MORNING REPORT

CHOLECYSTITIS

SKDI: 3B Rahmatul Mufidah

ICD X: K81.0
1908436665

CLINICAL CLERKSHIP OF SURGERY DEPARTMENT

FACULTY MEDICINE OF RIAU UNIVERSITY
ARIFIN ACHMAD GENERAL HOSPITAL
2019
PATIENT IDENTITY

 Name : Ny. M
 Age : 54 years old
 Admitted to hospital : November 11nd 2019
CHIEF COMPLAINT

Right upper stomach pain since 3 days before being hospitalized

PRESENT ILLNESS HISTORY
During 4 years before hospitalized, patient always complained that she had pain in upper
stomach. The pain feels dull and disappears, then patient treat the pain with mylanta and felt
better.
3 days before being hospitalized, patient complained that she had pain in right upper stomach,
pain spreading to the back, didn’t get better with rest and pain intensity increases while she do
her activities. Patient went to Ibnu Sina for treatment and Abdominal USG was performed and
she was told that there is a stone in the bile channel. Patient then referred to Digestive Surgery in
General Hospital Arifin Achmad Pekanbaru.
Pasien also complained that she had fever. She got better after having paracetamol, she vomit (+)
>3 times contain rice and water.
Patient also said that her urine color was dark amber-to-tea.
Patient declined that her stool was clay colored, never have itchy skin or yellowing skin.
PAST ILLNESS HISTORY

• Hypercolesteronemia (-)
• Hypertension (-)
• Diabetes mellitus (-)
FAMILY ILNESS HISTORY

 No history of family who has the complaint.

 History of hypertension, heart disease, diabetes mellitus were denied
SOCIAL EXAMINATION

 Patient often consume fatty food

PATIENT EXAMINATION
 General condition : Mild illness
 Consciousness : Cooperative Composmentis
 Vital sign:
Blood pressure : 110/70 mmHg
Heart rate : 94 times per minute
Respiratory rate : 20 times per minute
Temperature : 38 OC
 Weight: 120kg
 Height: 160cm
 BMI: 46,9 m2/kg (obesity type II)
PHYSICAL EXAMINATION

• Head & neck : normal limit

• Thorax : normal limit
• Abdomen : localized state
• Extremities : normal limit
LOCAL STATE

 Abdomen:
Inspection : Looked convex
Auscultation : Bowel sounds (+), freq 13 x/min
Palpation : Epigastric pain(+), Pain on right hipocondric kuadran (+),
Murphy’s Sign (+), Defans muscular (+), hepar and lien can’t palpable
Percussion : Timpani all kuadran
• Flank Area

Right Left
Trauma sign - -
Inflammation sign - -
Mass - -
Ballotement - -
• Supra pubis
 Inspection : lession (-), hematoma (-), inflammation sign (-)
 Palpation : mass (-), tenderness (-)
WORKING DIAGNOSIS

 Acute Abdomen ec Susp Acute Cholecytitis

DIFFERENTIAL DIAGNOSIS

 Peptic Ulcer
 Acute Pancreatitis
PLAN OF ADJUNCT EXAMS

• Blood test
• Amylase
• Liver function
• Abdomen USG
• MRI with MRCP
ADJUNCT EXAMINATIONS

 Hb : 10,5 g/dl (L)  Indirect billirubin : 0,28 mg/dl

 Ht : 30,9 % (L)  SGOT : 41 U/L (H)
 Eritrocytes : 3,40 x106 /uL  SGPT : 43 U/L (H)
 Leucocytes : 18,92x103 /uL (H)  GDS : 92 mg/dL
 Trombocytes : 376x103 /uL  Ureum : 122 mg/dl (H)
 Total billirubin : 1.47 mg/dl (H)  Creatinine : 3,03 mg/dl (H)
 Direct Bilirubin : 1.19 mg/dl (H)
ABDOMEN USG
Expertise:
Thickening of the gallbladder wall
Distended gallbladder
Multiple gallstones, size :2,54 cm
Pericholecystic fluid (+)

Conclusion:
Cholecystitis
Cholelitiasis Multiple
FINAL DIAGNOSIS

Cholelicytitis Acute on Chronic + Acute Kidney Injury

PLAN OF THERAPY

• Conservative:
 - bed rest
 - low fat diet
 - IVFD ringer lactate
 - IV ketorolac 30mg, 3x1
 - IV cefotaxime 1g, 2x1

• Definitive: Cholecystectomy (if sign and symptom didn’t get resolved after 2 x 24 hours)
VESICA FALEA
ANATOMY
 Bile secreted continuously by the liver enters the channel small bile in the heart. The
small bile ducts unite to form two larger ducts that come out of the lower surface of
the liver as the hepatic duct right and left which soon unite to form the communist
hepatic duct. The hepatic duct joins the cystic duct to form the coledocated duct.
 Gallstones do not cause complaints as long as the stone is not entered into the cystic
duct or the koledokus duct. Whenever the stone goes inside then the cystic duct can
only cause complaints. If that stone small, there is a possibility that the stone can
easily pass through the duct of coledocus and into the duodenum
CHOLECYSTITIS
DEFINITION

Cholecystitis refers to inflammation of the gallbladder

ETIOLOGY

There are three factors can make inflammatory respon in gallbaldder:

 Mechanical Inflammation, increased intraluminal pressure and distension with
resulting ischemia of the gallbladder mucosa and wall.
 Chemical Inflammation, caused by the release of lysolecithin (due to the action of
phospholipae on lecithin in bile) and other local tissue factors
 Bacterial Inflammation , which may play a role in 50-85% of patients with acute
cholecystitis .The organisms most frequently isolated by culture of gallbladder bile in
these patients include Escherichia coli, Klebsiella spp. , Streptococcus spp., and
Clostridium spp.
PATHOPHYSIOLOGY
TYPE OF CHOLECYSTITIS

 Acalculous Cholecystitis
 Acalculous Cholecystopathy
 Emphysematous Cholecystitis
SIGN AND SYMPTOM

• Pain in the RUQ with bloating, the pain spreading into the back or shoulder and pain precipitated by
fatty foods
• Food intolerance (espescially greasy and spicy foods)
• Nausea and some vomiting
• Fever and chills (38-38,5 OC)
• Jaundice occurs when stones obstruct the common bile duct it impedes the flow of bile
from the liver to the intestine
PHYSICAL EXAMINATION
 RUQ pain
 RUQ tenderness
 Murphy’s sign (+)
ADJUNCT EXAMINATIONS

 Laboratory tests:
• Leucocytosis
• SGOT, SGPT, Alkali fosfatase elevated
• Amilase serum sometimes elevated than normal
• Total Biliriubin elevated
ADJUNCT EXAMINATIONS

 Gallbladder ultrasonography is the best to evaluate gallbladder disease initially. A thickened

gallbladder wall and gallstones are common findings with this condition.
 Abdominal ultrasonography is the imaging test of choice for detecting gallbladder stones; sensitivity
and specificity are 95%. Ultrasonography also accurately detects sludge. CT, MRI , and oral
cholecystography (rarely available now, although quite accurate) are alternatives. Endoscopic
ultrasonography accurately detects small gallstones (< 3 mm) and may be needed if other tests are
equivocal.
 Magnetic Resonance CholangioPancreatography (MRCP) has excellent sensitivity for bile duct
dilatation, biliary stricture and intraductal abnormalities
THERAPY

 Medical Therapy:
• Oral intake is eliminated
• Nasogastric suction maybe indicated
• Lisis rock with drugs : Chenodeoxychoic Acid (CDCA), Ursodeoxylate Aci
• NSAID for analgesia
• Intravenous Antibiotic Therapy is guided by the most common organisms

 Surgery: The best treatment for cholecystitis is Laparoscopic cholecystectomy

COMPLICATIONS

 Empyema and Hydrops of the Gallbladder

 Gangrene and perforation
 Fistula formation and gallstone ileus
 Limey (milk of calcium) bile and porcelain gallbladder
THANK YOU