SLIDE ERCP

29 MARET 2019
PATIENT LIST
1. Tn. Abdul Malik
2. Tn. Kasmawardana
3. Ny. Nurliana
4. Tn. Sulfadi
5. Ny. Hasma
6. Ny. Dahlia Dg. Caya
7. Tn. Faizhal
8. Ny. Sukaena Samsi
9. Tn. Abu Darda
PATIENT 1
 PATIENT IDENTITY
Name : Mr. Abdul Malik
Birth of Date : 01/ 06/ 1957
MR number : 871763
Job : Government employee
Marital status : Married
Hospital : RSWS
Entry date : 13/03/2019
 CHIEF COMPLAINT

Enlarging abdomen accompanied with

yellow of both eyes and whole body
 Laboratory Finding
CBC Result Blood chemistry Result

Ureum 19 mg/dl
HGB : 13.6 g/dl
Creatinin 0.97 mg/dl
Total Bilirubin 31.77 mg/dl
PLT : 144,000/ mm 3
Direct Bilirubin 28.32 mg/dl
SGOT 324 U/L
WBC: 13,300/uL SGPT 223 U/L
Albumin 2.7 gr/dl
Sodium 127 mmol/l
Hematology Result
Potassium 3.2 mmol/l
Chloride 98 mmol/l
PT: 23.2 s
Blood amylase Menunggu hasil U/L
INR: 2.19
Blood lipase Menunggu hasil U/L
APTT: 47.8 s
MSCT Abdomen without contrast (7/2/2019)

 Intra and extra cholestatic liver due to common

bile duct stone (1.1 x 1.1 x 2.3)
 Splenomegally
Upper gastrointestinal endoscopy

 Grade 1 oesophageal varices

 Moderate Portal Hypertension Gastropathy
 Grade II Erosive Gastritis
Í ASESSMENT

Cholestatic Jaundice due to

suspected bile stone
Decompensated liver cirrhosis (CTP
class C)
Grade I Esophageal varices

Grade III ascites

 Therapy

Ursodeoxycholic acid 250 mg/ 12 h/ oral

ERCP
PATIENT 2
 PATIENT IDENTITY
Name : Mrs. Kasmawardana
Date of Birth : 07-12-1989
RM : 866468
Room : Palem Bawah B2-10
Tribe : Bugis
PS ASA :2
SPV : Dr.dr.Nu’man AS Daud SpPD.KGEH
 CHIEF COMPLAINT

Patien with complaints, sometimes nausea and

heartburn, Vomiting does not exist. Patients with
a history of esophageal dilatation 3 times in
December, January and February. There is history
of dysphagia, now patient can eat as usual.
 PHYSICAL EXAMINATION

•Compos mentis
•BP: 110/70 mmhg, HR 82x/min, RR 20x/min, S 36,8 C
•No anemic, no icterus
•No spider nevi, symmetric chest, sonor, vesicular, without rales
and wheezing.
•Regular I/II heart sound, no murmur
•Normal peristaltic, hepar not palpable, spleen not palpable
•No edema
Supporting investigation :
• CXR : No Abnormalities appear (26/12/2018)
• Esofagography : Corrosive divertikel Oesophagus (26/12/2018)
• MD : Within normal limits (26/12/2018)
• Laboratorium :

WBC : 6.600 GDS : ALP : -

HB : 10.6 108 GGT : -
PLT : 356.000 UREUM : PRO.TOTAL : -
HCT : 30% 44 ALBUMIN : 4,1
NEUT : 62,9% KREATININ : AMILASE : -
PT : 10,4 0,64 LIPASE : -
APTT : 24,7 BIL.TOTAL :- HBsAg/ANTI
INR : 1.00 BIL.DIREK :- HCV : NR
SGOT : NAT/K/CL :
36 139/4,1/105
SGPT :
 ASESSMENT

Esophagus and Pylorus Striktur dd

GOO

Kaheksia

Normositik Normokrom Anemia

 Therapy

- IVFD Asering 21 dpm

- Lansoprazole 30 mg/12 hour/ intravena
- Domperidon 10 mg/8 hour/ intravena
PATIENT 3
NURLINA
PATIENT 4
 PATIENT IDENTITY
Name : Mr. Sulfadhli
Birth of date : November 24th, 1965
MR : 854249
Address :-
Job : Employee
Marital status : Married
Hospital : Wahidin Sudirohusodo
Entry date : March 24th, 2019
CHIEF COMPLAINT

Jaundice
 PHYSICAL EXAMINATION

•Composmentis
•BP : 120/80 HR : 76 RR : 20 T : 36,7
•normal konjungtiva, icteric sclera
•Breath sound vesicular, ronchi and wheezing not exist
•Heart sound reguler, murmur not exist
•Peristaltic normal, hepar/ lien not palpable
•No edema of extremities, no erithema palmaris
 Laboratory Finding

CBC Result
WBC 10900
Hb 8,9
PLT 410.000
RBG 465
Ur 7
Cr 0,76
SGOT 40
SGPT 28
Alb 2.6
Bil.total 10.1
Bil.direct 9.73
PT 10.1
APTT 26.6
INR 0.97
MSCT ABDOMEN
(31/12/2018):
Intra and extra hepatic
colestatic ec caput
pancreas mass
 ASESSMENT

- Intra and extra hepatic colestatic ec caput pancreas mass.

 THERAPY

ERCP
Liver diet III
Levofloxacin 750 mg/24 H/IV
UDCA 250 mg/12 H/oral
Omeprazole 40 mg/24 H/ IV
Novorapid 10 unit/8 jam/SC
Levemir 10 unit/24 H/SC
PATIENT 5
 PATIENT IDENTITY
Name : Mrs. Hasma
Birth of date : April 28th, 1960
MR : 876945
Address :
Job : A Housewife
Marital status : Married
Hospital : Wahidin Sudirohusodo
Entry date : March 27th, 2019
CHIEF COMPLAINT

Jaundice
 PHYSICAL EXAMINATION

Composmentis/ obesitas
BP : 110/80 HR : 76 RR : 20 T : 36,7
normal konjungtiva, icteric sclera
Breath sound vesicular, ronchi and wheezing not exist
Heart sound reguler, murmur not exist
Peristaltic normal, hepar/ lien not palpable
No edema of extremities, no erithema palmaris
 Laboratory Finding

CBC Result
WBC 13.200
Hb 14
PLT 294.000
RBG
Ur 17
Cr 0,7
SGOT 88
SGPT 55
Alb 3.4
Bil.total 26.85
Bil.direct 16.84
PT 12.4
APTT 31.2
INR 1.2
MSCT ABDOMEN
(20/3/2018)
- Cholestatic ec
proximal CBD stone
- Distended GB
 ASSESSMENT
- Intra and extra hepatic colestatic ec proximal CBD stone
 THERAPY
ERCP
Liver diet III
Sequest 1 caps/ 8 H/ oral
Lansoprazole mg/24 H/IV
UDCA 250 mg/12 H/oral
PATIENT 6
 PATIENT IDENTITY
Name : Mrs. Dahlia Dg. Caya
Birth of date : July 21st, 1960
MR : 836306
Address :
Job : A Housewife
Marital status : Married
Hospital : Wahidin Sudirohusodo
Entry date : March 27th, 2019
CHIEF COMPLAINT

JAUNDICE
 PHYSICAL EXAMINATION

Composmentis
BP : 110/80 HR : 76 RR : 20 T : 36,7
normal konjungtiva, icteric sclera
Breath sound vesicular, ronchi and wheezing not exist
Heart sound reguler, murmur not exist
Peristaltic normal, hepar/ lien not palpable
No edema of extremities, no erithema palmaris
 Laboratory Finding

CBC Result
WBC 5.500
Hb 11,7
PLT 240.000
RBG 114
Ur 14
Cr 0,6
SGOT 68
SGPT 57
Alb 3.3
Bil.total 16.82
Bil.direct 14.43
PT 14.5
APTT 33.9
INR 1.42
 ASSESSMENT

Intra and extra hepatic colestatic ec susp caput pancreas mass

 THERAPY

ERCP
Liver diet III
Lansoprazole mg/24 H/IV
UDCA 250 mg/12 H/oral
PATIENT 7
 PATIENT IDENTITY
Name : Mr. Faizhal
Birth of date : September 16th, 1977
MR : 858424
Address :
Job : Employee
Marital status : Married
Hospital : Wahidin Sudirohusodo
Entry date : March 27th, 2019
 CHIEF COMPLAINT

Pro aff stent bilier

 PHYSICAL EXAMINATION

Composmentis/
BP : 120/80 HR : 76 RR : 20 T : 36,7
normal konjungtiva, icteric sclera
Breath sound vesicular, ronchi and wheezing not exist
Heart sound reguler, murmur not exist
Peristaltic normal, hepar/ lien not palpable
No edema of extremities, no erithema palmaris
 Laboratory Finding

CBC Result
WBC 6100
Hb 10.1
PLT 217.000
RBG 98
Ur 17
Cr 0,29
SGOT 23
SGPT 25
Alb 2.8
Bil.total 0.21
Bil.direct 0.11
PT 10.9
APTT 24.5
INR 0.91
MSCT ABDOMEN
(9/1/2018)
- Intra and extra
hepatic colestatic ec
caput pancreas mass
- Ascites
- Splenomegaly
- Iliary stent
 ASSESSMENT

- Intra and extra hepatic colestatic ec caput pancreas mass

 THERAPY

ERCP pro aff DJ Stent

Liver diet III
PATIENT 8
 PATIENT IDENTITY
Name : Mrs. Sukaena Samsal
Birth of date : April 4th, 1957
MR : 877318
Address :
Job : A Housewife
Marital status : Married
Hospital : Wahidin Sudirohusodo
Entry date : March 19th, 2019
CHIEF COMPLAINT

JAUNDICE
 PHYSICAL EXAMINATION

Composmentis
BP : 110/80 HR : 76 RR : 20 T : 36,7
normal konjungtiva, icteric sclera
Reg Colli Dextra et clavicula dextra: mass with size 10 x 10,
fixated, solid mass, no pain,
Breath sound vesicular, ronchi and wheezing not exist
Heart sound reguler, murmur not exist
Peristaltic normal, hepar/ lien not palpable
No edema of extremities, no erithema palmaris
 Laboratory Finding

CBC Result
WBC 5.000
Hb 9.4
PLT 216.000
RBG 88
Ur 12
Cr 0.1
SGOT 104
SGPT 108
Alb 4.9
Bil.total 49,66
Bil.direct 35,52
PT 11.2
APTT 26,5
INR 1.08
MSCT ABDOMEN
*22/3/2019:
- Intra and extra
hepatic colestatic ec
caput pancreas mass
- Cholstatic with
cholelith and
sludge GB
- Splenomegaly
- Distended GB
- Axillay dextra
Lymphadenopathy
 ASSESSMENT

Intra and extra hepatic colestatic ec caput pancreas mass

Cholesistitis
Normocytic Normochrome Anemia
Non Hodgkin Lymphoma
 THERAPY
ERCP
Liver diet III
Ceftazidine/ 1 gr/ 12 Hour/IV
Ranitidin 50 mg/12 H/IV
Maxiliv 1 caps/ 12 Hour/oral
UDCA 250 mg/12 H/oral
Durogesic parch 12.5 mcg/72 jam/transdermal
PATIENT 9
 PATIENT IDENTITY
Name : Mr. Abu Darda
Birth of Date : 09/ 03/ 1968
MR number : 876621
Job : Government employee
Marital status : Married
Hospital : RSWS
Entry date : 23/03/2019
 CHIEF COMPLAINT

Yellow of the whole body since 1

weeks ago
 PHYSICAL EXAMINATION

•Compos mentis
•BP: 120/90 mmhg, HR 84x/min, RR 20x/min, S 36,7 C
•Icteric of sclera (+), no pale of conjungtiva
•Symmetric chest, sonor, vesicular, without rales and wheezing
•Regular I/II heart sound, no murmur
•Normal peristaltic, hepar not palpable, spleen not palpable
•No edema
 Laboratory Finding (12-18 March 2019)

Imunoserology Result Microbiology Result

Gram Stain
HBsAg 0.00 (Non R)
Specimen Bronchial washing
Anti HCV 0.07 (Non R) Gram afinity Gram positive
Shape and configuration Paired coccus
Anti HIV Non Reactive Quantity Positive (1+)
Localization -
Other cell Lekosit: 3+ and epitel cell: 2+
Blood Chemistry Result
Fungal Unidentified
Total Bilirubin 6.63 mg/dl Fungal
Specimen type Bronchial washing
Direct bilirubin 5.67 mg/dl
Fungal Unidentified
SGOT 208 U/L
BTA Sputum 1 X (stain)
SGPT 284 U/L
Specimen type Bronchial washing
Albumin 3.4 gr/dl
BTA staining Negative
Laboratory Finding (21 March 2019)

Blood Chemistry Result

Alkali Phosphatase 387 U/L

Imunoserology Result

AFP 1.29 IU/ml

CEA 3.31 ng/ml

PSA 0.48 ng/ml

Beta HCG <2.00 mIU/ml

Laboratory Finding (22 March 2019)

CBC Result
HGB : 13.9 g/dl
PLT : 270,000/ mm3
WBC: 12,400/uL
HCT 42%
Total Bilirubin 11.49 mg/dl
Direct bilirubin 7.65 mg/dl
SGOT 108 U/L
SGPT 312 U/L
Albumin 3.3 gr/dl
Laboratory Finding (24 March 2019)

Hematology Result

PT: 12.5 s

INR: 1.22

APTT: 25.3 s

Blood Chemistry Result

Total Protein 7.0 g/dl

Albumin 3.7 gr/dl

 Laboratory Finding (26 March 2019)
CBC Result Blood chemistry Result

HGB : 13.5 g/dl Ureum 36 mg/dl

Creatinin 0.83 mg/dl

PLT : 255,000/ mm3
Total Bilirubin 14.60 mg/dl

WBC: 12.000/uL Direct Bilirubin 12.16 mg/dl

SGOT 92 U/L

Imunoserology Result SGPT 184 U/L

Total protein 6.3 g/dl

CA 19-9 > 500.0
Albumin 2.7 gr/dl

Globulin 2.8 gr/dl

LDH 608
 Laboratory Finding (28 March 2019)

Other Chemistry Result

Uric Acid 4.1 mg/dl

Blood Amylase 157/2 U/L

Blood Lypase 208.4 U/L

USG Whole Abdomen
MSCT Abdomen with contrast (28/3/2019)

Intra and extrahepatic cholestatic due to caput

pancreas mass.
Ascites
Bilateral pleural effusion
Bilateral nephrotic
Vesicolith
 ASESSMENT

Drug Induced Liver Injury Tipe mixed

Susp. Metastase hepatic tumor

Icterus cholestatic intra and extra
hepatik ec suspect caput pancreas
mass
 Therapy

Maxiliv 1 caps/12 hours/oral

Plan:
 ERCP
THANKYOU 