CASE REPORT
Entry Date:
Name: Ny. TA
10/03/22
Age: 43 years
Maternity history:
Gender: Female
P4A0
Addres: Brenggolo
Perjalanan Penyakit
Anamnesa Pasien masuk rumah sakit dengan keluhan nyeri
Keluhan Utama: ulu hati yang dialami sejak 1 bulan sebelum
Nyeri Ulu Hati masuk rumah sakit, sakit bertambah berat dan
tidak bisa ditahan sejak 1 hari sebelum masuk
Keluhan Penyerta:
Mual (+) Muntah (+) Demam (+) BAB
RS. Keluhan telah sering dirasakan hilang timbul
Warna sedikit Pudar (+) Lemas (+) sejak 2 tahun yang lalu. Nyeri dirasakan
menjalar hingga ke bahu. Pasien juga mengeluh
Riwayat Penyakit Dahulu: mual serta muntah, serta terdapat demam tapi
HT (-) DM (-) Asma (-) Jantung (-) Alergi
(-) Minum Alkohol (-) Merokok (-) pasien sudah periksa ke klinik dan mendingan.
Pasien mengeluhkan BAB berwarna sedikit
Riwayat Persalinan: pucat. Pasien juga mengeluhkan adanya BAK
Mempunyai 4 anak persalinan normal
berwarna seperti teh pekat Riwayat pasien
Riwaya Makan Sehari hari: berobat di penyakit dalam di RS HVA dengan
Gorengan (+) keluhan yang sama 2 tahun yang lalu, setelah itu
pasien tidak kontrol kembali setalah dirasa
Riwayat Olahraga:
Jarang (+) keluhan sudah membaik.
Pemeriksaan Umum
• Kesan Umum : Sakit Sedang
• Kesadaran : Compos Mentis
Vital Sign :
• Tekanan darah : 120/80 mmHg
• Nadi : 89 x/menit
• Suhu badan : 36.7oC
• Pernafasan : 20 x/menit
Pemeriksaan Fisik
Pemeriksaan Abdomen
• Inspeksi : Bentuk bulat, defans muskular (-), venektasi (-),
sikatrik (-
• Auskultasi : Peristaltik usus (+) kesan normal
• Palpasi : Nyeri tekan region hipokondrium dextra (+) Nyeri
Epigastrium (+), organomegali (-)
• Perkusi: Timpani, shifting dullness (-).
Pemeriksaan Lainya:
• Mata: Conjungtiva Anemis (-/-) Skelera Ikterik (+/+)
Pemeriksaan Pe-
nunjang Pemeriksaan Hasil Satuan Nilai Rujukan
• Multiple
• Faceted
• Consist of:
• Calcium salts
• Pigment
• Cholesterol (30% - 70%)
• 80% - associated with chronic cholecystitis
Gallstone Prevalence
Choledocho- Gallstone in the common bile duct (primary means originated there,
lithiasis secondary = from GB)
Cholangitis Infection within bile ducts usu due to obstrux of CBD. Charcot triad:
RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic
shock
Differential Diagnosis Of RUQ Pain
• Biliary disease
• Acute cholecystitis, chronic cholecystitis, CBD stone,
cholangitis
• Hepatitis
• In the GB:
• Biliary colic
• Acute and chronic cholecystitis
• Empyema
• Mucocoele
• Carcinoma
• In the bile ducts:
• Obstructive jaundice
• Pancreatitis
• Cholangitis
• In the gut:
• Gallstone ileus
Mirizzi syndrome
0.1–0.7% of patients who have gallstones
Csendes classification :
•Type 1: external compression of the common bile duct – 11%
•Type 2: cholecystobiliary fistula is present involving <1/3 rd the circumference of
the bile duct – 41%
•Type 3: a fistula is present involving upto 2/3 the circumference of the bile duct
– 44%
•Type 4: a fistula is present with complete destruction of the wall of the bile duct
– 4%
Diagnosis
• Ultrasound
• Blood tests
• Performed to look for signs of infection, obstruction, pancreatitis, or
jaundice
USG CT Scan
Management
• Cholecystostomy
• Subtotal cholecystectomy
• Open cholecystectomy
• Laparoscopic cholecystectomy
Cholecystostomy
•Advantages:
• Less post-op pain
• Shorter hospital stay
• Quicker return to normal activities
•Disadvantages:
• Learning curve
• Inexperience at performing open cholecystectomies
Cholecystectomy when to perform?
• After acute cholecystitis, cholecystectomy traditionally performed after 6
weeks