Cholelithiasis case

its all about surgery...

1. Welcome to the Morning Session Dr. Sharmin Intern Doctor Department Of Surgery Tairunnessa Memorial Medical College and Hospital,Gazipur

2. A LONG CASE ON CHOLELITHIASIS

3. Particulars of the patient: Name : Moynesa Khatun Age : 45 years Sex : Female Occupation : Housewife Marital status : Married Religion : Islam Present Address : Kunia , Targach , Gazipur Permanent Adress : Mymensingh Date of admission : 03.11.2019 at 12.30 pm Date of examination : 03.11.2019 at 01.00 pm

4. Chief complaints: 1. Pain in right upper abdomen for 3 days. 2. D iscomfort In upper abdomen for 1month. 3.Nausea for same duration

5. History of present illness: According to the statement of the patient she was reasonably well 1 month back then she developed right hypochondriac discomfort which was recurrent and was associated with nausea. Patient stated that the discomfort was more pronounced after the consumption of fat containing foods. On further inquiry patient gave history of 2 episodes of sudden excruciating right hypochondriac pain which was colicky, radiating to right shoulder, associated with vomiting that was followed by intake of oily fried food. Pain had no periodicity and was not associated with fever with chills and rigors. Her stool is normal and has no history of steatorrhea. She is non Diabetic, Non-Hypertensive. With these complains she is admitted to department of surgery of this Hospital for her better management.

6. History of past illness : She has No significant past medical and surgical history. Drug history : She has History of taken pain killer but she couldn’t mention name Family history: All other family members of her family are apparently healthy . Personal History : She is nonsmoker and non betel nut chewer .

7. Menstrual history : Her menstrual cycle is regular . Occupational history: She is a Housewife. Socioeconomic status: She belongs to a middle class family. Immunization history: She is not fully immunized as per EPI schedule of her time.

8. General examination: Appearance : Ill looking Body built : Average Co-operation : Co-operative Decubitus : On choice. Nutrition : Average Anemia : Mild Jaundice : Present

9. Cyanosis : Absent Edema : Absent Dehydration : Absent Clubbing : Absent . Koilonychia : Absent. Leukonychia : Absent Neck vein : Not engorged . Pulse : 84 beats/min

10. . Blood pressure : 120/80 mmHg. Temperature : 98°F. Respiratory rate : 18 breaths/min. Jugular venous pressure : Not raised. Lymph node : Not palpable. Thyroid gland : Not enlarged. Weight : 50kg

11. Alimentary system: Inspection : Oral cavity : normal Lips, mouth : normal Tongue : normal. Systemic Examination

12. Abdomen proper: Inspection : Shape of abdomen : Shape was scafoid shaped , had normal hair distribution and wear no visible impulses . Movement of the abdomen :Moves with respiration. Umbilicus : centrally placed, Inverted and vertical slit Visible pulsation : Absent Visible peristalsis : Absent Scar mark : Absent

13. Palpation: Superficial palpation: Temperature : Normal Tenderness : Soft and slight tender in Right Hypochondrium Any mass : Absent Deep palpation : Liver : not palpable Spleen : not palpable Kidney : not ballotable Urinary bladder : not palpable

14. Percussion: Percussion note : Tympanic Upper border of liver dullness : Right 5 th intercostal space Shifting dullness : Absent Auscultation: Bowel sound : Present No Hepatic bruit, splenic rub or renal bruit.

15. Respiratory system. Inspection: Shape of the chest : Normal Deformity : Absent Movement of chest : Normal Respiratory rate : 18 breaths/min Any scar marks : Absent Visible impulse & engorged vein : Absent

16. Position of trachea : Centrally placed Apex beat : F elt in left 5 th intercostal space just medial to the midclavicular line. Chest expansibility : Normal Vocal fremitus : Normal Palpation:

17. Percussion : Percussion note : resonant Upper border of liver dullness : in right 5th intercostal space in midclavicular line . Auscultation : Breath sounds : Vesicular Added sounds : absent Vocal Resonance : Normal.

18. Cardiovascular system: Inspection: Deformity of chest : Absent Visible Cardiac impulse : Absent Any Scar marks : Absent Palpation : Apex beat : F elt in left 5 th intercoastal space just medial to the midclavicular line Thrill : Absent Left parasternal heave : Absent Palpable P2 : Absent Epigastric pulsation : Absent

19. Auscultation: Heart sound : 1 st and 2 nd heart sounds are audible in all auscultatory area. Murmur : A bsent Added sound : A bsent

20. Nervous system: Higher psychic function : Intact Cranial nerve examination : all cranial nerves are intact Signs of meningeal irritation : Neck rigidity : Absent Kernig’s sign : Negative Brudzinski’s sign : Negative Motor function : Normal Sensory function : Normal Cerebellar function : Intact

21. Sal ien t Feature: Mrs Moynesa Khatun , 45 years old muslim female hailing from kunia targach , Gazi p ur was admitted at TMMC&H on the date 03.11.2019 with complains of recurrent Right upper abdominal Discomfort, fatty food intolerance and nausea since last 1 month

22. . On further inquiry she had 2 episodes of sudden excruciating Right Hypochondriac colicky pain, radiating to right shoulder, associated with vomiting which was followed by intake of oily fried food. Pain has no periodicity and was not associated with fever with chills and rigors, patient has no history of steatorrhea. She is non diabetic.On general examination showed that patient is non obese while her abdominal examination revealed that there was slight tenderness in Right Hypochondrium .

23. . On general examination, she is co operative,anaemic and icteric.Her dehydration, oedema,cyanosis,clubbing absent.her pulse 84/ m,bp 100/80mmhg,tem 98 F. Now she is admitted to this hospital for better management.

24. Provisional diagnosis: Cholelithiasis

25. Differential diagnosis: PUD 2. Cholecystitis

26. INVESTIGATIONS 1. CBC WITH ESR 2.HB% 3.BLOOD GROUPING 4.URINE R/E 5.USG OF W/A 6.XRAY OF ABDOMEN 7.ECG

27. Confirmatory diagnosis: Cholelithiasis

28. Plan: Laparoscopic Cholecystectomy under General Anesthesia

29. Treatment : During admission Bed rest D iet : Normal with avoidance of fatty food. Inf Hartman solution ( 2 L) +5% DNS(1L) I/V @ 2 drops/min Tab. Algin (50mg)/ Ti e monium methyl sulfate 1+ 1 +1 Tab. Anadol (50mg)/ Tramadol hydrocloride 1+ +1 - sos Tab. Maxpro (20mg)/ Esomeprazole magnesium trihydrate ----------------------1+0+1 (Before meal) Tab . Emistat (8mg)/Ondansetron 1+0+1 Tab Rivotril (0.5mg)/Clonazepam 1tab P/O-Sips of water

30. CONSERVATIVE TREATMENT: Bed test Diet: NPO(TFO) Inf H/S(1litre) I/V @20drps/min Inj Axon/ Ceftriaxone(1gm) I/V ----stat Inj Pantobex (40mg)/Pantoprazol Sodium Sesquihydrate 1vial i /v---stat

31. Definitive treatment : Bed rest Diet: NPO for 6 hours,then sips of water-semisolid-solid Inf 5%DA(1L) +5%DNS(1L) I/V@ 20drps/min Inj Axon(1gm )/Ceftriaxone 1vial I/V -8hourly Inf Flamyd (500mg/100ml)/Metronidazole 1bag i /v--8hourly

32. Inj Torax (30mg )/ketorolac tromethamine 1 vial I/M—12 Hourly Inj Pantobex (40mg )/Pantoprazol Sodium Sesquihydrate 1vial I/V---12hourly Inj Anset (8mg )/Ondansetron 1amp I/V—SOS Supp Voltaline (50mg )/Diclofenac Sodium 1 stick P/R---SOS Supp Napa (500mg )/Paracetamol 1stick P/R----S0S O2 inhalation—SOS Nebulization-- sos

33. DURING DISCHARGE ; 1.Tab Cef-3(200mg)/ Cefixime 1+0+1—7days 2.Tab Torax (10mg)/Ketorolac Tromethamine 1+0+1 if pain,after meal -3days 3.Tab Maxpro (20mg)/ Esomeprazol Magnesium Trihydrate 1+0+1 (30 min before meal)-14 days 4.Tab Omidon (10mg) 1+1+1 –5days

34. Advice: Take medicines regularly. Avoid fatty food. You will have dietary food habits and have also Vit C enriched fruits except Tamarind. Intake plenty of water. Maintain proper hygiene

35. Follow up * You will come at 3 RD POD for DRESSING at surgery ward. You will come at 6 th POD for stitch off . If any complications arise, consult in OPD of Surgery.

36. SHORT TOPIC ON : CHOLELITHIASIS

37. Cholelithiasis Cholelithiasis is derived from the Greek word ‘CHOL’ means “Bile” and “LITH” means ‘Stone’. Presence of stones in the gallbladder is reffered to as cholelithiasis .

38. Types of Gallstone There are three types of gallstone which is given below: CHOLESTEROL STONES ( 80% cholesterol by weight) vary in color from light yellow to dark green or brown and are oval 2to 3cm in length,often having a tiny dark center spot.

39. PIGMENT STONES are small,dark stones made of bilirubin,calcium salts and 20% cholesterol that are found in bile. MIXED GALLSTONES typically contain 20-80% cholesterol.Other common constituents are calcium carbonate,palmitate phosphate ,bilirubin and other bile pigments.Because of their calcium content,they are other radiographically visible.

40. Pathophysiology: Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salt. Two other factors are important in causing gallstones are: Incomplete and Infrequent emptying of the gallbladder may cause the bile to become overconcentrated and contribute to gallstone formation.

41. The second factor is the presence of proteins in the liver and bile that either promote or inhibit cholesterol crystallization into gallstones .

42. ETIOLOGY: Fat Forty Female Fertile Drugs Heriditary Bile stasis

43. Signs and symptoms: Gallstones may be asymptomatic,even for years.These gallstones are called “silent stones” and do not require treatment. Symptoms commonly begin to appear once the stones reach a certain size(>8mm) A characteristic symptom of gallstones is a “gallstone attack”, in which a person may experience intense pain in the upper right side of the abdomen.

44. Often,attacks occur after a particularly fatty meal and almost always happen at night. Abdominal bloating. Intolerance of fatty foods. Belching. Gas Indigestion

45. INVESTIGATIONS: USG of HBS LFTs ERCP/MRCP AXR CT Scan

46. TREATMENT: Conservative treatment for acute condition. SURGERY: Open cholecystectomy Laparoscopic cholecystectomy(the gold standard for treating symptomatic cholelithiasis

47. Medical treatment : 1.expectant incase of asymptomatic 2.Chemical ddissolution : By Chenodeoxycholic acid (when gall stone<2cm nd GALL BLADDER –normal function)

48. 3.Fragmentation by ESWL(extra corporial shock wave lithotripsy. Percutaneous cholecystolithotomy .

49. COMPLICATIONS: Cholecystitis Choledocholithiasis Perforated gallbladder Gallbladder cancer Cholangitis Pancreatitis Gangrene or abscesses

50. REFERENCES 1.Bailey and love’s Short Practice on Surgery, 26 th edition 2.Robbins and Cotran Pthologic Basic Of diseases 3.Wikipedia

51. THANK YOU HAVE A NICE DAY