Suspected Gallstone ileus Case Report Alif PSC 119 YES YOGYA.pptx

A case report of suspected gallstone ileus, rare type of obstructive bowel disease as a complication of severe cholecytitis in prehospital emergency service in yogyakarta indonesia. Presented in monthly meeting of PSC 119 YES Kota Yogyakarta Indonesia by dr. Alif Rasyid Humanindio

1. Suspected Gallstone Ileus as Complication of Severe Cholecystitis “From Prehospital Emergency Medicine POV” Alif Rasyid Humanindio Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT

2. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT INTRODUCTION Traumatic Injury (21.4%) Abdominal Pain/Problem (12.3%) Respiratory Distress (12.2%) Chest Pain/Discomfort (10.1%) Behavioral/Psychiatric disorder (7.8%) Common Prehospital Emergency Case Source: The National Emergency Medical Services Information System (NEMSIS)

3. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT INTRODUCTION Bowel Obstruction

4. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT INTRODUCTION

5. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT CASE DESCRIPTION - HISTORY Recent History Panggilan gawat seorang pria 59 tahun dilaporkan keluarganya mengalami penurunan respon , badan demam sejak 1 hari yang lalu: Gelisah Penurunan kesadaran Kejang seluruh tubuh selama +-30 detik Nyeri perut, tidak bisa BAB & kentut sejak 5 hari Past History Epilepsi (-) Stroke (-) Operasi rongga perut (-) Didiagnosa Cholecystitis Berat , Thrombositopenia dan usai dirawat inap +- 2 minggu yg lalu Risk Factor Diabetes Mellitus (-) Dyslipidemia (-) Hypertension (-) Smoking (-) Family History of Cardiovascular Disease (-)

6. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT CASE DESCRIPTION – EXAMINATION Vital Sign Somnolent (GCS 1 ) BP: 160/81 mmHg HR : 1 00-104 bpm RR: 28 x/min ( cepat , dangkal ) T : 3 8.7 C Sa : 54 % room air , 90% NRM 15 lpm General Head : sklera ikterik Neck : t.a.k Thorax : simetris Cor : Cardiomegali (-) murmur (-) Pulmo : suara tambahan (-) Abdomen : Distensi, defan muskular (-), Hipertimpani, Peristaltik usus meningkat, darm contour (-), darm steifung (-) , Extremities : Hangat , CRT < 2”, pitting oedem (-) Work-up GDS: 189mg/dl

7. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT CASE DESCRIPTION – EXAMINATION Penurunan Kesadaran Suspek Ileus Obstruktif Suspek Sepsis Chronic Cholecystitis Airway : Sniffing Position Breathing : O2 NRM 15 lpm Circulation : IVFD NaCl maintenance Disability : Head Up 15° Environment : Selimut Mencari rujukan RS dengan fasilitas ICU dan memiliki dokter spesialis syaraf, spesialis interna, spesialis bedah umum/ digestif Monitor TTV setiap 5 menit Rujuk RS Panti Rapih Kondisi stabil dan transportable Diagnosis Treatment Outcome

8. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT DISCUSSION It is a rare complication of cholelithiasis . Also rarest cause of all type of mechanical bowel obstruction. Howe ver : Accounts to 1-4% patient of non-strangulating mechanical small bowel obstruction and up to 25% of the elderly Mortality remain high , ranging from 12% to 27%, partially because of non-specific symptoms, unremarkable biochemical investigations, high misdiagnosis rate, and delayed discovery. It is more common in woman (3.5:1) and in elderly (>60yrs) Factors contributing are: long history of cholelithiasis, repeated episodes of acute cholecystitis, and stone greater than 2 cm. Ileus means temporary arrest of bowel movement, resulted from obstruction or paralysis of the bowel movement. Gallstone ileus was first described in 1654 by Dr. Erasmus Bartholin and is thought to be caused by the impaction of a gallstone in the gastrointestinal (GI) tract after passing through a biliary-enteric fistula, commonly at the ileum (60.5%), jejunum (16.1%), stomach (14.2%), colon (4.1%), and duodenum (3.5%). The small bowel obstruction commonly occured at the iliocecal . Turner AR, Sharma B, Mukherjee S. Gallstone Ileus. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430834/

9. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT DISCUSSION Sarah L. Gans, Margreet A. Pols, Jaap Stoker, Marja A. Boermeester, on behalf of the expert steering group; Guideline for the Diagnostic Pathway in Patients with Acute Abdominal Pain. Dig Surg 1 March 2015; 32 (1): 23–31. https://doi.org/10.1159/000371583 Obstruc-tion Worsens over time Bloating, Vomiting, Pain, Tenderness DehydrationSepsis Shock Penanganan definitifnya adalah dengan Enterolithotomy (one-stage or two-stage). Sementara, untuk penanganan awalnya adalah: Airway : Patensi jalan napas Breathing : Suplementasi oksigen hingga bantuan nafas jika perlu Circulation : identifikasi syok, pasang akses intravena bila perlu Disability : fiksasi dan proteksi spinal, penggunaan analgesik jika diperlukan, jangan memberi minum/makan. Environment : Jaga suhu tetap hangat Rujuk segera ke fasilitas kesehatan yang sesuai Secondary Survey dilakukan untuk menegakkan diagnosis kerja: Anamnesis OPQRST (Onset, provocation/palliation, quality, radiation, severity, time) Alergi obat / makanan / substansi lainnya Riwayat medis dan pengobatan Waktu makan dan minum terakhir Mual, muntah , warna muntahan, warna BAB Aktivitas terakhir sebelum sakit perut muncul Pemeriksaan Fisik Kesan umum Auskultasi : suara peristaltik, metallic sound Inspeksi : distensi, darm steifung, darm contour Palpasi : konsistensi, defan muskular, nyeri tekan Perkusi : timpani, redup

10. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT DISCUSSION Sarah L. Gans, Margreet A. Pols, Jaap Stoker, Marja A. Boermeester, on behalf of the expert steering group; Guideline for the Diagnostic Pathway in Patients with Acute Abdominal Pain. Dig Surg 1 March 2015; 32 (1): 23–31. https://doi.org/10.1159/000371583 Obstruc-tion Worsens over time Bloating, Vomiting, Pain, Tenderness DehydrationSepsis Shock Penanganan definitifnya adalah dengan Enterolithotomy (one-stage or two-stage). Sementara, untuk penanganan awalnya adalah: Airway : Patensi jalan napas Breathing : Suplementasi oksigen hingga bantuan nafas jika perlu Circulation : identifikasi syok, pasang akses intravena bila perlu Disability : fiksasi dan proteksi spinal, penggunaan analgesik jika diperlukan, jangan memberi minum/makan. Environment : Jaga suhu tetap hangat Rujuk segera ke fasilitas kesehatan yang sesuai Secondary Survey dilakukan untuk menegakkan diagnosis kerja: Anamnesis OPQRST (Onset, provocation/palliation, quality, radiation, severity, time) Alergi obat / makanan / substansi lainnya Riwayat medis dan pengobatan Waktu makan dan minum terakhir Mual, muntah , warna muntahan, warna BAB Aktivitas terakhir sebelum sakit perut muncul Pemeriksaan Fisik Kesan umum Auskultasi : suara peristaltik, metallic sound Inspeksi : distensi, darm steifung, darm contour Palpasi : konsistensi, defan muskular, nyeri tekan Perkusi : timpani, redup

11. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT DISCUSSION Sarah L. Gans, Margreet A. Pols, Jaap Stoker, Marja A. Boermeester, on behalf of the expert steering group; Guideline for the Diagnostic Pathway in Patients with Acute Abdominal Pain. Dig Surg 1 March 2015; 32 (1): 23–31. https://doi.org/10.1159/000371583 Peran Penunjang dalam diagnosis Riglers Triad (Pneumobilia, Small Bowel Obstruction, Ectopic Gallstone) Clinical Assessment + USG CT Scan (Superior in preoperative diagnosis) MRI Diagnostic Laparoscopy Primary Survey and Secondary Survey Imaging (USG, X-Ray, CT-Scan, MRI) Laparoscopy (minimally invasive) Surgery to evacuate gall stone from the lumen Post-operative Recovery

12. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT DISCUSSION

13. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT DISCUSSION

14. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT DISCUSSION

15. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT DISCUSSION Shah, BC & Degloorkar, Sarang & Rao, Aditya. (2015). Gall Stone Ileus: A Rare Case Report of Two Patients. Journal of Case Reports. 423-426. 10.17659/01.2015.0109. 77 yo Male Classical symptoms of intestinal o struction since 3 days History of unoperated gallstones 2 years back due to poor general and cardiac condition PE : Tachycardia, tachypneu, nontender abdomen with generalized distension & tympanic note. USG : suggestive of dilated bowel loops with pneumobilia and sludge in gall bladder. CT Scan : presence of two large 5x4 & 4x3 cm gall stone in distal ileum confirmed by diagnostic laporoscopy Mini-laparotomy and enterotomy sucessfully delivered 55 yo fe male Classic symptoms (colicky abdominal pain, bilious vomiting, constipation, abdominal distension) since 5 days Noncontributory past medical history PE: Tachycardia and hypotension. Mild generalized tenderness & tympanic note on percussion. USG: Suggestive cholelithiasis , CT Scan: small bowel obstruction with large gall stone in distal ileum 5x3cm. Confirmed with diagnostic laparoscopy Mini-laparotomy and enterotomy was delivered and success. Post-operative recovery was uneventful. OTHER CASES Decent diagnose QUICK SURGERY decisi on Alive and Recovered

16. Public Safety Center 119 Yogyakarta Emergency Service CEPAT, TEPAT, SELAMAT CONCLUSION Gallstone Ileus is rare yet common in elderly and woman, especially with a history of gall bladder disease Although CT Scan was superior compared to other modalities, USG and Plain Abdominal photo can be done to make preoperative diagnosis if CT unavailable Entherolithotomy is the definitive treatment for gallstone ileus, one-stage procedure preferred because of effectiveness and decrease duration of treatment.