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T

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U CK
A
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R LO
R
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,
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G B
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R
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P
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 RY
T O
I S
H
 IDENTIFYING DATA
Filipino
F.M.R Roman
41 years old Catholic
Female Date of
Admission:
Date of Birth:
May 7, 2017
May, 5 1976
Date of
Bicol
Interview:
May 7, 2017
 IN
PA
L
A
IN
M IN
T

O A

D
L
P
M

B C
O

A
C
H
IE
F
7 MONTHS PTA
Abdominal pain
Sudden onset, epigastric
Cramping, 5/10
(-) vomiting, diarrhea, constipation or fever
Consult at a local hospital -> given unrecalled
pain medication IV -> relief of symptoms
7 MONTHS PTA
Ultrasound result:
Normal sized liver, homogenous parenchymal
pattern, intact intrahepatic ducts and common
duct, smooth hepatic border
Moderately distended gallbladder, medium
level echoes intraluminally measuring 17mm,
intact gallbladder wall
Normal sized pancreas, homogenous
echopattern
Normal sized spleen, homogenous
echopattern
7 MONTHS PTA
Ultrasound result
Normal sized kidneys
Unremarkable ureters and urinary bladder
Normal sized uterus, homogenous
echopattern, intact endometrial stripe,
unremarkable adnexae
4 MONTHS PTA
Abdominal pain
Right upper quadrant pain after eating oily
food
No other associated signs and symptoms
HNBB (Buscopan) -> relief of symptom
No consultation
1 MONTH PTA
Abdominal pain
Sudden, right upper quadrant
Radiating to the right flank
No other associated symptoms
Went for consult
1 MONTH PTA
CLINICAL CHEMISTRY

Laboratory Result Reference

Range
Sodium 141.00 mmol/L 136-145
Potassium 4.00 mmol/L 3.5-5.1
Chloride 104.00 mmol/L 97-107
BUN 3.20 mmol/L 2.5-6.4
Creatinine 62.37 umol/L 53.0-88.0
Hemoglobin 6.00 % 4.8-6.2
A1C
FBS 6.02 4.1-5.9
Complete Blood Count

CBC Result Reference

Range
RBC 4.7 4.2-5.4
Hemoglobin 133 120-160
Hematocrit 0.40 0.36-0.47
Platelet Count 382 150-450
WBC 8.5 5.0-10.0
Chest X-ray
Clear lungs
Cardiomegaly with left ventricular
configuration
1 WEEK PTA
Abdominal pain
Insidious, progressive, right upper quadrant
Colicky, radiating to the right flank
(+) undocumented fever, vomiting, nausea,
loss of appetite, one episode of non-billous
vomiting
(-) jaundice, chills
Unrelieved by HNBB (Buscopan)
No consultation
FEW HOURS PTA
Progression and increased severity of
symptoms, hence consult.
 AL
C
I
E D
M Y
S T R
A O
P IST
H
PAST MEDICAL HISTORY
No previous admissions
No previous surgeries
No history of blood transfusion
No allergies to any medication and food
No chronic NSAID use
(-) Diabetes, Tuberculosis, Thyroid disease,
Cardiovascular disease
(+) Hypertension
Metroprolol 100 mg
(+) Asthma
 Y
IL RY
A M O
F IST
H
FAMILY HISTORY
(+) Gallstones mother
(+) Diabetes, hypertension, cardiovascular
disease - father
 ND
A RY
A L T O
N IS
SO H
R A L
E
P C I
S O
PERSONAL AND SOCIAL HISTORY
(+) Smoker (stopped last October 2016)
(+) Alcoholic drinker (stopped last
October 2016)
(-) illicit drug use
 F
O
E W S
VI M
E T E
R YS
S
REVIEW OF SYSTEMS
Gener (-) Febrile episodes
al
(-) Skin discoloration
Skin (-) Dryness, itchiness, rashes,
sores, lumps; Hair changes

(-) Headache, dizziness,

Head lightheadedness

(-) Blurred of vision; (-) pain, redness,

Eyes excessive tearing, spots, specks,
flashing lights.
 (-) Tinnitus; (-) vertigo, earaches,
Ears infection, discharge

Nose
and (-) Colds, nosebleeds; sinus trouble
Sinuses

Throat
(-) Bleeding, (-) dentures, (-) sore
(Mouth
tongue, (-) dry mouth, (-) sore
and throat, (-) hoarseness, (-) thrush, (-)
Pharyn non-healing sores
x)
 (-) Swollen glands, lumps,
Neck pain, or stiffness in the neck

(-) Cough, difficulty of

Respirat
ory breathing, shortness of breath,
audible wheezing

(-) Easy fatigability,

Palpitations
CVS
(-) Orthopnea, Paroxysmal
Nocturnal Dyspnea
 (-) Heartburn, Nausea and vomiting,
GIT Melena/Hematochezia/ Hematemesis,
Diarrhea/Constipation, Steatorrhea

(-) Burning or pain during urination, flank

Urinary pain, suprapubic pain, incontinence

Periphe
ral (-) Edema; (-) color change in fingertips or
Vascula toes
r
(-) Muscle and joint pain; (-) Paralysis,
numbness or loss of sensation (-) tingling or
NMS pins and needles, tremors or other
involuntary movements; (-) seizures
 (-) Heat or cold intolerance,
Endocri excessive sweating, excessive
ne thirst or hunger, polyuria,
change in glove or shoe size
 L N
A T IO
I C A
YS IN
H
P XA M
E
GENERAL APPERANCE
Awake, conscious, coherent
Not in cardiorespiratory distress
VITAL SIGNS
Blood Pressure: Pain Scale:
130/80
Heart Rate: 106
7/10
bpm Height:
Respiratory Rate: 411
20 cpm
Temperature: 37.0 Weight: 68.2
Degree Celsius Kg
O2 Saturation: BMI: 30.3
98%
(Obese)
 Uniformly fair in complexion
Warm, dry, elastic and mobile
No primary and/or secondary lesions
SKIN noted
No cyanosis, erythema , angiomatas
noted
No Jaundice

HEAD No tenderness, lesion noted on

AND scalp
FACE
No esotropia, exotropia, exophthalmia
Pupil are equal and reactive to light and
accommodation
EYES Pink palpebral and bulbar conjunctiva
Anicteric Sclerae
Lacrimal apparatus is moist
 Some cerumen noted on
external ear
Responds to normal and
whispered voice on both ears
EARS Air conduction is longer than
bone conduction on Rinnes
test
Equally lateralize on both ear
on Webers test
Septum in the midline
NOS mucosa is pinkish, both
E nostrils are patent.
Nasal sinus non tender
 Lips and oral cavity appears
MOUTH
pinkish and moist, no pallor,
cyanosis, dryness, lesions
noted
Uvula is at the midline.
PHARY Tonsils not inflamed
NX
Positive gag reflex
No atrophy noted
No palpable cervical
NECK lymphadenopathy
No neck vein distention
Thyroid gland non palpable
 Adynamic precordium
No heaves, lifts, thrills
HEAR Point of maximal impulse palpated at 5th
intercostal space left mid clavicular line
T Apex Beat same as PMI
No murmur

No pectus excavatum nor carinatum

Equal chest expansion
With regular breathing pattern
Equal tactile fremitus
LUN

Resonant
Vesicular breath sound
GS No adventitious breath sound
No egophony or whispered pectoriloquy
ABDOMEN
Soft, globular abdomen
Normoactive bowel sound
Tender on deep palpation on epigastric
region and right upper quadrant
No palpable mass
Liver and spleen is non-palpable
ABDOMEN
(+) Murphys Sign
Negative Cullens and Grey Turners
Sign
No Psoas, Obturator, Rovsings Sign
No fluid shift
No CVA tenderness
DRE: No mass, non-tender, non-
collapsed rectal vault, good sphincteric
tone, no blood, no fecal material
 Bladder non palpable
GUT No genital lesions, discharges noted

Full equal pulses

No palpable lymph nodes, no edema
PERIPHERA noted
L
No nailbed cyanosis, no clubbing
Capillary refill less than 2 seconds.

No lesions, deformity noted

Symmetrical range of motion without any
MUSCULOSKELET
AL difficulty
Normal muscle tone. Grade 5/5 muscle
strength
 N T S
I E RE
A L U
S A T
F E
HISTORY
41 years old Ultrasound result
Female (October 2016):
Moderately distended
Persistent
gallbladder, medium
abdominal pain
level echoes
Cramping, colicky
intraluminally
Epigastric, right upper
measuring 17mm,
quadrant pain radiating
intact gallbladder wall
to the right flank
Associated with nausea Family history of
and vomiting, loss of gallstone (mother)
appetite
PHYSICAL EXAM
Abdomen
Epigastric and right
upper quadrant
tenderness upon
palpation
(+) Murphys sign No jaundice,
Negative Cullens and anicteric sclera
Grey Turners Sign
No Psoas, Obturator,
BMI: 30.3 (Obese)
Rovsings Sign
No fluid shift
No CVA tenderness
 N G
K I
R N
O O
W SI
RY S
A RE
I M P
PR I M
CHOLECYSTOLITHIAS
IS
 AL
T I
N E S
R E S
E N O
F
IF IAG
D D
 ACUTE PANCREATITIS
MOST LIKELY LESS LIKELY
Can be caused by: (-) >3x elevation of pancreatic
Gallstones enzymes
Alcohol (-) Cullens sign
Hyperlipidemia (-) Grey turner sign

3rd to 4th decade alcohol and drug

induced 6th decade gallstone and trauma

Females gallstones

Patient manifestation
Epigastric pain radiating to the
right upper quadrant to the
right flank area, cramping, 7/10
Others: undocumented fever,
vomiting, nausea, loss of
appetite
 ACID PEPTIC DISEASE
MOST LIKELY
Abdominal pain aggravated by
food intake
Smoking history is a
contributory factor doubling
the risk in developing PUD.
Increases gastric acid
secretion and
duodenogastric reflux.
LEAST LIKELY
The patient stopped smoking 6
months PTC.
Patient had no prior history of
chronic NSAID use
No laboratory workup to
support H. pylori infection
 HYDROPS OF THE GALLBLADDER

MORE LIKELY LESS LIKELY

RUQ and Epigastric Pain Unremitting pain

Nausea and Vomiting Undocumented fever
Distended Gallbladder
17mm Intraluminal Echoes
 IC
S T
NO
G
IA
D
S
WHOLE ABDOMEN ULTRASOUND REPORT
The liver is normal in size with homogenous parenchymal
echopatern. The intrahepatic ducts and common duct are
intact. The hepatic borders are smooth.

The gallbladder is moderately distended with note of medium

level echoes sen intraluminally measuring 17 mm. The
gallbladder wall is intact.

The pancreas is normal in size with homogenous echopattern.

The spleen is normal in size with homogenous echopattern.

Both kidneys are normal in size with the right kidney

measuring 96 mm x 46 mm x 39 m while the left kidney
measures 98 mm x 43 mm x 44 mm. The parenchymal
echopattern is homogenous with no solid masses or cystic
foci. The collecting systems are not dilated with lithiasis
noted.

October 2016
 The ureters and urinary bladder are unremarkable .

The uterus is normal in size measuring 49 mm x 29 mm x

27 mm with homogenous echopattern. he endometrial
stripe is intact measuring 7 mm. The adnexae is
unremarkable.

REMARKS:
CHOLELITHIASIS

Normal liver, pancreas and spleen

Normal kidneys and urinary bladder
Normal uterus, negative adnexae
CHEST XRAY PA/AP
Chest examination shows clear lungs.
There is blunting of the right lateral
costophrenic sulcus.
Heart is enlarged with left ventricular
prominence.
Aorta is unremarkable.
Other chest structures are
unremarkable.
CHEST XRAY PA/AP

IMPRESSION:
Clear lungs.
Cardiomegaly with left ventricular
configuration.
COMPLETE BLOOD COUNT
04/03/2017
EXAMINATION RESULT NORMAL INTERPRETATIO
REFERENCE N
VALUE
RBC Count 4.7 4.2-5.4 Normal

Hemoglobin 133 120-160 Normal

Hematocrit 0.40 0.36-0.47 Normal

WBC 8.5 5-10 Normal

Neutrophils 0.49 0.50-0.70 Decrease
Lymphocytes 0.39 0.20-0.50 Normal
Eosinophils 0.03 0.00-0.06 Normal
Platelet 382 150-450 Normal
BLOOD CHEMISTRY
04/03/ 2017
EXAMINATION RESULT NORMAL INTERPRETATIO
REFERENCE N
VALUE
BUN 3.20 2.5-6.4 mmol/L Normal
Creatinine 62.37 62.0-115.0 Normal
umol/L
Sodium 141.00 136-145 Normal
mmol/L
Potassium 4.00 3.5-5.1 mmol/L Normal
Chloride 104 97-107 mmol/L Normal
COAGULATION REPORT

04/03/2017
EXAMINATION RESULT NORMAL INTERPRETATI
REFERENCE ON
VALUE
PT Patient 11.5 11.8-14.6 Decrease
seconds d
PT Control 13.0 10-14 Normal
seconds
% Activity 132%
INR 0.86 0.80-1.20 Normal
PTT Patient 29.4 26.00- Normal
37.00
PTT Control 32.6 25-33
seconds
HEMOGLOBIN A1C AND FBS

04/19/2017
EXAMINATION RESULT NORMAL INTERPRETATI
REFERENCE ON
VALUE
Hemoglobi 6 % 4.8-6.2 Normal
n A1C
FBS 6.02 4.1-5.9 Increased
OTHER DIAGNOSTIC WORK-UPS
Total bilirubin (Direct, Indirect)
Alkaline phosphatase
MRCP
Endoscopic cholangiography
 E D
A S T
B EN
E M M
L E
B AG
R O N
P MA
PRE-OPERATIVE Problem
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN #1
COMMENT
Epigastric pain Pain Scale: 5/10 Cholelcystitis/ Pain It blocks the
- Cramping in Cholelithiasis medication IV muscarinic
character Ultrasound result: Hyoscine-N- receptors on the
- Noticed right - Moderately butylbromide smooth muscle
upper distended or HNBB walls, blocking
quadrant pain gallbladder, (Buscopan) the action of
after eating medium level acetylcholine on
oily food with echoes the smooth
pain radiating intraluminally muscle of the
to the right measuring 17mm, gastrointestinal
flank intact gallbladder and urinary tract
wall and thus reduces
the spasms and
contractions. This
relaxes the
muscle and thus
reduced the pain
from the cramps
and spasms.
MIMS Phils
2016
PRE-OPERATIVE Proble
m #2
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN COMMENT
- Insidious, Pain Scale: 7/10 Acute Laparoscopic Patients with
progressive, Blood Pressure: Cholecystitis cholecystecto symptomatic
right upper 130/80 my gallstones should
quadrant for 7 Heart Rate: 106 be
months bpm advised to have
- Described as Resp Rate: 20 elective
colicky, cpm laparoscopic
radiating to Temperature: 37.0 cholecystectomy.
the right flank Degree Celsius
- Associated O2 Saturation: Cholecystectomy
with 98% is the definitive
undocumented Height: 411 treatment for
fever, Weight: 68.2 Kg acute
vomiting, BMI: 30.3 (Obese) cholecystitis and
nausea, loss of Abdominal laparoscopic
appetite, one Examination: cholecystectomy
episode of - Tender on is the procedure
non-billous deep palpation of choice.
vomiting on epigastric Early
region and management
right upper within 2-3 days is
quadrant preferred.
- (+) Murphys - Schwartz 10th
Sign ed
PRE-OPERATIVE Proble
m #2
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN COMMENT
- Insidious, Pain Scale: 7/10 Acute IV Fluids Fluid therapy
progressive, Blood Pressure: Cholecystitis - Plain LR restores and
right upper 130/80 solution 1L maintains
quadrant for 7 Heart Rate: 106 circulating blood
months bpm Antibiotics volume that
- Described as Resp Rate: 20 - Cefuroxime occurs from
colicky, cpm 750mg IV vomiting, reduced
radiating to Temperature: 37.0 oral intake, third
the right flank Degree Celsius Analgesic and spacing of fluids,
- Associated O2 Saturation: antipyretic increased
with 98% - Paracetamol respiratory losses,
undocumented Height: 411 1g IV every 8 and diaphoresis.
fever, Weight: 68.2 Kg hrs
vomiting, BMI: 30.3 (Obese)
nausea, loss of Abdominal Pain
appetite, one Examination: management - Schwartz 10th
episode of - Tender on - Ketorolac ed
non-billous deep palpation 30mg IV
vomiting on epigastric every 8 hrs
region and - HNBB
right upper
quadrant
- (+) Murphys
Sign
PATIENTS INDICATION FOR
SURGICAL MANAGEMENT

Symptomatic pain/biliary colic

Gallbladder stone in her ultrasound

Presentation of Acute Cholecystitis

PATIENTS INDICATION FOR
SURGICAL MANAGEMENT

Symptomatic

- pain/biliary colic

Diabetic patients with symptomatic gallstones

- More prone to develop acute cholecystitis and often severe

Pregnant women with symptomatic gallstones

- Safe to undergo laparoscopic cholecystectomy: 2nd semester

 INTRA-OPERATIVE

From initial plan

of
laparoscopic
cholecystectom
y there was
conversion to
open
cholecystectom
y
 INTRA-OPERATIVE

4x2 cm gallbladder
with walls of
whitish fluid inside
is a solitary 2x1 cm
intraluminal stone
Dense adhesions
on umbilical and
hypogastric area.

https://www.google.com.ph/search?
q=open+cholecystectomy+procedure&rlz=1C1RLNS_e
 Proble
POST-OPERATIVE m #1
SUBJECTIVE OBJECTIVE ASSESSME PLAN COMMENT
NT
S/p Open -Monitor vital Empyema IVF: D5LR Replaced
Cholecystecto signs of the 1L x 8 fluids
my gallbladder hours
- Check RBC, with
Hemoglobin and cholecystolit LSLF diet The purpose
Hematocrit hiasis of a low-salt,
low-fat and
low-
cholesterol
diet, is to
reduce the
amount of
cholesterol in
your blood
and also to
prevent fluid
retention.
 Proble
POST-OPERATIVE m #1
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN COMMENT
S/p Open - Monitor vital Empyema of Medication The antibiotics
Cholecystectom signs the gallbladder s: should
y with - Paracetam cover gram-
- Check RBC, cholecystolithi ol 1g IV 3 negative
Hemoglobin and asis doses aerobes as well
Hematocrit - Nalbuphine as anaerobes. A
10mg IV 6 thirdgeneration
doses cephalosporin
- Cefuroxime with good
750mg IV 3 anaerobic
doses coverage or a
- Metronidaz second-
ole 500 mg generation
IV 3 doses cephalosporin
IV 3 doses combined with
- Cefoxitin metronidazole
1g is a typical
- Ketorolac regimen.
30 mg IV 3
doses
Regular - Schwartz
wound 10th ed
cleaning
and
dressing
 N
S IO S
IS

S
IA
H
IT

U
L
O
T

C
S
Y
C
E

IS
L
O
H
C

D
GALLBLADDER ANATOMY
7 10 cm long pear-shaped sac
Capacity of 30 50 mL
Located at the inferior surface of the liver
Divided into four anatomic areas
Fundus
Corpus
Infundibulum (Hartmanns Pouch)
Neck
GALLBLADDER ANATOMY
Simple columnar epithelium
Tubuloalveolar glands
Infundibulum and neck
Secretes mucus
GALLBLADDER ANATOMY:
LAYERS
Mucosa
Lamina propria
Tunica muscularis
Circular longitudinal fibers
Oblique fibers
Subserosa
Serosa
GALLBLADDER ANATOMY:
BLOOD SUPPLY
Right Hepatic Artery -> Cystic Artery

Triangle of Calot
Cystic duct
Common hepatic duct
Liver margin
RISK FACTORS FOR
CHOLECYSTOLITHIASIS
Gallstone formation
Cholesterol stones high cholesterol levels
Pigment stones
Black hemolytic disorders
Brown bacterial infections
 RISK FACTORS FOR
CHOLECYSTOLITHIASIS
Cholesterol Stone Formation
Previous smoking history
Chronic hypertension
Ultrasonographic evidence

Brown Pigment Stone Formation

Undocumented fever suggestive of ongoing
infection
Ultrasonographic evidence
RISK FACTORS FOR
CHOLECYSTOLITHIASIS

44 y/o
Femal Age/G
e
ender
Family Social
Histor Histor
y y
Gallstones 2- Smoker
fold greater, Alcohol
(mother) Drinker
Possible DM BMI of 30.3
SYMPTOMS SUGGESTIVE OF CHOLECYSTOLITHIASIS

RUQ pain after eating oily foods

Pain radiating to the right flank
Undocumented fever
Vomiting
PHYSICAL EXAMINATION FINDINGS SUGGESTIVE OF CHOLECYSTITIS

Tender on deep palpation at RUQ and

epigastric area
(+) Murphys Sign
(-) Cullens and Grey Turners Signs
(-) Psoas, Obturator, Rovsings Signs
(-) Fluid shift
(-) CVA tenderness
PATHOPHYSIOLOGY

Cholecystolithiasi
Stone Formers,
Creation of s,
Estrogenic State,
Gallstones Choledocholithias
Cholesterol
is

Risk Ultrasound findings of RUQ pain aggravated by oily/fatty food

Factor moderately distended GB w/ intake
s 17mm medium level Colicky
intraluminal echoes Radiates to the right flank
Fever, nausea, vomiting, loss of
appetite
OPERATIVE PROCEDURE
Laparoscopic Cholecystectomy converted
to Open Cholecystectomy
The most common reason for conversion were
severe adhesions caused by tissue
inflammation (Genc et. al.)

Intra-operative Finding
4x7 cm gallbladder, thickened wall with
whitish fluid inside. Solitary 2x1 cm
intraluminal stone. Dense adhesions on
umbilical and hypogastric area
POST-OPERATIVE DIAGNOSIS

Empyema of the
Gallbladder,
Cholecystolithiasis
POST-OPERATIVE MANAGEMENT
Home Medications
Cefuroxime 500mg tab BID for 7 days
Metronidazole 500mg tab TID for 7 days
Tramadol + Paracetamol tab TID
Celecoxib 200mg tab BID

Health Teachings
Daily wound care
 A L
R N
U
JO
 JOURNAL TITLE

Open versus
laparoscopic
cholecystectomy in
acute cholecystitis.
Systematic review and
meta-analysis
AUTHORS:
Coccolini et. al.

SOURCE: https://www. Journal-surgery.net

OPEN VERSUS LAPAROSCOPIC CHOLECYSTECTOMY
IN ACUTE CHOLECYSTITIS. SYSTEMATIC REVIEW
AND META-ANALYSIS

P- In patients with cholelithiasis

I- Laparoscopic cholecystectomy
C- Open cholecystectomy
O- Morbidity, mortality
M- Meta-analysis
JOURNAL ARTICLE
Post-operatively
Morbidity was half with LC (OR = 0.46)
Wound infection and pneumonia rates
decreased in LC (0.54, 0.51)
Mortality rate reduced with LC (0.2)
Mean hospital stay shortened with LC (-4.74
days)

No significant differences in leakage rate,

blood loss, operation time
REFERENCES
[1] Genc, V., Sulaimanov, M., Cipe, G., Basceken, S. I.,
Erverdi, N., Gurel, M., Hazinedaroglu, S. M. (2011).
What necessitates the conversion to open
cholecystectomy? A retrospective analysis of 5164
consecutive laparoscopic operations. Clinics, 66(3),
417420. http://doi.org/10.1590/S1807-
59322011000300009

Schwartz Principles of Surgery, 10th Edition

THANK YOU!