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I.

Patient Identity: Name Sex Age Address Religion Hospitalized Date : Mrs. M : Female : 47 years old : Pegagan Kidul : Islam : 10 May 2010

II.

Anamnesa (Autoanamnesa at 11 May 2010) Main Complaint: Pain in the right upper abdomen since 5 days SMRS Present History of Disease: The patient came to Emergency Unit through Poliklinik Arjawinangun surgical hospitals with complaints of pain in the right upper abdomen since 5 days SMRS. Intermittent abdominal pain is felt. Pain usually occurs about 15 minutes after eating. Pain can be felt radiating up to Back. However, abdominal pain disappeared a few hours later. The patient also complained of pain in the pit of the stomach area. If the food filled stomach, the patient felt pain and nausea. This complaint felt since one month ago but largely ignored by the patient.

Past History of Disease

The history of the same disease ignored The history of Diabetes Melitus ignored The history of Hipertension ignored

The History of Family Disease : None III. Phsycally examination General state General state Awareness Vital sign : BP P T RR Head : Normocephal Eye : Conjungtiva Anemis -/Sclera icteric -/Pupil : isochor Pupil Reflex -/Neck : Tiroid isnt palpable enlarge Lymphaticus Nodes isnt palpable enlarge : moderate illnes : Compos mentis : 110/70 mmHg : 84 x/minute : 36oC : 20 x/ minute

Thoraks

Cor

I : iktus cordis isnt visible P : iktus cordis palpable at ICS V midclavicula line P : heart border is easily assesed A : BJ I-II regular, murmur(-), gallop(-)

Pulmo I : symmetrical piston movement in a static state and dynamic P : vokal fremitus right and left hemitoraks are the same P : sonor for both of hemithoraks A : vesicular, rhonki -/-, wheezing -/Abdomen I A P P Ekstremitas : convex, simetris : Bowel sound (+) normal : Timpani in all part of abdomen : soft , tenderness (-), slippery, Murphy sign (+), Pain in the right upper abdomen

left and right superior : udem (-) , warm akral Left superior dan left inferior are localize state left and right inferior : udem (+) , warm akral

IV.

Laboratory result (Blood Test): Hb Leukosit Eritrosit : 12,1 g/dl : 8,8 x 103/l : 4,07 x 106/l

Trombosit : 417 x 103/ l Hematokrit KGDS : 33,6 %

: 120 mg/dl

SGOT SGPT HbsAg

: 15 U/I : 6 U/I : 0,445 COI

V.

Work Diagnosis : Cholelithiasis

VI.

Differential Diagnosis : GERD Miokard Infark

VII.

Suggest Examination : USG Upper Abdomen

VIII.

Treatment : Phamacological treatment: Pre-Operative Antibiotic : ceftriaxon 2x1gr Analgetic : ketorolac 2x1 Operative Procedure : Cholesistectomy

IX.

Prognosis:

Quo ad vitam

: dubia ad bonam : dubia ad bonam

Quo ad fungsionam

CHOLELITHIASIS ANATOMY Gall bladder ovate shaped like a lawyer with 4-6 cm long and containing 30-60 ml of bile. Part fundus generally slightly protruding edge hearts out, under the right rib arch, beside the lateral m.rektus abdominis. Most of the corpus attached and buried in the heart tissue. Gall bladder viseralis entirely covered by peritoneum, but no gall bladder infundibulum fixated to heart by lining the peritoneum. When the gall bladder distention due to retention experienced by the rock, its stands out as the infundibulum bag called Hartmann pouch. Sistikus duct 1-2 cm long with a diameter of 2-3 mm. lumen walls contain spiral shaped valve diaphragm valve called Heister, which facilitates bile flow into the gallbladder, but resist the flow discharg . Extra- hepatic bile duct is located in the upper limits hepatoduodenale ligament porta hepatic, which limits distal papilla Vater. Intrahepatic bile duct upstream part stems from the small vessels called kanalikulus who continue flushing secretion of bile through the bile ducts to interlobularis lobaris ductus, and further to hylus hepaticus ductus.

Hepatikus duct length right and left respectively between 1-4 cm. Duct long communist hepatikus is depending on the place of the mouth of the duct sistikus. Koledokus duct runs behind the duodenum and pancreas tissue penetrating duodenal wall forming Vater papilla which is located to the medial wall of the duodenum. Distal tip surrounded by sfingter Oddi muscle, which regulates the flow of bile into the duodenum. Pankreatikus duct generally boils down to the same place in the papilla of Vater koleokus ducts , but can also be detached. PHYSIOLOGY One of the functions of the liver is to produce bile , normally between 600-1200 ml / day . Gallbladder can store about 45 ml of bile. Outside the meal, bile is stored temporarily in the

gall bladder , and here suffered around 50 % concentration . Primary function of the gall bladder bile is thicken with water and sodium absorption . Gallbladder able to condense a tight solutes contained in hepatic bile and reduce your volume 5-10 times 80-90 %. According to Guyton & Hall , 1997 gall perform two important functions , namely: Bile plays an important role in the digestion and absorption of fat, because bile acids are doing two things , among others : bile acid helps emulsify the fat particles are big into smaller particles with the aid of lipase enzyme secreted in the rubber pancreas, bile acid helps transport and absorption of digested fat end products to and through the intestinal mucous membrane . Bile work as a tool to produce a significant number of waste products from the blood , among others bilirubin , an end product of hemoglobin destruction , and advantages in the form of cholesterol by the liver cells . Gall bladder emptying kolesistokinin influenced by hormones , this occurs when fatty foods enter the duodenum about 30 minutes after eating . Policies that caused evacuation is rhythmic alteration of wall gall bladder contractions , but also the effectiveness of evacuation requires a corresponding relaxation of Oddi sfingter in charge of communist biliaris exit duct into the duodenum. Besides kolesistokinin , gall bladder also strongly stimulated by nerve fibers that menyekresi acetylcholine from the vagus and enteric nervous system . Emptying gallbladder bile storage condensed into the duodenum , especially in response to stimulation kolesistokinin . Currently there is no fat in the diet , gall bladder emptying held bad , but when there adekuat amount of fat in the diet , normal whole gall bladder empty in about 1 hour. Bile salts, lecithin, and cholesterol is the major component ( 90 %) bile . The rest is bilirubin , fatty acids , and inorganic salts . Bile salts are steroids made by hepatocytes and is derived from cholesterol . Arrangements affected production feedback mechanism can be enhanced up to 20 times the normal production if needed

Epidemiology

Country western 20 % kolelitiasis affect adults and elderly . Most asymptomatic cholelithiasis . 80 % of gallstones are cholesterol stones . Gallstones are found in Indonesia began at a young age under 30 years , although the average age is 40-50 years common . At the age of 60 years , the incidence of gallstones increases . Number of patients with more women . Increased incidence of gallstones can be seen in the high risk group called " 4 F " : female (woman), fertile (fertile) - especially during pregnancy, fat (fat), and forty (forty years) . Cholelithiasis can occur with or without the risk factors . However , the more risk factors , the greater the possibility for the occurrence of cholelithiasis. The risk factors , among others : Genetic Age : The average age of most frequent occurrence of gallstones are 40-50 years old . Very few people with gallstones are found in adolescence , after that as we grow older the more likely to get gallstones , so that at the age of 90, chances are one in three people. Gender : Gallstones are more common in women than in men by a ratio of 4 : 1 . Several other factors : Other factors that increase the risk of gallstones include: obesity , diet , family history, physical activity, nutrition and long-term venous.

Pathogenesis Gallstones are almost always formed in the gall bladder and bile ducts are rarely on the other and are classified based on its constituent materials . Gallstone etiology is still unknown perfectly , however , the most important predisposing factor apparently is a metabolic disorder that is caused by changes in the composition of bile , bile stasis and

gallbladder infection . Changes in the composition of bile may be the most important in the formation of gallstones , due to deposition of cholesterol in the gallbladder . Stasis of bile in the gallbladder may increase the supersaturation progressive , changes in chemical composition , and deposition of these elements . Bacterial infection in the bile ducts may act partly in stone formation , through enhanced and cell desquamation and mucus formation . Associated with the secretion of cholesterol gallstone formation . On abnormal conditions , cholesterol may precipitate , causing the formation of gallstones . Various conditions can lead to the deposition of cholesterol are : too much water absorption of bile , too much absorption of bile salts and lecithin from bile , too much cholesterol in the bile secretion , amount of cholesterol in the bile is partly determined by the amount of fat that is eaten because the cells hepatic synthesis of cholesterol as one of the products of fat metabolism in the body . For this reason , those who received the highfat diet in a few years time , will be susceptible to the development of gallstones . Gallbladder stones can migrate into koledokus duct through the cystic duct . In the journey through the cystic duct , the stones can cause blockage of bile flow by partial or complete gejalah causing biliary colic . If the stone in the cystic duct stalled because its diameter is too large or restrained by stricture , stone will remain there as the cystic duct stones Stone Type a) Cholesterol stones Cholesterol stones contain at least 75 % of cholesterol crystals . And the rest is kalsiumkarbonat , kalsiumpalmitat , and kalsiumbilirubinat . The shape varies over form pigment stones . The formation is almost always didalma gallbladder , can be solitary or multiple stones . The surface may be slippery or multifaceted , round , spiked , and there's nothing like mulberries . Cholesterol stone formation process through four stages ,

namely saturation of bile by cholesterol , nidus formation , crystallization and stone growth . The degree of saturation of bile by cholesterol can be calculated through the solubility capacity . This saturation can be caused by the increased secretion of cholesterol or bile acids relative decline or phospholipids . Sekeresi increase biliary cholesterol among other things, the state of obesity , a diet high in calories and cholesterol , and taking medications that contain estrogen or klofibrat . Bile acid secretion will be decreased in patients with impaired absorption in iliem , or impaired emptying of the primary content of bile . Saturation excess cholesterol can not form stones, except when there nidus and there are other processes that lead to crystallization . Nidus can be derived from bile pigments , mukoprotein , lenders and other proteins , bacteria or other foreign objects . After crystallization include nidus , there will be the formation of stones . Stones growth occurs due to deposition of cholesterol crystals on inorganic matrix and the speed is determined by the relative speed of dissolution and precipitation . The structure is a matrix containing mineral deposits of calcium salts . Gallbladder stasis also play a role in stone formation , in addition to the factors mentioned above

b. Pigment stones / stone Bilirubin This stone is often found irregularly shaped , small , can amount to a lot , the color varies between brown , reddish to black , and shaped like clay or fragile soils . This stone is often coalesce to form larger stones . Pigment stones are very large bile duct can be found . Pigment stones are cholesterol gallstones that less than 25 % . Black pigment stones formed in the gall bladder is mainly formed on the balance of metabolic disorders such as hemolytic anemia and cirrhosis of the liver without prior infection. Such as the formation of cholesterol stones, the stones bilirubin associated with age . Infection , static , dekonjugasi bilirubin and calcium excretion is a causal factor. At bakteribilia are gramnegative bacteria, especially E. coli. Gender, obesity and impaired absorption in the ileum

did not increase the risk of bilirubin stones. In patients with bilirubin stones, which are not conjugated bilirubin concentration increased. Either (in the gallbladder or in the liver). Stone mixed is a mixture of cholesterol stones containing calcium. This stone is often found to be almost 90 % in patients with cholelithiasis. This stone is plural , dark brown . Most of mixed stones have the same basic metabolism of cholesterol stones.

Clinical Manifestations 1 . Gall Bladder stones (Cholelithiasis) Asymptomatic. Stones in the gallbladder are often no symptoms (asymptomatic). It can give symptoms of acute pain due to cholecystitis, biliary pain, chronic recurrent abdominal pain or dyspepsia, nausea (Suindra, 2007). Study course of the disease and 50 % of all patients with gall bladder stones, regardless of type, are asymptomatic . Less than 25 % of patients who actually have asymptomatic gallstones will experience symptoms that require intervention after a period of 5 years. No data are recommending routine cholecystectomy in all patients with asymptomatic gallstone. Symptomatic The main complaint of pain in the epigastric region, the upper right quadrant. Other pain is biliary colic that lasted more than 15 minutes, and sometimes newly disappeared a few hours later. Biliary colic, postprandial right upper quadrant pain, usually precipitated by fatty foods, occurred 30-60 minutes after eating, ended after a few hours and then recovered, caused by gallstones, referred to as biliary colic. Nausea and vomiting often associated with biliary colic attack.

Complications Acute cholecystitis is a complication of gallstone disease is the most common and often led to abdominal emergencies, particularly among middle-aged and elderly women. Acute inflammation of the gall bladder, associated with cystic duct obstruction or in the infundibulum. Typical picture of acute cholecystitis is the upper right abdominal pain is sharp and constant, either in the form of an acute attack or preceded by discomfort in the post- prandial epigastric region. The pain increases with movement or a moment of inspiration and can spread kepunggung or to the end of the scapula. This complaint may be accompanied by nausea, vomiting and decreased appetite, which can last for days. On examination marks can be found toxemia, tenderness in the right upper abdomen and a classic sign of " Murphy sign " (patients stop breathing during the upper right abdomen is pressed). Period which can be palpated found only in 20 % of cases. Most patients will eventually undergo open or laparoscopic cholecystectomy. Gall stone channel (koledokolitiasis). At koledokus duct stones, or a history of colicky pain in the epigastric and right upper abdomen accompanied by signs of sepsis, such as fever and chills in the event of cholangitis. Cholangitis attack when arises which is generally accompanied by obstruction, will be found in accordance with the clinical symptoms of cholangitis weight is. Acute cholangitis is usually mild to moderate non-pyogenic bacterial cholangitis characterized by Charcot triad of fever and chills, liver area pain, and jaundice. In the event of kolangiolitis, usually in the form of intrahepatic pyogenic cholangitis, there will be 5 pentade Reynold symptoms, such as Charcot's triad of three symptoms, plus the shock, and mental confusion or loss of consciousness up to coma. Koledokolitiasis often cause very serious problems due to mechanical and infectious complications that may be life threatening. Koledokus duct stones accompanied by bakterobilia in

75 % percent of patients as well as in the presence of bile duct obstruction, acute cholangitis may arise. Severe episodes of acute cholangitis can cause liver abscess. Small gallstone migration through the ampulla of Vater when there is a common channel between koledokus distal duct and pancreatic duct can cause gallstone pancreatitis . Gallstone lodged in the ampulla will cause obstructive jaundice.

Physical Examination
1. Gallbladder Stones.

If abnormalities are found, usually associated with complications, such as acute cholecystitis with local or general peritonitis, gallbladder hydrops, empyema of the gallbladder, or pancreatitis. On examination found tenderness to the area where the maximum punktum gallbladder anatomy. Murphy's sign was positively if pain increases when patients hit a deep breath because the inflamed gallbladder touched fingertips to the patient stops breath. bile duct stones. Bile duct stones cause no symptoms or signs in the quiet phase. Sometimes slightly enlarged liver palpable and sclera jaundice. However, if the blood bilirubin levels less than 3mg/dl, symptoms of jaundice is not obvious. If the bile duct blockage gets worse, there will be a new clinical jaundice. Cholangitis attack when arises which is generally accompanied by obstruction, it will be found in accordance with the clinical symptoms of the cholangitis. Acute cholangitis is usually mild to moderate bacterial cholangitis nonpiogenik marked with Charcot's triad, ie fever and chills, pain in the liver area area, and jaundice. In case of intrahepatic pyogenic cholangitis, there will be 5 pentade reynold symptoms, such as symptoms of Charcot 3, plus shock and mental confusion or loss of consciousness

and

coma.

If it is found that a history of intermittent cholangitis, had suspected the possibility hepatolitiasis. Management 1. Conservative a. Lysis stone with drugs Most patients with asymptomatic gallstones will not have any complaints and the number, magnitude, and composition of the stone is not associated with the onset of complaints during monitoring. If complaints arise later generally mild that treatment can be elective. Ursodeoksilat acid dissolution therapy with cholesterol gallstones to dissolve drug delivery takes 6-12 months and required monitoring to achieve dissolution. Effective therapy in a small stone size of 1 cm with a recurrence rate of 50 % in 5 years . b. issolution contact Although experience is still limited, infusion of the potent cholesterol solvent ( Methyl - Ter - Butyl - Ether ( MTBE ) ) into the gallbladder through a catheter that is placed percutaneous been seen to be effective in dissolving gallstones in selected patients. This procedure is invasive and its main disadvantage is the high recurrence rate (50 % in 5 years). c. Lithotripsy (Extarcorvoral Shock Wave Lithotripsy = ESWL) Wave lithotripsy elektrosyok although very popular a few years ago , the cost benefit analysis at this point is limited to patients who have actually been considered for this therapy. Effectiveness of ESWL require adjuvant therapy

ursodeoksilat acid. d. Endoscopic Retrograde Cholangiopancreatography ( ERCP ) At ERCP, an endoscope is inserted through the mouth, esophagus, stomach and into the small intestine. Radiopaque contrast dye into the bile duct through a hose in the sphincter of Oddi. At sphincterotomy, sphincter muscle rather wide open so that gallstones that block the channel will move to the small intestine. ERCP and sphincterotomy was successfully performed in 90 % of cases. Less than 4 out of every 1,000 people who died and 3-7 % had complications, so this procedure is safer than abdominal surgery. ERCP is usually effective only performed in patients with bile duct stones who are older, who had gall bladder removed.

2. Operative a. Open Cholecystectomy This operation is a standard for the treatment of patients with symptomatic gallstones. The most common indication for cholecystectomy is recurrent biliary colic, followed by acute cholecystitis. Severe complications are rare, include trauma, bleeding, and infection. Data recently showed mortality in patients undergoing open cholecystectomy in 1989, the overall mortality rate of 0.17 %, in patients less than 65 years 0.03 % while the mortality rate in patients over 65 years the death rate reached 0.5 %. b. Laparoscopic Cholecystectomy Advantages of these actions include minimal postoperative pain, faster recovery, better cosmetic results, truncate hospital care and lower cost. Commonest indication is recurrent biliary pain. Absolute contraindications are similar to open

the action can not tolerate general anesthesia and coagulopathy that can not be corrected. Complications such as bleeding, pancreatitis, cystic duct stump leak and bile duct injury. Risk of bile duct injury is often discussed, but generally range between 0.5-1 %. By using the laparoscopic technique better quality of recovery, there is no pain, re-run the normal activity within 10 days, quickly working again, and all the abdominal muscles intact so it can be used for sports activities. c. Minilaparatomi cholecystectomy Modification of action open cholecystectomy with a smaller incision with effect lower postoperative pain.

REFERRENCES LIST 1. Sjamsuhidayat R, de Jong W Buku Ajar Ilmu Bedah, Edisi Revisi, Jakarta : EGC,1997. 2. Schwartz S, Shires G, Spencer F. Prinsip-prinsip Ilmu Bedah (Principles of SurgerY). Edisi 6. Jakarta: Penerbit Buku Kedokteran EGC. 2000.459-64. 3. Guyton AC, Hall JE. Sistem Saluran Empedu dalam: Buku Ajar Fisiologi Kedokteran. Edisi ke-9. Jakarta: EGC, 1997. 4. Dunphy Englebert J, MD, Way W Lawrence, MD, Current Surgical Diagnosis & Treatment.

5. Lesmana L. Batu Empedu dalam Buku Ajar Penyakit Dalam Jilid 1. Edisi 3. Jakarta: Balai Penerbit Fakultas Kedokteran Universitas Indonesia. 2000.

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