Refleksi kasus radiologi

Joovan Naaidu
09/280488/KU/13459
24 Oktober 2014

Identitas

Nama: Ny. P
Umur: 37thn
Jenis Kelamin: Perempuan
Alamat: Kapulogo Tengah RT, Jawa tengah
No.RM: 0170xxxx

Keluhan utama
Nyeri di ulu hati menjalar ke punggung

Riwayat penyakit sekarang (RPS)

3 BSMRS, mengeluh nyeri di perut kanan atas lalu pasien ke
Puskesmas D dan di beri obat, tetapi nyeri masih menetap.
1MSMRS, os ke RS Wonosari dengan keluhan sama lalu di rujuk ke
RSUP sardjito
HMRS os ke RSUP Sardjito dengan nyeri perut kanan mejalar ke
punggung lalu di lakukan pemeriksaan USG.

Riwayat Penyakit Dahulu

Demam (-), Mual(-), Muntah(-), Riwayat kuning(-)

Riwayat Penyakit Keluarga

Penyakit serupa disangkal
DM (-)
HT(-)

Pemeriksaan fisik
Vital signs: TD: 120/80
Suhu: 36,5

Nadi: 84x/menit

Respirasi: 20x/menit

KU: CM, Sedang

Kepala: CA (-), SI (-)
Leher: Limf ttb
Thorax: I : Normal, KG ( - )
P : Sonor
A : Vesikuler, Rh -/-, Wheezing -/Abdomen: I : Normal
A: BU( + ), Peristaltik normal
P : Tympani ( + )
P : Murphy sign ( + ) , RUQ pain
Extremitas : Akral hangat, Nadi kuat

Cor: S1-S2 reg, Bising ( - )

Diagnosis:
- Cholelithiasis

Pemeriksaan penunjang: Lab

WBC: 10.3

NEU%: 51.8
LY%: 28.7
MO%: 8.3
EO%: 3.0
BA%: 0.2

RBC: 6.34
HGB: 12.6
HCT: 41.4

Albumin: 3,50

SGOT: 12

SGPT: 10

HBsAg: Non reaktif

Bilirubin Total: 0.2mg/dl

Bilirubin direk: 0.1mg/dl

Na: 141mmol/L

Kalium: 3.80mmol/L

Klorida: 106mmol/L

Gol darah: B+

Pemeriksaan penunjang radiologi apakah yang

akan anda pesan?
USG
Foto thorax polos

Foto thorax PA view

Posisi erect
Simetris
Inspirasi and kondisi cukup, hasil;
-Tampak kedua apex pulmo
tenang
-Tampak corakan bronchovascular
normal
-Tampak kedua diafragma licin
dan tak mendatar
-Cor., CTR = 0.49
-Sisitem tulang yang
tervisualisasi intact
Kesan :
-Pulmo tak tampak kelainan
-Besar cor normal

Hasil
USG : Keterengan Klinis : Cholelithiasis
: Hasil
: Hepar : Ukuran dan echostrukture normal, permukaan licin, sistem milier dan vascular
intrahepatal tak prominen, tak tampak massa/nodul
: Vesica Felea : Ukuran normal, dinding tak tampak menebal, tak tampak massa maupun
sledge. Tampak lesi hiperechoic dengan posterior acoustic shadow ( +), bentuk bulat, batas
tegas, ukuran lk. 0.75cm
: Lien : Ukuran dan echostruktur normal, tak tampak massa/nodul, hilus lienalis tak prominen
: Pancreas : Ukuran dan echostruktur normal, tak tampak massa maupun kalsifikasi, ductus
pancreaticus tak prominen.
: Ren Dextra : Ukuran dan echostruktur normal, batas cortex dan medulla tegas, Tak tampak
massa/batu.
: Ren sinistra : Ukuran dan echostruktur normal, batas cortex dan medulla tegas, Tak tampak
massa/batu.
Vesica urinaria : Terisi cairan, dinding tampak reguler tak menebal, tak tampak batu maupun
massa.

Position of Gallbladder Sonography

-First Position
High/Lateral view
Looking through Ribs Probe Angled
More Ant Than for FAST exam
-Second Position:
Subcostal view with patient rolled
to left Lateral Decubitus

Cholelithiasis
Cholelithiasis involves the presence of gallstones, which are
concretions that form in the biliary tract, usually in the gallbladder.

Anatomy of gallbladder and extrahepatic

biliary tree
Bile
Helps the body digest fats
Made in the liver
Stored in the gallbladder until the body needs
it
Contains:
Water
Cholesterol
Bile pigments
Phospholipids
Concentrations vary - different kinds of stones
may be formed

Pigment stones

Cholesterol stones

Mixed stones
Multiple
Faceted
Consist of:
Calcium salts
Pigment
Cholesterol (30% - 70%)

80% - associated with chronic cholecystitis

Symptoms
Pain in the RUQ
Most common and typical symptom
May last for a few minutes to several hours
Mostly felt after eating a heavy and high-fat meal

Pain under right shoulder when lifting up arms

Fever, nausea and vomiting
Jaundice (obstruction of the bile duct passage)

Diagnosis
Ultrasound

Most sensitive and specific test for gallstones

Computerized tomography (CT) scan

May show gallstones or complications, such as

infection and rupture of GB or bile ducts

Cholescintigraphy (HIDA scan)

Used to diagnose abnormal contraction of

gallbladder or obstruction of bile ducts

Endoscopic retrograde
cholangiopancreatography (ERCP)

Used to locate and remove stones in bile ducts

Blood tests

Performed to look for signs of infection,

obstruction, pancreatitis, or jaundice

USG

HIDA Scan

Treatment
Surgery: Cholecystectomy (gallbladder
removal)
Indications:

Those with large (>2 cm) gallstones

Those who have a nonfunctional or calcified
(porcelain) gallbladder on imaging studies and who
are at high risk of gallbladder carcinoma
Those with spinal cord injuries or sensory
neuropathies affecting the abdomen
Those with sickle cell anemia in whom the distinction
between painful crisis and cholecystitis may be
difficult

Two surgical options

Open cholecystectomy
Laparoscopic cholecystectomy

 Nonsurgical treatment:
Only in special situations
When a patient has a serious medical condition preventing surgery
Only for cholesterol stones

Oral dissolution therapy

Contact dissolution therapy