Download as PPTX, PDF, TXT or read online from Scribd
Download as pptx, pdf, or txt
You are on page 1/ 76
DAVAO MEDICAL SCHOOL FOUNDATION
HOSPITAL DEPARTMENT OF SURGERY
CASE PRESENTATION
PGI PAMA PGI TAMONDONG GENERAL DATA Patient A. G. 24 years old Female Single Angliongto, Davao City DOB: 12/20/1994 Date admitted: 01/19/19 CHIEF COMPLAINT
Right upper quadrant
HISTORY OF PRESENT ILLNESS
• 1 month prior to admission
• RUQ pain, intermittent • Painscale 3/10 • (+) vomiting • Unrecalled IV medication- relieved HISTORY OF PRESENT ILLNESS
• 1 day prior to admission
• RUQ pain • (+) vomiting • (+) difficulty of breathing • (+) headache • Consult • Given IV medication • Ultrasound: Acute calculous cholecystitis with sludge formation • Admission PAST MEDICAL HISTORY
• (-) Hypertension • (-) Diabetes Mellitus • (-) Bronchial Asthma • (-) Tuberculosis or any exposure to people with TB • Denies any previous hospitalizations or any previous surgery PAST MEDICAL HISTORY
• OB-GYN History: • G1P1 (1001) • Menarche: 13 years old • Interval: Regular • Duration: 3-5 days • Amount: 3-4 pads per day • (+) Dysmenorrhea • LMP: 01/16/19 FAMILY HISTORY
• (-) Hypertension • (-) Diabetes Mellitus • (-) Bronchial Asthma • (+) Gallstones – maternal • (+) Cancer – breast cancer- maternal PERSONAL/SOCIAL HISTORY
• (-) cigarette smoking
• (+) occasional alcohol beverage drinker • (-) allergies to food and drugs DIET
• Denies any dietary restrictions
• Three meals in a day; usual diet consists of meat and vegetables, and occasionally fruits • (+) oily/food fried REVIEW OF SYSTEMS
• Eyes: (-) pain (-) redness (-) blurry of vision
• Ears: (-) hearing loss (-) tinnitus (-) vertigo (-) discharge • Nose: (-) colds (-) discharge (-) bleeding • Mouth and throat: (-) sore throat (-) bleeding gums (-) hoarseness (-) tonsillitis REVIEW OF SYSTEMS
• Pulmonary: (-) dyspnea, respiratory distress,
shortness of breath • Cardiovascular: (-) palpitations (-) orthopnea (-) pleuritic chest pain • Gastrointestinal: (-) heartburn (-) nausea and vomiting (-) change in bowel pattern • Urinary: (-) frequency (-) nocturia (-) urgency, (-) dysuria REVIEW OF SYSTEMS
with good skin turgor, (-) edema, scars, or jaundice • Head: (-) scaling, lesions or masses • Eyes: Anicteric sclera, pinkish palpebral conjunctiva • Ears: (-) lesions, discharges, tenderness PHYSICAL EXAMINATION
• Nose: pink mucosa, septum in midline, (-)
deformities, discharges • Mouth/Throat: moist lips, pink and moist buccal mucosa, uvula and tongue midline, (-) tonsillopharyngeal enlargement or exudates • Neck: (-) masses, neck vein distension, lymphadenopathies PHYSICAL EXAMINATION
• Chest/Lungs: Symmetrical chest expansion,
equal tactile fremitus, resonant on both lung fields, clear breath sounds
• Heart: Adynamic precordium, (-) thrills/heaves,
regular heart rate and rhythm, no murmurs PHYSICAL EXAMINATION
• Abdomen: • I: Flat, (-) lesions • A: Normoactive bowel sounds • Pe: dullness on the RUQ, tympanitic on the rest of the quadrants • Pa: (+) tenderness on RUQ, (+) Murphy’s sign, (-) organomegaly PHYSICAL EXAMINATION
• Musculoskeletal: No muscle atrophy,
good range of motion, no swelling, no tenderness • Neurologic: Oriented to time, person & place; Intact cranial nerves, good muscle bulk and tone, 100% sensory on all extremities SALIENT FEATURES:
History: Physical 24 years old Examination: Female BMI: 25.3 RUQ pain (+) tenderness on RUQ (+) vomiting (+) Murphy’s sign (+) difficulty of breathing (+) headache (+) family history: gallstones (+) diet: fatty foods ADMITTING DIAGNOSIS
• Acute Cholecystitis COURSE IN THE WARD Hospital Day 0 CBC: Ultrasound of the Hgb: 140 Whole Abdomen: Hct: 0.41 RBC: 4.94 (done as OPD) WBC: 14.18 (H) Acute Calculous N: 0.80 (H) Cholecystitis with L: 0.10 (L) Sludge Formation M: 0.10 (H) Plt: 391 COURSE IN THE WARD
Hospital Day 1 Protime: Total Bilirubin: 24.0 Patient: 14.9 secs (H) INR: 1.25 Direct Bilirubin: 17.0 Control: 13.1 secs (H) Normal: 11.2 – Indirect Bilirubin: 7.0 14.2 Alk. Phosphatase: 58.00 COURSE OF THE WARD
Hospital Day 2
LAPAROSCOPIC CHOLECYSTECTOMY COURSE IN THE WARD
Hospital Day 3 COURSE IN THE WARD
Hospital Day 4 FINAL DIAGNOSIS
• Emphysematous Cholecystitis • S/P Laparoscopic Choleystectomy DISCUSSION ANATOMY OF THE GALLBLADDER
• Pear-shaped sac • 7 to 10 cm long • 30 to 50 mL capacity • 300 mL when obstructed ANATOMY OF THE GALLBLADDER
L R ANATOMY OF THE GALLBLADDER HISTOLOGY BLOOD SUPPLY LYMPHATICS NERVE SUPPLY BILE DUCTS
Right Hepatic Left Hepatic
Duct Duct VARIATIONS OF THE CYSTIC DUCT ANATOMY PHYSIOLOGY
• The liver produces bile continuously
and excretes it into the bile canaliculi. • 500 to 1000 mL of bile a day • Vagal stimulation: increases secretion of bile • Splanchnic nerve stimulation: results in decreased bile flow BILE COMPOSITION
• Water • pH of hepatic bile is • Electrolytes usually neutral or • bile salts slightly alkaline • Proteins • an increase in • Lipids protein shifts the bile to a more acidic pH • bile pigments BILE COMPOSITION
• Cholesterol and phospholipids –
principal lipids found in bile
• Bilirubin diglucuronide – metabolic
product from the breakdown of hemoglobin Primary bile salts
Secondary bile salts GALLBLADDER FUNCTION
• Concentrate and store hepatic bile
• to deliver bile into the duodenum in response to a meal Neurohormonal Regulation
Vagus nerve bile secretion
Splanchnic nerve bile secretion Neurohormonal Regulation
Cholecystokinin: - Gallbladder contraction - Sphincter of Oddi relaxation
the digestive tract • prevalence of gallstones from 11% to 36% • Risk factors: age, gender, and ethnic background • Women: 3x more likely to develop gallstones than men • First-degree relatives of patients with gallstones: twofold greater prevalence GALLSTONE DISEASE
• Most patients will remain asymptomatic from their gallstones
throughout life. • Some patients progress to a symptomatic stage, with biliary colic caused by a stone obstructing the cystic duct
• acute cholecystitis • choledocholithiasis with or without cholangitis • gallstone pancreatitis • cholecystocholedochal fistula • cholecystoduodenal or cholecystoenteric fistula leading to gallstone ileus, • gallbladder carcinoma CHOLESTEROL STONES
• Pure cholesterol stones: uncommon and account for <10% of
all stones • Occur as single large stones with smooth surfaces • >70% cholesterol by weight • whitish yellow and green to black • most are radiolucent; <10% are radiopaque • supersaturation of bile with cholesterol PIGMENT STONES
• <20% cholesterol • dark because of the presence of calcium bilirubinate PIGMENT STONES
• Black pigment stones
• usually small, brittle, black, and sometimes spiculated • supersaturation of calcium bilirubinate, carbonate, and phosphate, most often secondary to hemolytic disorders such as hereditary spherocytosis and sickle cell disease, and in those with cirrhosis. • Asian countries such as Japan PIGMENT STONES
• Brown pigment stones
• usually <1 cm in diameter, brownish- yellow, soft, and often mushy • form either in the gallbladder or in the bile ducts, usually secondary to bacterial infection caused by bile stasis. • Precipitated calcium bilirubinate and bacterial cell bodies compose the major part of the ACUTE CHOLECYSTITIS
• secondary to gallstones in 90% to 95% of cases • Obstruction of the cystic duct by a gallstone is the initiating event • leads to gallbladder distention, inflammation, and edema of the gallbladder wall ACUTE CHOLECYSTITIS
• gallbladder wall becomes grossly
thickened and reddish with subserosal hemorrhages • Pericholecystic fluid often is present • the mucosa may show hyperemia and patchy necrosis CLINICAL MANIFESTATIONS
• Begins as an attack of biliary colic but does not
subside • Pain in RUQ or epigastrium • Fever, anorexia, nausea, vomiting • PE: focal tenderness and guarding in the RUQ, (+) Murphy’s sign CLINICAL MANIFESTATIONS
• Mild to mod leukocytosis (12,000-
15,000cells/mm3) • Mild elevation of serum bilirubin (<4 mg/mL) • Mild elevation of alkaline phosphatase, transaminases, and amylase EMPHYSEMATOUS CHOLECYSTITIS
• Thought to begin with acute cholecystitis (calculous or
acalculous) followed by ischemia or gangrene of the gallbladder wall and infection by gas-producing organisms. • C. welchii or C. perfringens, E. coli • Elderly men and in patients with DM • Dx: • plain abdominal film: gas within gallbladder lumen • Dissecting within the gallbladder wall to form gaseous ring • Pericholecystic tissues DIAGNOSTICS
• Antibiotics should cover gram-negative aerobes as well as anaerobes • Cholecystectomy- definitive treatment • Laparoscopic cholecystectomy- procedure of choice TREATMENT
• Cholecystectomy – definitive treatment
• Laparoscopic cholecystectomy – procedure of choice TOKYO GUIDELINES 2018
• Diagnostic criteria and severity grading
of acute cholecystitis ANTIMICROBIAL THERAPY FOR ACUTE CHOLECYSTITIS
• limit both the systemic septic
response and local inflammation • to prevent surgical site infections in the superficial wound, fascia, or organ space • to prevent intrahepatic abscess formation THANK YOU!
