ASSALAMUALAIKUM

Member of 2

nd

Group

Badiatul khilqo6130014011
Claudia Narinda 6130014012
Dinda Mutiara Sukma6130014013
Maimunah Faizin 6130014014
Elsa Kusumawati 6130014015
Nuris Umi Rizqi 6130014016
Hessty Rochendah Onjiah 6130014017
Sri Safariawati M. A. Afif6130014018
Luthfi Kalindra 6130014019
Aanisa Ikbar6130014020

Scenario
You are a health care worker who was on duty at the IRD get a Ny.S patient, 45
years old, came with complaints of pain in the right upper abdomen.
Disease History Now:
Patients complain of pain in the right upper abdomen accompanied by body
heat since two days ago. Pain accompanied by nausea and vomiting. Pain
accompanied by BAK yellow color as dark as tea and BAB white as putty. Body
color becomes yellowish since approximately one week ago.
Past medical history :
Pain in the upper right abdomen felt by patients since one year ago. Pain is felt
through to the rear and is preceded by nausea, especially a few hours after
eating fatty foods, but the pain at that time can be reduced with anti-pain
medication.
There is no previous history of jaundice.
Physical examination :
General appearance: weak, GCS 456, RR 28 times per minute, t 38,4oC, blood
pressure of 100/60 mmHg BMI obesity
Head / neck: icterus +
Abdomen: abdominal pain in the right upper quadrant deep inspiration +

Laboratory examination:
Hb 13.0 g / dL (12.5 to 15.3)
WBC 16,500 / mm3 (4400-11300)
Total bilirubin 5.6 mg% (<1.0)
Direct bilirubin 3.8 mg% (<0.2)
Alkaline phosphatase was 642 IU / L (<104)
Amylase 1245 IU / L (<100)
Lipase 500 IU / L (<190)
AST 24 IU / L (<32)
ALT 56 IU / L (<31)
GT 150 IU / L (<39)
Urine analysis: dark yellow color, Bil +2, +2 uro
Radiological examination:
USG Abdomen:
Dilatation of the gallbladder with thickening of the gallbladder
wall and multiple stones. Looks stones in the distal common bile
duct, with dilatation of the bile duct.

Key Word
Murphy's sign
Lekositosis
The post-hepatic
obstruction
CHAPTER white as
putty
Consistency of feses
dark yellow like tea
Pancreatitis acute
Dilatation gallbladder
+ multiple stones

Dilatation of the cystic

duct
RR = 28 beats per
minute
T = 38,4oC
BMI = obesity
SGOT and SGPT
increased
4F (Fat, Female, fourty
and Family)
Weak

MIND MAPPING

LEARNING OBJECTIVE
1.
2.
3.
4.
5.
6.
7.
8.
9.

analysis of case scenarios

explain diagnosis of case scenarios
the differential diagnosis of case scenarios
etiopathogenesis of case scenarios
pathophysiology of case scenarios
the clinical manifestation of case scenarios
the risk factors of case scenarios
the management of case scenarios
the complications that may arise in case
scenarios

TPL

PPL

ANAMNESA :

Colic Pain

Physical examination:

Nausea and vomit

Laboratory

Intolerance fat

Jaundice

Clay-colored bilirubinemia

cholangitis (found on the case)

There

examination
Radiological
examination:

Assessment

Planning Dx

kolelitiasis

1.

X- ray

2.

Kolangiogram

kolangiografi

transhepatik percutan
3. ERCP ( Endoscopic Retrograde
Cholangio Pancreatographi)

are

multiple

stones.

Looks

stones in the distal common bile

duct, with dilatation of the bile duct.

Murphys sign

Nausea & vomit

Ikterus

Febris

Leukositosis

Dilatasi

kantong

penebalan
empedu
Febris

Nausea and vomit

Pain colic
leukocytosis

1.

Tes darah untuk memeriksa adanya

indikasi-indikasi

inflamasi

atau

infeksi.

empedu

2.

USG atau CT scan

1.

Blood tests to determine the levels

dengan

pada dinding kantong

kolesistitis

Pankreatitis acute

of pancreatic amylase and lipase.

2.

Scanning

procedures

using

ultrasound, CT scan, and MRI.

3.

Endoscopic pancreas (ERCP), the

method of inspection using special

Cholelithiasis (gall stones)

Cholelithiasis is the formation of stones in the gall
bladder. Gall bladder stones is a combination of
several elements that make up a rock-like material
that form inside the gallbladder. Gallstones that
obstruct bile ducts will make the gallbladder stretch,
so that the flow of blood and lymph to be changed,
there was a lack of oxygen and tissue death bile.
Then diagnosis of patients with cholelithiasis can be
accompanied
with
acute
cholecystitis
and
pancreatitis.

DIFFERENTIAL DIAGNOSE
Diferential Diagnose

Clinical findings

Continued Examination Findings

Acute cholangitis

Classic findings are fever and chills, jaundice

and abdominal pain (Charcot's
triad). Approximately 50% to 70% of
patients with cholangitis develop all three
symptoms.

MRI: intraductal purulent material with low signal

intensity on T2-weighted images weight and / or
intermediate signal intensity images T1-weighted fat
suppressed.

Chronic cholecystitis

mild attack or recurrent attacks of chronic

irritation with large gallstone

There is no special investigation.

mucosal atrophy and fibrosis of the gallbladder wall in
the postoperative specimen.

Peptic ulcer

Burning epigastric pain that occurs several

hours after eating or starvation.Often
waking the patient at night. Pain improved
by eating.
Epigastric or periumbilical abdominal pain
that radiates to the back.

Endoscopy can reveal a peptic ulcer.

appendicitis

The pain is usually located in the right iliac

fossa but may begin in the periumbilical
region.

CT scan of the abdomen: dilated appendix with

thickened, wall murals hyperenhancing and
stratification of the appendix.

Acute Coronary Heart Disease

Usually the central chest pain, squeezing in

nature, radiation to the jaw or left arm. Pain
can be felt in the epigastric.
Perhaps the history of angina and the risk
factors for CAD (eg, smoking, hypertension,
diabetes mellitus, obesity).

ischemic changes on the ECG (ST elevation or

depression, T-wave inversion, left bundle-branch block).

Hepatitis

Fever
fatigue
Loss of appetite Nausea
Gag
abdominal pain
jaundice

IgM anti-HAV (Hepatitis B)

HBsAg in acute and chronic infections (hepatitis B)
IgM anti-HBc positive acute infection (Hepatitis B)

Acute pancreatitis

Three times that of amylase. An inflammation of the

pancreas on abdominal CT.

Pathogenesis formation of Gallstones

In women who use hormonal contraceptives, the
formation of gallstones due to an increase biliary
cholesterol saturation. Obesity is a significant factor for
the occurrence of gall bladder stones. In these
circumstances the liver to produce excess cholesterol,
then poured into the gallbladder so that its
concentration in the gallbladder becomes very
saturated. This situation is a predisposing factor for
stone formation. People with more than 40 years of
age are more likely to be exposed to cholelithiasis
compared with younger people. This happens due to
increased secretion of cholesterol by the liver and
decrease the synthesis of bile acids. Besides the aging
process, is a process of gradual disappearance of the
network's ability to self-repair or replace themselves
and maintain their normal structure and function that

colelithiasis
CBD
obstruction
Bile cant flow
out
Inflammation
of hepatocyte
SGPT
increased
Stimulate vagal
nerves
Inhibit parasymphatic
nerves

Bile reflux

inflammation

Bacterial
infection
icterus

pancreatitis

Decrease peristaltic
Gas
accumulation
Food stuck in the stomach
with full gass flavor
nausea

Gall Bladder
distention

Absorbed
trought the
blood
Systemic
circulation

pain
hyperbillirubinu
ria

Patophysiology of
pankreatitis

Clinical Manifestation
The pain was great and biliary
Right upper abdominal painsevere abdominal
pain and radiating to the back or shoulder
Nausea and vomiting
Jaundice + feses dark yellow
Murphy sign positive
Fever
Leukocytosis
Vitamin deficiency.

THE RISK FACTORS (KASPER, 2005;

DKK).
The risk factors for cholelithiasis,
namely:
a. Age
b. Gender
c. Weight (BMI)
d. Genetic
e. Food
f. physical activity

Management Of
Cholelithiasis
A. CONSERVATIVE
(NON-SURGICAL)
Low-fat diet
Anticholinergic
drugs
antispasmodik
Analgesics
Antibiotics, when
accompanied
cholecystitis.

B. SURGERY
Cholecystectomy
If the gall bladder stones
cause recurrent pain attacks
although it has made a change
in diet, it is advisable to
undergo gall bladder removal.
With cholecystectomy,
patients can still live a normal
life, eating as usual. Is
generally performed in
patients with biliary colic or
diabetes.
1. Open cholecystectomy
2. Close cholecystectomy

complications of
cholelithiasis
Intrahepatic cholestasis
Empyema and hydrops
Gangren dan perforasi

Conclusion
The scenario in the diagnosis of patients with
cholelithiasis can be accompanied with acute
cholecystitis
and
pancreatitis.
This
was
concluded from analisis data is based on the
results of anamnesis, physical examination, or
investigation.
Cholecystitis
and
acute
pancreatitis itself a rises because of the
obstruction of the stone in the distal part of the
ductus choledochal which causes the flow of
bilirubin bile static and inhibit the flow resulting
in increased levels of the enzyme pancreatic like
amylase and lipase, and also inflammation in the
bladder gall accompanied dilatation bile duct.

Thank you >-<

Any Question?