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Middle-aged Stoner A Case DiscussionRyan Em C. DalmanMD MBA - 070070February 11, 2010

ObjectivesPresent a case of CholelithiasisHistory and Physical ExamDifferentialsDiagnostics Discuss its basic concepts of management

Case PresentationPatient History

General DataEI63-year-oldFemaleBorn on May 22, 1947Roman CatholicInformant: Patient, good reliability

Chief ComplaintMasakit ang tiyan(abdominal pain)

History of Present IllnessAbdominal pain, RUQMostly felt after eating oily/fatty food, took pain killers with partial reliefIntermittent and described as crampyNo radiationPain 5/10No yellowing of skin, no nausea, no vomiting, no fever, no blood in stool, no history of traumaSought consultDiagnosed with cholelithiasis and liver cirrhosis via ultrasound and CTDischarged with pain and other unrecalled medicationsSymptoms resolved

3 years PTANo recurrence of symptoms6History of Present IllnessRUQ pain 10/10Sudden, episodic, sharp and crampyAfter eating oily/fatty food Fever, undocumentedYellowing of skinVomiting 1x Non-projectile, non-bloody, non-bilous Tea colored urine No radiationConsult at a local clinic, given pain medications and was dischargedNo nausea, no fever, no acholic stool, no change in bowel movement

1 month PTAConsultSymptoms persisted7Review of SystemsGeneral: no weight loss, no change in appetiteCutaneous: no lesions,no pruritusHEENT: with occasional headaches no rednessno aural/nasal dischargeno neck massesno sore throatCardiovascular: no easy fatigability, fainting spells, no palpitation Respiratory:no cough, coldsGenitourinary: no pain in urination, no genital dischargeEndocrine: no polyuria, polydypsia, no heat/cold intoleranceMuskuloskeletal: no weakness, numbness on all extremities Hematopoietic: no easy bruisability, or bleeding

8Past Medical HistoryNo Hypertension No Diabetes, AsthmaNo Cancer, Allergies

Liver cirrhosis, probably 2o to schistosomiasis (2008)Previously treated for PTB

s/p BTL

Not taking any maintenance medications

Family HistoryHistory hypertensionNo heart disease, cancer, stroke, diabetes, asthma, or allergiesPersonal and Social HistoryOwns a small businessUsed to dwell in the rice fields as a kidLives with her familyNon-smokerOccasional alcoholic beverage drinkerNo substance abuseCase PresentationPhysical ExamPhysical Exam (ER)Icteric sclerae

AbdomenFlabbyDirect tenderness RUQNo murphys signNo rebound tendernessPhysical Exam (floors)General SurveyAwake, coherent, and not in cardiorespiratory distressVital Signsfebrile at 37.9oC 130/80RR 20 bpmHR 71 bpmHeight:162cm weight:53kg BMI: 20.2Physical ExamSkinJaundicedNo rashes, hemorrhages, scarsMoistCRT 1-2 secondsHEENTHeadno lesionsEyesicteric sclerae, pink palpebral conjunctivapupils 2-3mmEarsno discharge, tendernessNoseseptum medline, moist mucosaThroatmouth and tongue moistno TPCChest and LungsNeck no cervical lymphadonapathyno nuchal rigidity Chestadynamic precordiumno heaves, thrills, or lifts, PMI at 5th ICS MCLregular rate, normal rhythmno murmursLungssymmetrical chest expansion, no retractionsclear breath soundsAbdomen/ Perineum Abdomenflat, no scars, no lesionsnormoactive bowel soundstympanitic on all quadrantsdirect tenderness on the RUQno Murphys signno rebound tendernessno masses, no organomegallyno psoas, obturator, and Rovsings sign

Salient FeaturesHistory63 year old femaleDiagnosed with cholelithiasis and liver cirrhosis via ultrasound and CT, 3 yearsRUQ pain of 1 month VomitingFever, undocumentedTea-colored urine No history of trauma

Physical ExamJaundiced skinIcteric scleraeRUQ tendernessFebrile at 37.9oC

Case DiscussionPrimary ImpressionAcute calculous cholecystitisLiver cirrhosis probably 2o schistosomiasis

Differentials CholangitisMalignancy (biliary, pancreatic, ampullary)Pancreatitis Appendicitis Duodenal ulcerDiverticulitis

Acute Cholecystitis Inflammation of the gallbladder 95% caused by gallbladder stonesBegins suddenly as stones block the cystic duct

CholelithiasisPresence of 1 or more calculi in the gallbladder1 in 17 (5.88%) or 16 million people in USAPrevalence lower in Asians60 years and above: men (12.9%) women (22.4%)

EtiologyCholesterol stones - > 85%Black pigment stonesBrown Pigment stonesMixed Risk FactorsFemale, Fat, Fertile, FortyPregnancyOral contraceptivesHyperlipidemiaTotal parenteral nutritionPathophysiology Imbalance or change in composition of bile!

Supersaturationcrystallizationstone formation

Gallbladder sludge... (acalculous cholecystitis)Diagnostics/WorkupSerumCBCLiver function testBilirubinLipaseAmylase Diagnostics/WorkupPlain abdominal film10-15% of cholesterol50% of pigment stonesUltrasonographyAs small as 2mm can be confidently identifiedOral cholecystography (OCG)Used to assess patency of cystic duct and gallbladder emptying functionReplaced by US29Diagnostics/WorkupCT scansSimilar findings as in ultrasoundTo further characterize complicationsGood for detection of intrahepatic stones or recurrent pyogenic cholangitisEndoscopic retrograde cholangiopancreatography (ERCP)Common hepatic ductCommon bile ductPancreatic ductManagementWho can undergo surgery?Symptoms that affect patients daily activitesPresence of prior complication of gallstone disease Underlying condition predisposing patient to increased risk of gallstone complicationProphylactic cholecystectomy > 3cm stonesManagementLaparoscopic CholecystectomyShortened hospital stayComplications 4%Conversion to laparotomy 5%Death