Brokenshire Integrated Health Ministries Incorporated

Department of General Surgery

Cholecystolithiasis

CASE PRESENTATION
PGI: Ian Ross Fernandez
July 21, 2019
General data
64 years old

Female

IP Married

Filipino

Roman Catholic

J.P. Laurel, Davao City

 CHIEF
COMPLAINT

Right Upper Quadrant Pain

 History of Present Illness
2 weeks PTA

RUQ Pain  Normal liver

 Cholecystolithiasis; non-dilated
Vomiting biliary tree

 Normal pancreas and spleen

Pneumonia
 Bilateral renal parenchymal disease

 Normal urinary bladder

 Normal sized uterus

History of Present Illness
2 days PTA

Vomiting

Consult
History of Present Illness
Day of admission

RUQ Pain

Vomiting

Surgery
 (+) Hypertension (5 yrs)

Past (+) Diabetes Mellitus (25 yrs)

Medical
History (+) Hypercholesterolemia (2019)

(+) Colonoscopy (2019)

(+) Pneumonia (2018)

(+) Tubal Ligation (1986)

Family History OB/Gyne History
(+) Hypertension Menopause at 50y/o
(+) Diabetes Mellitus Menarche at 13y/o
(-) Cardiac, thyroid,
kidney diseases
(-) BA
(-) Cancer
Personal/Social History
Non-smoker

Non-alcoholic beverage drinker

Denies illicit drug use

Midwife

Boarding house with husband and son

 Review of Systems
General (-) weight loss/gain (-) fatigue

Skin (-) rash (-)cyanosis (-)jaundice (-) flushing

HEENT (-) blurring of vision (-) ear discharges
(-) dizziness (-) nasal discharges (-) sore throat
Respiratory (-) cough (-) hemoptysis (-) dyspnea
Cardiovascular (-) chest pain (-) palpitations
Gastrointestinal (-) melena (-) constipation

Endocrine (-) heat or cold intolerance, (-) excessive sweating

GUT (-)incontinence (-) edema (-) discharges

Extremities (-) numbness on lower extremities
 Physical Examination

Awake, conscious, coherent,

General Appearance: NIRD, GCS 15

Temp: 36.6 C
BP: 140/80 mmHg
SaO2%:
Vital signs: PR: 62 bpm
98%
RR: 20 cpm

Height: 152cm
Anthropometrics: Weight: 50.45 kg
BMI: 21.8
 Physical Examination

Warm, good turgor, no

Skin: rashes

Anicteric sclerae
Pale palpebral
HEENT: conjunctivae
Moist lips and tongue

Equal chest expansion,

Chest/lungs: No retractions,
clear breath sounds
 Physical Examination
Adynamic precordium, distinct
CVS: heart sounds
Normal rate, regular rhythm

Flat, normoactive bowel sounds, (-)

Abdomen: tenderness, (-) Murphy’s sign

Genitourinary: (-) KPS

Full peripheral pulses, CRT <2sec,

Extremities:
(-) Bipedal edema, Full ROM
 Physical Examination

Neurologic

MSE: oriented to time, person and place

intact
CN:
 Plan

For Laparoscopic
Cholecystectomy
Course in the Wards
At the Ward
HOSPITAL DAY 1

S O
(+) RUQ Pain
(+) Vomiting
(-) tenderness
(-) Fever
(-) Murphy’s sign
(-)Jaundice
At the Ward
HOSPITAL DAY 1

A Cholecystitis
Chronic Kidney Disease Stage 4 sec
to Diabetic Kidney Disease and
Hypertensive Nephrosclerosis
DM Type II
At the Ward
HOSPITAL DAY 1
Diabetic Diet 1,000 kcal divided into 3
D meals and 2 snacks
P
Dx CBC, PT, APTT, Na, K, Ca, Mg, Crea,
CBG q6h
Medications:
Tx 1. Betahistine diHCl
2. Metoclopramide
3. Perindopril +Indapamide +Amlodipine
4. Nebivolol
5. Fenofibrate
6. Atorvastatin
7. Insulin Degludec + Insulin Aspart (Ryzodeg)
8. Multivitamins
9. NaHCO3
10. Ketosteril
11. FeSO4
Surgery: Laparoscopic Cholecystectomy
At the Ward
HOSPITAL DAY 1

CBC 7/15/19
APTT 7/15/19
WBC 8.4 x 109/L Patient 26.5
RBC 3.2 x 1012/L Control 25.4
HEMOGLOBIN 10.1 g/dl PTT 7/15/19
HEMATOCRIT 28% Patient 11.6
MCV 87.7 Fl INR 0.98
MCH 31.2 pg %Activity 109.6
MCHC 356 g/L Control 12.5
PLATELET COUNT 400 x 109/L
DIFFERENTIAL COUNT
NEUTROPHILS 0.67 Blood Chem 7/15/19
LYMPHOCYTE 0.22
Magnesium 0.95
MONOCYTE 0.07
Calcium 1.19
EOSINOPHIL 0.03
BASOPHIL 0.01
Creatinine 254
eGFR 15.7
At the Ward
HOSPITAL DAY 2
At the Ward
HOSPITAL DAY 3-4

S O
(+) Flatus
(-) pain (-) icteric sclerae
(-) nausea/vomiting
(+) adequate urine
output
(-) tenderness
(-) Murphy’sign
At the Ward
HOSPITAL DAY 3 -4

A Cholecysolithiasis
Diabetes Mellitus Type II
S/P Laparoscopic Cholecystectomy
At the Ward
HOSPITAL DAY 3 -4

P Discharge

Medications:
Ampicillin- Sulbactam
Celecoxib
Multivitamins (Centrum Silver)
NaHCO3
Amino Acids (Ketosteril)
FeSO4
Perindopril +Indapamide +Amlodipine (Triplixam)
Fenofibrate
Atorvastatin
Insulin Degludec + Insulin Aspart (Ryzodeg)
Cholecystolithiasis
Cholecystolithiasis
 Most common disease involving the gallbladder and biliary tree

 Four factors that explain most gallstone formation:

 Supersaturation of secreted bile
 Concentration of bile in gallbladder
 Crystal nucleation
 Gallbladder dysmotility
Cholecystolithiasis
 Cholesterol Stones
 Pure cholesterol
 <10% of all stones
 Single
 Large
 Smooth
Cholecystolithiasis
 Cholesterol Stones
 Others
 >70% cholesterol by weight, + bile pigments and calcium
 Multiple
 Variable in size
 Hard and faceted OR irregular, mulberry-shaped, and soft
 Whitish yellow and green to black
Cholecystolithiasis
 Pigment stones
 <20% cholesterol + calcium bilirubinate
 Black pigment stones
 Small, brittle, sometimes spiculated
 Brown pigment stones
 <1cm
 Brownish-yellow, soft, often mushy
Cholecystolithiasis
 Most are asymptomatic
 Symptoms occur when a stone is dislodged in the cystic
duct
 Complications:
 Acute cholecystitis
 Choledocholithiasis with or without cholangitis
 Gallstone pancreatitis
 Commonly diagnosed incidentally on imaging
Cholecystolithiasis
 Symptomatic cholecystolithiasis
 When a stone obstructs the cystic duct
 Epigastric pain radiating to the back
 PE unremarkable – no tenderness
 Blood tests
 CBC – normal
 Liver function tests – normal
 UTZ
 Sp and Sn >90%
 Echogenic focus with shadowing
Cholecystolithiasis
 Treatment: ELECTIVE CHOLECYSTECTOMY

 Candidates for prophylactic cholecystectomy:

 Elderly patients with DM
 Individuals who will be isolated from medical care for extended periods of
time
 Increased risk for gallbladder cancer
 Calcified gallbladder wall (porcelain gallbladder)
 >2.5cm stones
 Long common channel of the bile and pancreatic duct
 Hemolytic anemias
 Undergoing bariatic surgery
 THANK YOU
References:
1. Schwartz’s Principles of Surgery 10th edition
2. Sabiston Textbook of Surgery 20th edition