/. ↑WBC.fever. ↑LFT. fever (seen in 70% of patients). +Murphy’s = inspiratory arrest Cholangitis • Charcot triad: RUQ pain. can lead to septic shock Pancreatitis • Anamnesis are similar to cholelithiasis. Do the pancreatic enzymes test.


500mm3/ul : 82.0 %  Trombosit : 321.8 % : 4.000 mm3/ul .Laboratory result 27-12-2013  Hemoglobin  Malaria  Hematokrit  Eritrosit  Leukosit  Granulosit : 11.4 g% :: 36.18 mm6/ul : 12.

ECG 27-12-2013 .

USG 30-12-2013 .





Gallstones  The presence of gallstones in the gallbladder is called cholelithiasis. .

can lead to septic shock . fever (seen in 70% of pts). no fever/WBC. No fever/WBC. +Murphy’s = inspiratory arrest Recurrent bouts of colic/acute chol’y leading to chronic GB wall inflamm/fibrosis.fever. GB inflammation due to biliary stasis(5% of time) and not stones(95%). Charcot triad: RUQ pain.Definitions Symptomatic cholelithiasis Acute cholecystitis Chronic cholecystitis Acalculous cholecystitis Choledocholithiasis Cholangitis Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone. Persistent RUQ pain +/. ↑LFT. Seen in critically ill pts Gallstone in the common bile duct (primary means originated there. jaundice. ↑WBC. secondary = from GB) Infection within bile ducts usu due to obstrux of CBD. normal LFT Acute GB inflammation due to cystic duct obstruction.

 The exact cause of gallstone formation is unknown.Etiology / Pathophysiology  Can be caused by an obstruction.  Bile gets trapped and acts as an irritant which causes cellular infiltration within 3 – 4 days. gallstone or tumor it prevents bile from leaving the gallbladder. gallstone or a tumor.  When there is an obstruction. .  90% of all cases caused by gallstones.

 Eventually this occlusion along with bile stasis causes the mucosal lining of the gallbladder to become necrotic.  Bacterial growth occurs due to ischemia. This infiltration causes an inflammatory process – the gallbladder becomes enlarged and edematous. Necrotic Gallbladder .

 Rupture of the gallbladder becomes a danger.  If the disease is severe and interferes with the blood supply it can cause the gallbladder to become gangrenous. along with spread of infection of the hepatic duct and liver. Gangrenous gallbladder Gallstones .

Those who are most at risk.  These are all adjectives to describe the person most at risk of developing symptomatic gallstones. FAIR FAT FORTY FEMALE .

Something to think about.  INDONESIA?  They are responsible for the hospitalization of more than half a million people each year.S. .  The two most common conditions are cholecystitis & cholelithiasis.  Disorders of the biliary system are COMMON in the U.

nausea.  Increased heart and respiratory rate – causing patient to become diaphoretic which in turn makes them think they are having a heart attack.Signs and Symptoms. . vomiting and flatulence.  Anorexia.  Localized pain in the rightupper quadrant epigastric region.  Complaints of indigestion after eating high fat foods.

Mild jaundice. Clay colored stools caused by a lack of bile in the intestinal tea-colored. .  Urine may be dark amber. Elevated leukocyte count.Signs and Symptoms. Stools that contain fat – steatorrhea.      Low grade fever.

 Ultrasound of the gallbladder.Diagnostics.  Fecal studies.  Serum bilirubin tests. .

removed from the blood by the liver and excreted by the liver into the bile – it is concentrated in the gallbladder outlines the gallstones that are radiolucent (x-rays pass through them). HIDA scan - Oral cholecystogram -  Operative cholangiography – common bile duct is directly injected with radiopaque dye.   imaging test used to examine the gallbladder and the ducts leading into and out of the gallbladder . the patient takes iodine-containing tablets by mouth iodine is absorbed from the intestine into the bloodstream . .also referred to as cholescintigraphy.Diagnostics.

 If the attack of cholelithiasis is mild –  bed rest is prescribed.  patient is placed on NPO to allow GI tract and gallbladder to rest.Medical Management.  Lithotripsy  for patients with only a FEW stones.  fluids are given IV in order to replace lost fluids from NG tube suction.  an NG tube is placed on low suction. .

Medical Management. vein and artery are ligated. The gallbladder along with the cystic duct. . Cholecystectomy or Laparoscopic Cholecystectomy – removal of the gallbladder. This is the treatment of choice.

additional instruments are passed that enable the removal of stones and the stretching of narrowed regions of the ducts.Medical Management. .  A number of various instruments are inserted through the endoscope in order to "cut" or stretch the sphincter. an endoscopic sphincterotomy must be performed to remove them BEFORE a cholecystectomy is done.  Drains (stents) can also be used to prevent a narrowed area from rapidly returning to its previously narrowed state.  If stones are present in the common bile duct.  Once this is done.

 .Will you survive?  Prognosis is usually excellent with prompt treatment.  Prognosis is NOT favorable for those who develop pancreatitis.  Laparoscopic surgery has decreased the number of complications.

Eww! .

Thank You .

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