case presentation carcinoma of gall bladder.pptx

....

1. Case presentation of late stage ca gb

2. Case 1 Name; Renu Gomber Age/Sex: 61/F CR No: 571908 Date of admission: 03/03/24 Date of expiry: 30/03/24

3. Diagnosis : Locally advanced CAGB with SOJ st Stented with tent block in cholangitis Management: ERCP Parellel stenting

4. History Pt. 61-Year-old female known case of locally advanced CAGB with SOJ status ERC stented presented with complaints of Fever and vomiting for 2 days. Patient previously presented with pain abdomen for one and half months and jaundice for 15 days and was admitted and worked up. On evaluation she was found to have Carcinoma GB with surgically obstructed jaundice. She underwent ERCP and stenting on 08/02/24 in outside hospital .

5. Patient was previously admitted previously on 17/02/24 and was worked up and was planned for neoadjuvant chemotherapy and was discharged on 29/02/24. Patient again presented with above mentioned complaints now. History of loss of weight and appetite present. No history of DM/HTN/Asthma/Epilepsy. No previous surgeries in the past

6. At admission: ECOG -03. PR -106/MIN BP: 80/60mmHg SPO2 – 97% on RA Soft, RHC mass present, minima l epigastric tenderness present.

7. Key events: Patient was admitted with above mentioned complaints and was evaluated. She was found to have stent block with cholangitis. Her case was discussed with MGE and was planned for Repeat ERCP. Repeat ERCP and parallel stenting was done on 04/03/24. Post ERC stenting her bilirubin levels reduced and WBC counts reduced. Ryles tube was inserted and feeding were started. She had developed anasarca and worsening respiratory infection, for which she required ventilatory support and intubation was done.

8. She had worsening sepsis with elevated counts and hypotension for which antibiotics were escalated and ionotropic support were given. She developed hypotension and bradycardia followed by cardiac arrest on 30/03/24 at 11 00 AM. Despite Resuscitative measures she was not revived and was declared died at 11 30 PM on 30/03/24.

9. INVESTIGATIONS : DATE 03/03/24 07/03/24 15/03/24 21/03/24 25/03/24 28/03/24 HEMOGLOBIN 8.4 8 8 7.5 8.5 8.9 TLC 29900 14400 14800 10400 12400 51600 DLC 98/9 90/6 88/06 80/09 86/06 93/03 PLATELETS 51k 13k 1.24 1.85 1.65 60k BU/S. CR 65/2.2 152/3.3 53/1.1 32/1.0 27/1.2 36/1.5 S. ELECTRO. 139/4.4 130/4.6 139/4.7 140/4.2 139/5.4 145/5.1 T. BILIRUBIN 8.2/5.5 4.2/1.7 1.7 1.6 1.7 0.7 SGOT/SGPT 71/39 99/96 55/39 57/29 51/25 37/18 ALP 404 193 267 203 249 268 T.PROT/S. ALB 2.1 4.8/2.4 4.2/1.7 4/1.8 4.7/2.7 4.6/2.2 PT/INR 1.1   1.3      

10. CECT TRIPLE PHASE ABDOMEN (05/02/24): The gallbladder is overdistended and shows presence of mild diffuse wall thickening with post-contrast enhancement in the portal venous and delayed phases. There is contiguous infiltration of the adjacent segment 4 and 5 of liver. There is also presence of calculi in the region of gallbladder fundus and at the gallbladder neck measuring 9.5 mm and 12 mm respectively. No significant pericholecystic fat stranding is noted. There is preservation of fat planes with the adjacent second part of duodenum. There is presence of multiple enlarged confluent periportal and peripancreatic lymph nodes / largest measuring 2 cm in short axis. These lymph nodes are completely encasing the right hepatic artery, however, with preserved Luminal enhancement . There is also partial encasement of the main portal vein, however, with maintained luminal enhancement. There is resultant abrupt cut off of the intrapancreatic CBD with dilatation of the supra-pancreatic CBD (12 mm with moderate bilobar IHBR dilatation. Primary biliary confluence and both secondary confluence are patent. There is also presence of surrounding peripancreatic fat stranding in the neck region. The presence of a large aortocaval (16 mm and sub-centimetre sized precaval lymph node is noted.

11. MRI UPPER ABDOMEN (03/02/24): The gallbladder is overdistended and shows presence of mild diffuse wall thickening. There is apparent contiguous infiltration of the adjacent segment 4 and 5 of liver with area of restricted diffusion. There is also presence of a calculus in the gallbladder lumen with surrounding sludge. A suspicious obstructive calculus is also seen at the gallbladder neck measuring 12 mm. There is presence of multiple enlarged confluent periportal and peripancreatic lymph nodes - largest measuring 2 cm in short axis. There is resultant Abrupt cut off of the intrapancreatic CBD with dilatation of the supra-pancreatic CBD (8.8 mm) with moderate bilobar IHBR dilatation. Primary biliary confluence and both secondary confluences are patent

12. Ultrasound Abdomen; 03/03/24; CBD is dilated with stent insitu with central IHBRD with bilobar minimal Pnuemobilia CBD 18 mm. Minimal FFA in pelvis.

13. HPE (09/02/24): Adenocarcinoma, Mid CBD stricture

14. COUSE OF DEATH Septic shock with MODS-- Ca GB with SOJ without GOO st stented