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Tutor :

dr.Hasta handayani idrus, M.kes

MASITHA (11020170002)
HUMAIRAH SHALEH (11020170057)
KASMA (11020170087)
KARISMAN (11020170129)
RATU DINI FAUZIAH (11020170156)

A 45-year-old woman comes to the out patient clinic with complaints of yellow all
over the body that have been experienced for the past 3 days, complaints of right
abdominal pain over loss arising from the last 1 month. History of frequent
consumption of fatty foods
 A 45-year-old woman
 yellow all over the body that have been experienced for the past 3 days
 complaints of right abdominal pain over loss arising from the last 1
 History of frequent consumption of fatty foods
1. How could the skin become yellow
2. explain the patomechanism of bilirubin and what is the difference between
direct bilirubin indirect?
3. What is the relationship between fatty foods and jaundice that patients
suffer from?
4. what causes right upper abdominal pain in the scenario?
5. explain the differential diagnosis of the scenario?
6. explain prevention according to the scenario?
7. Islamic perspective on the scenario?
Jaundice occurs when there is too much
bilirubin (a yellow pigment) in the blood—a
Increased bilirubin production due to increased red
condition called hyperbilirubinemia. Bilirubin
blood cells being destroyed (this is known as this is
is formed when hemoglobin (the part of red
known as hemolysis)
blood cells that carries oxygen) is broken
down as part of the normal process of
recycling old or damaged red blood cells.
Bilirubin is carried in the bloodstream to the
liver, where it binds with bile. Bilirubin is then Failure of the liver to process the bilirubin to be
moved through the bile ducts into the excreted
digestive tract, so that it can be eliminated
from the body. Most bilirubin is eliminated in
stool, but a small amount is eliminated in
urine. If bilirubin cannot be moved through
the liver and bile ducts quickly enough, it
builds up in the blood and is deposited in Blockage of the passage of bile into the gut: this include
the skin.The result is jaundice gallstones and cancer of the bile duct or liver.

Harrine, S. 2018. Jaundice In Adults. Division of Gastroenterology and Hepatology. Thomas Jefferson University.
Abbas, M. 2016. Jaundice: A Basic Reviews. Nishtar Medical College. International Journal of Research in
Medical Sciences. Vol 4. Issue 5. pp 1313-1314.
2. explain the patomechanism of bilirubin and what is the difference
between direct bilirubin indirect?
Differences in indirect bilirubin & direct bilirubin :

Conjugated bilirubin / direct bilirubin

Indirect conjugated bilirubin / bilirubin is bilirubin which has been conjugated
is non-conjugated bilirubin with with glucoronic acid. This bilirubin can
glucoronic acid. This bilirubin can react react directly with the diazio and
with diazo and Ehrlich reagents after Ehrilch reagents without the addition
the addition of alcohol. Bilirubin is fat of alcohol, is not fat soluble, polar,
soluble, non-polar, and insoluble in and soluble in water. Therefore, direct
water. bilirubin can be found in urine

Ref : BM Lubis. 2016. Journal of Bilirubin Albumin Ratio in Neonates with

Hyperbilirubinemia. Field. University of Northern Sumatra
3.what is the relationship between fatty foods and the disease they
suffer ?
Free cholesterol is in rapid equilibrium between serum lipoproteins and red cells. The level
of red cell cholesterol is influenced by bile salts, which shift the serum/cell partition of free
cholesterol to the cell phase and which inhibit the cholesterol-esterifying mechanism. When
exposed to serum from patients with obstructive jaundice or to normal serum with added
bile salts, red cells accumulate cholesterol and increase their surface area, thereby
acquiring a flattened shape and an increased resistance to osmotic lysis. The described
gains and losses of red cell cholesterol and surface area do not involve metabolic injury
and occur with no significant change in phospholipid content.
The red cells of patients with obstructive jaundice are flat and osmotically resistant and
have an increased cholesterol:phospholipid ratio. When transfused into normal subjects
these “target cells” rapidly lose their osmotic resistance. Similarly, normal cells acquire
osmotic resistance in the circulation of patients with obstructive jaundice. These reversible
changes in shape occur with half-times of about 9 and 24 hr, respectively, and occur
without impairing cell viability. These studies indicate that the red cell membrane
accumulates cholesterol in obstructive jaundice as a consequence of the elevated levels of
bile salts

Ref :
4.what causes right upper abdominal pain in the scenario?

Ref :[price,sylvia Anderson.2015.patofisiologi.jakarta:egc].

5. explain the differential diagnosis of the scenario?

 Definition
Acute cholangitis is a morbid condition with acute inflammation and
infection in the bile duct.
 Pathophysiology
The onset of acute cholangitis involves two factors: (1)increased bacteriain the
bile duct, and (2) elevated intra-ductal pressure in the bile duct allowing
translocation ofbacteria or endotoxin into the vascular and lymphatic system
(cholangio-venous/lymphatic reflux). Because of its anatomical characteristics, the
biliary system is likely to be affected by the elevated intraductal pressure. In
acute cholangitis, bile ductules tend to become more permeable to the translocation
of bacteria and toxins with the elevated intraductal biliary pressure.
 Historical aspect of terminology
Signs of hepatic fever Hepatic fever was a term used forthe first time by Charcot in
his report published in 1887 [3].Intermittent fever accompanied by chills, right
upper quadrant abdominal pain, and jaundice have been estab-lished as
Charcot’s triad.Acut obstructive cholangitis Acute obstructive cholangitis was
defined by Reynolds and Dargan [4] in 1959 as a syndrome consisting of lethargy
or mental confusion and shock, as well as fever, jaundice, and abdominal pain
caused by biliary obstruction.
 Causes and symptoms
As noted above, the two things that are needed for cholangitis to occur are: 1) obstruction to bile flow, and 2)
presence of bacteria within the bile ducts. The most common cause of cholangitis is infection of the bile ducts
due to blockage by a gallstone. Strictures (portions of ducts that have become narrow) also function in the
same way. Strictures may be due to congenital (birth) abnormalities of the bile ducts, form as a result of injury
to the bile duct (such as surgery, trauma), or result from inflammation that leads to scar tissue and
narrowing.The bacterium most commonly associated with infection of the bile ducts is Escherichia coli (E.
coli) which is a normal inhabitant of the intestine
 Diagnosis
The above symptoms alone are very suggestive of cholangitis; however, it is important to determine the exact
cause and site of possible obstruction. This is because attacks are likely to recur, and different causes require
different treatments. For example, the treatment of cholangitis due to a stone in the CBD is different from that
due to bile duct strictures

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

 pathogenesis and stone type

According to the macroscopic definition and chemical composition, bile duct stones can reach three categories of
mayors, namely: 1) cholesterol stones in which cholesterol content increases by 70%, 2) brown pigment stones or
calcium bilirubinate stones containing Ca-bilirub as a rich component non-extracted black residues ma, and 3) black
pigment stones that in Western societies the main composition of gallstones is cholesterol

 empedu stone complications

Acute cholecystitis :
Approximately 15% of patients with symptomatic stones experience acute cholecystitis. Symptoms include upper right
abdominal pain with a combination of nausea, vomiting, and heat. Physical examination found tenderness in the right upper
abdomen and often palpable enlarged gallbladder and signs of peritonitis. Laboratory tests will show that in addition to
lecocytosis sometimes there is also a mild increase in bilirubin and liver physiology probably due to local compression of the
bile ducts The pathogenesis of acute cholecystitis due to the closure of the cystic duct by pinched stones. Then there is
hydrops from the gallbladder.
 Diagnosis :
the diagnostic value of ultrasound in diagnosing bile duct stones had bile ducts with a sensitivity of 90%, a specificity
of 98%, it causes complications of pancreatitis and cholangitis which can still be fatal compared to endoscopic
retrograde cholangio pancreatography (ERCP) as a standard reference method for direct cholangiography. Overall the
accuracy of ultrasound for bile duct stones is 77% ERCP is very useful in detecting stones and 96% accuracy, but this
procedure is invasive and can cause complications of pancreatitis and cholangitis which can be fatal.

 management of the empedu channel stone

Therapeutic ERCP by performing endoscopic sphincterotomy to excrete bile duct stones without surgery was first
performed in 1974. Since then this technique has developed rapidly and has become the standard standard of non-
operative therapy for bile duct stones with wire basket or balloon-extraction through the already large estuary towards
duodenal lumen Furthermore the stones in the bile duct are removed so that the stones can come out with the stool or
are removed by mouth with the scop

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

 Chronic cholecystitis
Chronic cholecystitis is more common in clinical
 Acute cholecystitis settings, and is very closely related to litiasis and
inflammation of the gallbladder (acute cholecystitis) more often arises slowly.
is an acute inflammatory reaction of the gallbladder Clinical Symptoms
wall accompanied by complaints of right upper the diagnosis of chronic cholecystitis is often
abdominal pain, tenderness, and fever. until now the difficult to enforce because the symptoms are
pathogenesis of this disease that is quite often very minimal and not prominent such as
encountered is still unclear. although there are no dyspepsia, full feeling in the epigastrium and
epidemiological data on the population, the nausea especially after eating high-fat foods,
incidence of cholecystitis and gallstones which sometimes disappear after belching.
(cholelithiasis) in our country is relatively lower History of gallstones in the family, recurrent
compared to western countries. jaundice and colic, local pain in the gallbladder
area with positive Murphy signs, can support the
1.Acute cholecystitis

 Etiology and pathogenesis

factors that influence the onset of attacks of acute cholecystitis are bile stasis, bacterial infections, and gallbladder
wall ischemia. the main cause of acute cholecystitis is a gallbladder stone (90%) located in the cystic duct which
causes static bile, while a small number of cases arise without the presence of gallstones (acute calculus
 Diagnosis
Plain abdominal photographs cannot show a picture of acute cholecystitis. only in 15% of patients is it possible to see
opaque stones (radiopaque) because they contain enough calcium.oral cholecystography cannot show the gallbladder
if there is obstruction so that this examination is not useful for acute cholecystitis.ultrasound examination (USG)
should be done routinely and is very useful to show the size, shape, thickening of the gallbladder wall, stones and
extra hepatic bile ducts
 Treatment
Common treatments include complete rest, parenteral nutrition, a mild diet, painkillers such as pethidine and
antispasmodics. Antibiotic administration in the early cloud phase is very important to prevent complications of
perionitis, cholangitis, and septicema. ampicillin, cephalosporins and metronidazole are sufficient to kill germs that
are common in acute cholecystitis such as E. Coli, Strep.
2.chronic cholecystitis

 Clinical Symptoms
the diagnosis of chronic cholecystitis is often difficult to enforce because the symptoms are very minimal and not
prominent such as dyspepsia, full feeling in the epigastrium and nausea especially after eating high-fat foods, which
sometimes disappear after belching.
 Diagnosis
Oral cholecystography examination, ultrasonography and colloangiography can show cholelithiasis and gallbladder
function. endoscopie retrograde choledochopancreaticography (ERCP) is very useful for showing the presence of
gallstones in the gallbladder and koledokus duct.
 Prognosis
In most patients with chronic cholecystitis with or without symptomatic gallbladder stones, it is recommended for
cholecystectomy. The decision for cholecystectomy is rather difficult for patients with minimal complaints or other
diseases that increase the risk of surgery.

Ref : Sudoyo, Aru W. et al. Internal medicine textbook. Volume II Edition VI. Jakarta: International
Publishing Center for Internal Medicine Publishing. Page 479-480
6. explain prevention according to the scenario?

Providing adequate antibiotics
at the beginning of the attack to
prevent complications of
peritonitis, cholangitis, and Completerest

Reduceeating foods
containing betacarotine (such
as squash, melon, papaya, Painkillerssuch as
and carrots) pethidine and
Ref : Sudoyo, Aru W, et al.2015. Book Teaching Internal Medicine Volume II edition V. Jakarta:
Interna Publishing
7. islamic perspective on the scenario?
Prophet Muhammad sallallaahu 'alaihi wa sallam said:
(‫ أخرجه الحافظ السيوطي في الجامع الصغير‬:‫ التخمة‬:‫صل كل داء البردة) البردة‬
" The source of all diseases is al-baradah." Al-baradah: at-Tukhmah (Poor digestion of food) (narrated by
Imam al-Hafizh as-Suyuthi rahimahullah in al-Jaami 'ash-Shaghiir)
Basically, self-originating diseases do not originate from viruses, bacteria, germs, mosquitoes, cell mutations
and other viruses or bacteria that are rampant in the body when sick are not as a result.

So the source of the disease is human actions themselves through our daily behavior that is less praiseworthy
before Allah SWT, unfavorable character makes the angel Ratib record and report it before Allah SWT. where
it has been going on for years or even decades so that finally Allah decreases disaster in the form of a disease
as a warning to his people to immediately return to its path
Word of Allah SWT in surah As-Surah verse 42-30
"And whatever changes happen to you are caused by the creation of your own hands and Allah forgives as
much of your mistakes. And you do not let go (of the punishment of Allah) on the face of the earth and you
do not get a protector or helper besides Allah ".