5. Explain the differential diagnosis of the scenario?

CHOLELITHIASIS
Gallstone disease (cholelithiasis) are commonly found inthe gallbladder, but they can
migrate through the cystic duct into the bile duct into a bile duct stone and are called as
secondary bile duct stones D1
Clinical Symtomps Causes
• The right upper or epigastric • Bile stasis gallbladder stone (90%)
stomach colic. • Bacterial infections
• Tenderness and increase in body • Gallbladder wall ischemia.
temperature. • Bile density
• Sometimes the pain radiates to • Cholesterol
the right shoulder or scapula • Lysolesitin
and can last up to 60 minutes
without subsiding.
Pathogenesis

• Cholesterol hypersaturation in the gall bladder

• Acceleration of crystallization of cholesterol
• Gall motility and intestinal motility disorders
• The presence of pigments in cholesterol stone nuclei associated with gallbladder mud
in the early stages of formation stone
• B-glucuronidase enzymes (endogenous) by these enzymes will form non bilirubin
conjugated which will precipitate calcium bilirubinate
• The p-enzyme comes from the germ E coli and other germs in the bile glucuronidase
bacteria. This enzyme can be inhibited by glucaro, whose concentration increases in
patients with low protein and low fat

Ref : Sudoyo, Aru W. et al. Internal medicine textbook. Volume II Edition VI. Jakarta: International
Publishing Center for Internal Medicine Publishing. Pages 2022-2025
 CHOLANGITIS

Definition
Acute cholangitis is a morbid condition with
acute inflammation and infection in the bile duct.

Causes and Symptoms

• Obstruction to bile flow
• Presence of bacteria within the bile ducts
• Abdominal pain
• Fever
• Jaundice
Pathophysiology

The onset of acute cholangitis involves two factors:

1. Increased bacteria in the bile duct
2. Elevated intra-ductal pressure in the bile duct allowing translocation
ofbacteria or endotoxin into the vascular and lymphatic system (cholangio-
venous/lymphatic reflux).

In acute cholangitis, bile ductules tend to become more permeable to the

translocation of bacteria and toxins with the elevated intraductal biliary
pressure. This process results in serious and fatal infections such as hepatic
abscess and sepsis.

Figure 1. Flow of management of acute cholangitis according to Tokyo Guidline 2013].

https://medical-dictionary.thefreedictionary.com/cholangitis
 CHOLECYSTITIS
Acute cholecystitis
Acute inflammatory reaction of the
gallbladder wall accompanied by
complaints of right upper abdominal
pain, tenderness, and fever.
Clinical Symtomps
• The right upper or epigastric stomach
colic.
• Tenderness and increase in body
temperature.
• Sometimes the pain radiates to the right
shoulder or scapula and can last up to 60
minutes without subsiding.
Chronic cholecystitis
Chronic cholecystitis is more
common in clinical settings, and is
very closely related to litiasis and
more often arises slowly
Clinical Symtomps
• Dyspepsia
• Full feeling in the epigastrium
• Nausea after eating high-fat foods, which
sometimes disappear after belching.
• History of gallstones in the family
• Recurrent jaundice and colic
• Local pain in the gallbladder area with
positive Murphy signs
Pathogenesis
• Gallbladder stone (90%) located in the cystic duct which causes static bile
• Bile density,cholesterol, lysolesitin and many prostaglandins damage the
mucous lining of the gallbladder wall followed by inflammatory reactions and
suppuration
• Acute calculus acute cholecystitis can occur in patients who are treated long
enough and receive nutrition parenterally
• Stones in the bile duct or is one of the complications of other diseases such as
typhoid fever and diabetes mellitus.

Ref : Sudoyo, Aru W. et al. Internal medicine textbook. Volume II Edition VI. Jakarta: International
Publishing Center for Internal Medicine Publishing. Page 479-480
 CHOLELITHIASIS
• dyspepsia which is sometimes accompanied by
intolerance to fatty foods.
• pain in the epigastric or pain / colic in the
right upper abdomen or pericondrium (15
minutes-hour)and increase when breathing
Anamnesis
deeply
• yellow eyes and body, body itching, colored
urine like tea, colored stools such as putty and
the spread of pain in the middle back,
scapula, or shoulder peak, accompanied by
nausea and vomiting.
• the patient will experience tenderness with
maximum punktum in the area of the anatomy
Physical of the gallbladder
examination • Murphy sign (+)
• History of jaundice and cutaneous jaundice
and sclera
CHOLANGITIS CHOLECYSTITIS
Severe pain in your upper right
Previous biliary disorder
or center abdomen, Pain that
cholangitis are asymptomatic.
spreads to your right shoulder
Jaundice Fever, chills, and
or back, Tenderness over your
rigors,Abdominal pain, Pruritus,
abdomen when it's
Acholic or hypocholic stools,
touched,Nausea, Vomiting,
Malaise
Fever.
Fever (90%), although elderly
patients may have no fever,
RUQ tenderness (65%), Mild
hepatomegaly, Jaundice
(60%),Mental status changes
(10-20%) Sepsis,Hypotension
(30%),Tachycardia, Peritonitis
(uncommon, and should lead to
a search for an alternative
diagnosis)
 CHOLELITHIASIS CHOLANGITIS CHOLECYSTITIS

Broad-spectrum antibiotics
are usually used
complete rest, parenteral
Laparoscopic cholecystectomy is a Endoscopic, radiographic
nutrition, a mild diet,
minimally invasive surgical technique in and other techniques have
painkillers such as
the abdominal cavity using a made it possible to
pethidine and
Treatment pneumoperitoneum, endocamera system successfully remove stones
antispasmodics, antibiotic
and special instruments through the and dilate strictures that
ampicillin, cephalosporins
monitor screen without seeing and previously required
and metronidazole
touching the gallbladder directly. surgical intervention, often
with high morbidity and
mortality.