Cholelithiasis

SKDI:2
ICD-10: K.80.2

Deya Seisora Ismet

PATIENT’S IDENTITY
 Name : Mrs. YH
 Age : 39 years old
 Address : Soe-ta st.Pekanbaru
 Admitted to hospital : September 25th 2019
 MR : 01021413
 Chief Complaint

Upper right abdominal pain since 3 days

before admitted to the hospital
Present illness history

2 years before admitted to the hospital patient said that she

had this complaint before which is pain of RUQ on abdominal. This
pain felt referred to the back. Patient went to GP and said that she
had a dyspepsia and gave her the medicine of dyspepsia
syndrome. After that, the patient went to internist and diagnose her
with gall-blader stone and give her ursodiol. Patient regularly
consumed her drugs but there was no change.
8 months ago, the pain was worsening and she went to
digestive surgeon and recommended her for taking out this stones,
but patient denied.
3 months ago, patient said that the pain was unbearable
which is referred to the back and it difficult to breathe and
aggravated 3 days ago. Nausea and vomiting was often felt if the
patient consumed a fatty food. There was no clay colored stools,
dark amber- to tea-colored urine and fever.
Past illness history

Hadn’t complaint before

History of hypertension (+) 8 years ago.
Patient consumed amlodipin 10 mg
once a day
Patient had uncontrol
hypercholestrolemia.
History of DM was denied.
Family illness history

No family history

Histories of hypertension, heart disease,
diabetes mellitus, and
hypercholestrolemia were denied
Social history

Patient often eat fatty food

Exercise (-)
Alcohol consumption (-)
 Physical Examinations
 General appearance : mild illness
 Consciousness : cooperative composmentis
 BMI : Obese I; Weight: 75 kg,
Height: 160 cm. BMI: 29,1kg/m2
 Vital sign:
 Blood pressure : 140/90 mmHg
 Heart rate : 88 bpm
 Respiratory rate : 23 x/m
 Temperature : 36,5 C
Physical Examinations
 Head and Neck Examination
 Eye : anemic conjunctiva (-/-), icteric sclera (-/-),
 isochoric pupil (2mm/2mm),
 Neck : There’s no enlargement of lymph gland

 Thorax Examination
 Inspection : symmetrical chest movement
 Palpation : symmetrical vocal fremitus, ictus cordis felt in
ICS V linea midklavikula sinistra
 Percussion : sonor in all lung fields, right heart border in
linea sternal dextra, left heart border in linea
midklavikula sinistra
 Auscultation : vesicular breath sounds, S1 and S2 regular
Physical Examinations

Abdomen: Localized status

Extremities:
Warm extremities
CRT <2s
Localized status
 Abdomen:
 Inspection : the abdomen looked convex
 Auscultation : Bowel sounds (+), freq 10 x/min
 Palpation :Tenderness on RUQ(+) murphy sign (+)
lien and hepar was not palpable.
 Percussion : tympanic all region
Working diagnosis

Acute abdomen ec susp cholelithiasis

Controlled Hypertension
Obese I
Differential diagnosis

Choledocolithiasis
Cholecystitis
Plan of Adjunct Exams

Complete Blood Test

USG Abdomen
CT-Scan Abdomen
Laboratory finding

On patient Normal range

 Hb : 12,8 g/dl 12-16 g/dL
 Ht : 37.9 % 37 – 47 %
 Eritrocytes : 4.94 106 /UL 4.2 – 5.4 106 /UL
 Leucocytes : 7.33 103 /UL 4.8 – 10.8 103 /UL
 Trombocytes : 258 103 /UL 150 – 450 103 /UL
 Direct Bilirubin : 0.3 mg/dL 0 – 0.49 mg/dL
 GDS : 90 mg/dL <100 mg/dL
 Ureum : 19 mg/dL 12 – 42.8 mg/dL
 Creatinine : 0.9 mg/dL 0.5 – 1.33 mg/dL
Thorax x-ray
Correct identity
Marker “R”
Good quality
Medial trachea
Intact bone
Normal vertebrae
Soft tissue <2cm
Sharp costofrenicus
angle
Smooth diafragma
CTR<50%
Pulmo: within normal limit

Expertise: with in normal

limit
USG Abdomen
Expertise:
Cholelhitiasis
Susp. spleen cyst
CT-Scan
CT-Scan
CT-Scan

Expertise:
Cholelithiasis
Splenomegali
 Diagnosis
Acute abdomen ec
cholelithiasis
Controlled hypertension
Obese I
Therapy

Conservative Definitive
 Bed rest  Cholecystectomy
 Low fat diet

 IVFD RL 2600cc/24h: 36
makrodrips/minute
 IV inj. ketorolac 30 mg
3x1
What is it?

 By definition,
cholecystitis is an
inflammation of
the gallbladder
wall and nearby
abdominal lining.

Abdominal wall

Gallbladder
Etiology / Pathophysiology

Can be caused by an obstruction,

gallstone or a tumor.
 90% of all cases caused by gallstones.
 The exact cause of gallstone formation is
unknown.
 When there is an obstruction, gallstone or
tumor it prevents bile from leaving the
gallbladder.
 Bile gets trapped and acts as an irritant which
causes cellular infiltration within 3 – 4 days.
 This infiltration causes an
inflammatory process –
the gallbladder becomes
enlarged and
edematous.
 Eventually this occlusion
along with bile stasis causes
the mucosal lining of the
gallbladder to become
necrotic.
 Bacterial growth occurs
due to ischemia. Necrotic Gallbladder
  Rupture of the gallbladder becomes a danger,
along with spread of infection of the hepatic duct
and liver.
 If the disease is severe and interferes with the blood
supply it can cause the gallbladder to become
gangrenous.

Gangrenous
gallbladder Gallstones
Gallstones . .

The presence of
gallstones in the
gallbladder is
called
cholelithiasis.
Those who are most at risk.

These are all adjectives to describe

the person most at risk of developing
symptomatic gallstones.
FAIR/FERTILE FAT FORTY FEMALE
Something to think about.

Disorders of the biliary system are

COMMON in the U.S.

They are responsible for the

hospitalization of more than half a
million people each year.

The two most common conditions are

cholecystitis & cholelithiasis.
Signs and Symptoms.
 Complaints of indigestion
after eating high fat
foods.
 Localized pain in the
right-upper quadrant
epigastric region.
 Anorexia, nausea,
vomiting and flatulence.

 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.

 Low grade fever.

 Elevated leukocyte count.
 Mild jaundice.
 Stools that contain fat – steatorrhea.
 Clay colored stools caused by a lack
of bile in the intestinal tract.
 Urine may be dark amber- to tea-
colored.
Type of gall stones
 Cholesterol Stones : radiating crystal like
appearance
 Mixed stones : contains cholesterol, calcium salts of
phospatase and carbonante, palmitate.
 Pigmented stones : small, black or greenish black,
multiple and often sludge like.
How to diagnose?

Anamnesis
Often asymptomatic
With dyspepsia
Intolerans to fatty foods
Pain in the upper right abdomen,
epigastrium, pericordial
Pain disappears
Corresponding complications
How to diagnose?

Physical examination
Associated with complications
Tenderness in the upper right abdomen
Murphy sign (+)

Supporting investigation
Laboratory
Abdomen x-ray
USG abdomen
Diagnostics.
 Fecal studies.

 Serum bilirubin tests.

 Ultrasound of the
gallbladder.
Diagnostics.
 HIDA scan - imaging test used to
examine the gallbladder and the
ducts leading into and out of the
gallbladder - also referred to as
cholescintigraphy.
 Oral cholecystogram - the patient
takes iodine-containing tablets by
mouth - iodine is absorbed from the
intestine into the bloodstream -
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).
 Operative cholangiography –
common bile duct is directly
injected with radiopaque dye.
 Recap. Stages of Acute
Cholecystitis.
- Gallbladder has a grayish
appearance & is edematous.
-There is an obstruction of the
cystic duct and the
gallbladder begins to swell.
- It no longer has the "robin
egg blue" appearance of a
normal gallbladder.
- As acute cholecystitis - Gallbladder undergoes
progresses, the gangrenous change and
gallbladder begins to the wall becomes very
become necrotic and gets dark green or black.
a speckled appearance as
- This is the stage when
the wall begins to die.
perforation occurs.
Medical Management.

 Non surgical
Lysis rock with drugs
 Chenodeoxychoic Acid (CDCA)
 Ursodeoxylate Acid
 Contact dissolution
ESWL

 Surgery
 Open cholecystectomy
Minilaparotomi cholecystectomy
Laparoscopic cholecystectomy
Medical Management.

Lithotripsy  If the attack of

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

 Removal of the gallbladder.

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

Cholecystitis
Obstructive jaundice
Cholangitis
Pancreatitis
Will you survive?

 Prognosis is usually excellent with

prompt treatment.

 Laparoscopic surgery has decreased

the number of complications.

 Prognosis is NOT favorable for those

who develop pancreatitis.
thankyou.