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CHOLELITIASIS

CASE REPORT

By: dr. Moh. Rezza Rizaldi


Mentor: dr. Ratna Wilian
Supervisor: dr. Dodi, Sp.PD
Patient Identity

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

(08 Maret 2022) Fungsi Ginjal      


Hematologi creatinine 1,2 mg/dl 0,5-1,1
ureum (BUN) 21 mg/dl 10-20
Pemeriksaan Hasil Satuan Nilai Rujukan Uric Acid  5,4 mg/dl 2,4-6,1
Darah Lengkap       Fungis Liver      
Hemoglobin 11,9 g/dl 13,5-16,1 -Eosinophils 0,1 % 0-5
Lekosit 14.920 sel/mm3 3.500-10.000 -Basophils 1,6 % 0-1
LED   mm/jam 0-10 -Neutrofil 93,5 % 50-70
Hitung Jenis       -Limfosit 2,9 % 20-40
-Eosinophils 0,1 % 0-5 -Monocyte 1,9 % 3-8
-Basophils 1,6 % 0-1 Hematokrit 33,7 % 40-52
-Neutrofil 93,5 % 50-70 Trombosit 188.000 sel/mm3 150.000-450.000
-Limfosit 2,9 % 20-40 Eritrosit 3.900.000 sel/mm3 3.5-5.5 juta
-Monocyte 1,9 % 3-8 Retikulosit 86,2    
Hematokrit 33,7 % 40-52 MCV 30,4 fl 81.1-96
Trombosit 188.000 sel/mm3 150.000-450.000 MCH 35,3 pikogram 27-31.2
Eritrosit 3.900.000 sel/mm3 3.5-5.5 juta MCHC 440 g/dl 31.8-36.4
Retikulosit 86,2     ALC 32,24 /ul 800-4000
MCV 30,4 fl 81.1-96 NLR   Up to 3,13
MCH 35,3 pikogram 27-31.2
MCHC 440 g/dl 31.8-36.4
ALC 32,24 /ul 800-4000
NLR   Up to 3,13
Rapid test
Parameter Hasil Nilai Rujukan
nCoV IgG/IgM IgM non reaktif, IgG NON REAKTIF
reaktif
What Are Gallstones?
• Small, pebble-like sub-
stances
• Multiple or solitary
• May occur anywhere within
the biliary tree
• Have different appearance -
depending on their contents
Pigment Stones
• Small
• Friable
• Irregular
• Dark
• Made of bilirubin and
calcium salts
• Less than 20% of
cholesterol
• Risk factors:
• Haemolysis
• Liver cirrhosis
• Biliary tract infections
• Ileal resection
Cholesterol Stones
• Large
• Often solitary
• Yellow, white or green
• Made primarily of cholesterol
(>70%)
• Risk factors:
• 4 “F” :
• Female
• Forty
• Fertile
• Fat
• Fair (5th “F” - more prevalent in
Caucasians)
• Family history (6th “F”)
Mixed Stones

• Multiple
• Faceted
• Consist of:
• Calcium salts
• Pigment
• Cholesterol (30% - 70%)
• 80% - associated with chronic cholecystitis
Gallstone Prevalence

• 10% of people over 40 yrs.

• 90% “silent stones”

• Risk factors for becoming symptomatic:


• Smoking
• Parity
Risk Factors
• Women
• Age > 60 years
• American Indians & Mexican Americans
• Overweight or obese men and women
• People who tend to fast or lose weight quickly
• Family history of gallstones
• Diabetes
• Diet high in cholesterol
• Use of OCPs
• Pregnancy
Gallstone Pathogenesis

• Bile = bile salts, phospholipids, cholesterol

• Gallstones due to imbalance rendering cholesterol & calcium


salts insoluble
• Pathogenesis involves 3 stages:
Cholesterol supersaturation in bile
Crystal nucleation
Stone growth
Definitions
Symptomatic Wax/waning postprandial epigastric/RUQ pain due to transient cys-
cholelithiasis tic duct obstruction by stone, no fever/WBC, normal LFT

Acute chole- Acute GB inflammation due to cystic duct obstruction. Persistent


cystitis RUQ pain +/- fever, ↑WBC, ↑LFT, +Murphy’s = inspiratory arrest

Chronic Recurrent bouts of colic/acute chol’y leading to chronic GB wall in-


cholecystitis flamm/fibrosis. No fever/WBC.

Acalculous GB inflammation due to biliary stasis(5% of time) and not


cholecystitis stones(95%). Seen in critically ill pts

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

• Inflamed or perforated duodenal ulcer

• Hepatitis

• Also need to rule out:


• Appendicitis, renal colic, pneumonia or pleurisy, pancre-
atitis
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)
• Acute pancreatitis (gallstone enters the duct leading to pancreas
and blocks it)
Murphy’s Sign: Inspiratory arrest with manual pressure be-
low the gallbladder
Complications Of Gallstones

• 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

• 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 CT Scan
Management

• Asymptomatic gallstones do not require operation

• Whilst awaiting for surgery


• Low fat diet
• Dissolution therapy (ursodeoxycholic acid) generally useless
Surgical options

• Cholecystostomy

• Subtotal cholecystectomy

• Open cholecystectomy

• Laparoscopic cholecystectomy
Cholecystostomy

• Patients at high risk related to multisystem organ failure

• Severe pulmonary, renal, or cardiac disease


• Recent myocardial infarction

• Cirrhosis with portal hypertension


• Acalculus cholecystitis after severe trauma, burns, or surgery
• Empyema or gangrene of the gallbladder
Subtotal Cholecystectomy

• Severe inflammation renders identification of the


anatomy impossible, eg. Gangrenous cholecystitis

• Scarred partially intrahepatic gallbladder

• Severe cirrhosis and portal hypertension


Cholecystectomy
Laparoscopic Surgery

•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

• Arguments for 6 weeks later


• Laparoscopic dissection more difficult when acutely inflammed
• Surgery not optimal when patient septic/dehydrated
• Logistical difficulties (theatre space, lack of surgeons)

• Arguments for same admission


• Research suggests same admission lap chole as safe as elective chole (conversion to
open maybe higher)
• Waiting increases risk of further attacks/complications which can be life threatening
• Risk of failure of conservative management and development of dangerous complica-
tion such as empyema, gangrene and perforation can be avoided

• National guidelines state any patient with attack of gallstone pancreatitis


should have lap chole within 3 weeks of the attack
Complications of Lap Cholecystectomy

• Trocar/Veress needle injury


• Hemorrhage
• Wound infection and/or abscess
• Ileus
• Bile leak
• Gallstone spillage
• Deep vein thrombosis
• Retained common bile duct (CBD) stone
• CBD injury & stricture
• Pancreatitis
• Conversion to open procedure
• Nonsurgical treatment:
• Only in special situations
• When a patient has a serious medical condition preventing surgery
• Only for cholesterol stones

• Oral dissolution therapy


• Ursodeoxycholic acid - to dissolve cholesterol gallstones
• Months or years of treatment may be necessary before all stones dis-
solve
• Contact dissolution therapy
• Experimental procedure
• Involves injecting a drug directly into the gallbladder to dissolve choles-
terol stones
Prevention

A sensible diet is the best way to prevent gall stones

Avoid crash diet or very low intake of calories

Eat good sources of fiber