Anda di halaman 1dari 44

CHOLELITIASIS

CASE REPORT

By: dr. Moh. Rezza Rizaldi


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

Entry Date: 06/03/22


Name: Ny. TA Maternity history: P4A0
Age: 43 years Body Weight: 69 Kg
Gender: Female Height: 145 cm
Addres: Brenggolo Kediri
MR Number: 015385
Anamnesa Perjalanan Penyakit
Keluhan Utama:
Nyeri Ulu Hati Pasien masuk rumah sakit dengan keluhan nyeri
ulu hati yang dialami sejak 1 bulan sebelum masuk
Keluhan Penyerta: rumah sakit, sakit bertambah berat dan tidak bisa
Mual (+) Muntah (+) Demam (+) ditahan sejak 1 hari sebelum masuk RS. Keluhan
BAB Warna sedikit Pudar (+) Lemas telah sering dirasakan hilang timbul sejak 2 tahun
(+) yang lalu. Nyeri dirasakan menjalar hingga ke
bahu. Pasien juga mengeluh mual serta muntah,
Riwayat Penyakit Dahulu:
serta terdapat demam tapi pasien sudah periksa
HT (-) DM (-) Asma (-) Jantung (-)
Alergi (-) Minum Alkohol (-) ke klinik dan membaik. Pasien mengeluhkan BAB
Merokok (-) berwarna sedikit pucat. Pasien juga mengeluhkan
adanya BAK berwarna seperti teh pekat Riwayat
Riwayat Persalinan: pasien berobat di penyakit dalam di RS HVA
Mempunyai 4 anak persalinan nor- dengan keluhan yang sama 2 tahun yang lalu,
mal setelah itu pasien tidak kontrol kembali setalah
dirasa keluhan sudah membaik.
Riwayat Makanan Sehari hari:
Gorengan (+)

Riwayat Olahraga:
Jarang (+)
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

(06 Maret 2022) Fungsi Ginjal      


Hematologi creatinine
ureum (BUN)
1,2
21
mg/dl
mg/dl
0,5-1,1
10-20
Pemeriksaan Hasil Satuan Nilai Rujukan Uric Acid  5,4 mg/dl 2,4-6,1
Fungis Liver      
Darah Lengkap       -SGOT 120 u/l <31
Hemoglobin 11,9 g/dl 13,5-16,1 -SGPT 122 u/l <31
Lekosit 14.920 sel/mm3 3.500-10.000
LED   mm/jam 0-10 Gula Darah Acak
Hitung Jenis       114 mg/dl <180
-Eosinophils 0,1 % 0-5
-Basophils 1,6 % 0-1 Kolesterol Total
145 mg/dl <200
-Neutrofil 93,5 % 50-70
-Limfosit 2,9 % 20-40 Trigliderida
-Monocyte 1,9 % 3-8 100 mg/dl <200
Hematokrit 33,7 % 40-52
Trombosit 188.000 sel/mm3 150.000-450.000
Eritrosit 3.900.000 sel/mm3 3.5-5.5 juta
Retikulosit 86,2    
MCV 30,4 fl 81.1-96
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
USG Gallblader

GB : dinding baik, echo


batu ukuran ± 1cm,
multiple (5-8 Biji),
sludge (+), nyeri tekan
probe (+)
Kesan : Cholelithiasis
multiple disertai tanda-
tanda kolesistitis
Tatalaksana
Medikamentosa
DIAGNOSA IVFD RL 20 TPM
Diagnosa Kerja Inj. Ceftriaxone 1gr/12 jam
Cholelitiasis disertai Colesis- Inj. Metamizole 500mg/8 jam
titis Inj. Omeprazole 20mg/24 jam
Inj. Ondansentron 8mg/8 Jam
Diagnosa Banding Po. Ursodeoxycholic acid 2-3x250mg
Cholangitis Po. Sukralfat syrup 3x1cth
Bile Duct Stricture
Galbllader Polyps Diit: Low Intake Lemak
Gastritis
Galblader Empyema
Follow Up 06-10/03/2022

S O A P
Nyeri ulu hati Keadaan Umum Cholelitiasis IVFD RL 20 tpm
berkurang, mual Tampak sakit sedang disrtai Inj. Cetriaxone
berkurang tidak Kesadaran: Compos Mentis Cholesistitis 1gr/12j/iv
muntah, demam Tanda vital Inj. Norages 1Amp/8
mereda, masih terasa TD: 110/80 mmHg Jam
pegal dibagian Nadi 82x/min Inj. Pumpitor 1Amp/24
belakang dada sampai Suhu 36,8 Jam
perut RR 20x/min Inj. Ondansentron
Pemeriksaan fisik 4mg/Kp
Kepala : Mata: Sklera ikterik (+/+) Po. Sukralfat 3x1 cth
Thorax : retraksi suprasternal (-), diet makanan rendah
retraksi intercostal (+), C/P S1S2 lemak
regular, VBS +/+,Rh+/+, wh-/- pasien boleh pulang
Abdomen : BU(+) normal, tympani, kontrol poli dalam
peristaltik (+) kesan normal, defans
(-)
Definition

Gallstones are a combination of several


elements that form a stone-like material that
can be found in the gallbladder
(cholecystolithiasis) or in the bile ducts
(choledocholithiasis) or both.
Epidemiology
Indonesia has a portion of 10% of the
population suffering from cholelithiasis with
cholesterol gallstones predominating which
occurs in 70% of all cases of gallstones. The
remaining 30% is pigment stone and its
composition varies.
PHYSIOLOGY OF GALLBLADDER
 Acts as a storage depot for bile.
 Between meals, when the sphincter of Oddi is closed,
bile produced by the hepatocytes enters the gallblad-
der.
 During storage, a large portion of the water in bile is
absorbed through the walls, bile is 5-10 times more
concentrated than that originally secreted by the liver.
 When food enters the duodenum, the gallbladder
contracts & the sphincter of Oddi relaxes, allowing
the bile to enter the intestine.
PHYSIOLOGICAL FUNCTION

 Elimination of excess cholesterol


 Solubilize cholesterol which prevent
precipitate in the gallbladder
 Facilitate digestion of triglycrides through
emulsification
 Facilitate absorption of fat soluble vitamins.
RISK FACTORS

 Women  Obesity
 Mutiparity  Diabetes
 Birth control  Sedentary life style
pills  Liver disease
 Pregnancy  Rapid weight loss.
 A family history
TYPES OF GALLSTONES

 There are three types of gall stone-


CHOLESTEROL STONES
 Composed mainly of cholesterol (> 50% of stone
composition) & comprises multiple layers of choles-
terol &mucin glycoproteins.
 Pure cholesterol stones are not common;
they comprise less than 10% of all stones.
 Most other cholesterol stones contain variable
amounts of bile pigments & calcium.
 If excessive cholesterol or insuf-
ficient bile acids are secreted,
bile becomes supersaturated
with cholesterol which then
precipitates out as cholesterol
crystals & stones.
 The incidence increase with
age, & the prevalence higher in
women. Stones are usually
smooth & whitish yellow to
tan.
PIGMENT STONES
 It probably form when un-
conjugated pigments
in the bile precipitate to
form stone.

In these people bile
contains an excess of
unconjugated bilirubin.
 Pigment stone are dark due to the presence of cal-
cium bilirubinate & are usually formed secondary to
hemolytic disorders such as sickle cell disease &
spherocytosis, & in those with cirrhosis. Two types
are recognized, black & brown.
 Pigment stone cannot be dissolved & must be re-
moved surgically
Black pigment stones

 Most common
 Formed in gall bladder
 Common in hemolytic disorders,cirrhosis
 Multiple , small & hard in consistence.
 bilirubinate, phosphate, bicarbonate, calcium.
Brown stones-Rare

 Formed in bile duct usually after bacterial in-


fection caused by bile stasis.
 The bacteria responsible for the infection enzymati-
cally catalyze the conversion of bilirubin glu-
curonide to insoluble unconjugated bilirubin.
 Major constituents are precipitated calcium biliru-
binate & bacterial cell bodies.
MIXED STONES
 Most common type.
 It may be combination of cholesterol & pig-
ment stones or either of these with some other
substances.
 Calcium carbonate, phosphate, bile salts, &
palmitate make up more common minor con-
stituents.
CLINICAL MANIFESTATIONS
May develop two types of symptoms:
⚫ Due to disease of the gallbladder itself
⚫ Due to obstruction of the bile passages by a
gallstone.
 May be acute or chronic.

 Epigastric distress, such as fullness, abdominal disten-


tion & vague pain in the right upper quadrant.
 May follow a meal rich in fried or fatty foods.
PAIN & BILIARY COLIC
 Gallstone obstructs the cystic duct, becomes dis-
tended, inflamed & eventually infected (acute
cholecystitis).
 Develops a fever & may have a palpable abdominal
mass.
 May have biliary colic with excruciating upper right ab-
dominal pain that radiates to the back or right shoulder,
is usually associated with nausea & vomiting & is no-
ticeable several hours after a heavy meal.
 Moves about restlessly, unable to find a comfort-
able position ,the pain is constant rather than col-
icky.
 Such a bout of biliary colic is caused by contraction of
the gallbladder, which cannot release bile because of
obstruction by the stone.
 When distended, the fundus of the gallbladder
comes in contact with the abdominal wall in the re-
gion of the right ninth & tenth costal cartilages.
 Produces marked tenderness in the right upper
quadrant on deep inspiration & prevents full inspi-
ratory excursion.
 If dislodged & no longer obstructs the cystic duct, the
gallbladder drains & the inflammatory process sub-
sides after a relatively short time.
 If continues to obstruct the duct, abscess, necrosis &
perforation with generalized peritonitis may result.
JAUN-
DICE
 Occurs in a few patients & usually occurs with
obstruction of the CBD.
 The bile, which is no longer carried to the duode-
num, is absorbed by the blood & gives the skin &
mucous membrane a yellow color.
 frequently accompanied by marked itching of the
skin.
CHANGES IN URINE & STOOL
COLOR
 The excretion of the bile
pigments by the kidneys
gives the urine a very
dark color.
 The feces, no longer
colored with bile pig-
ments, are grayish, like
putty, & usually de-
scribed as clay- col-
ored.
VITAMIN DEFICIENCY
 Obstruction of bile flow also interferes with absorp-
tion of the fat soluble vitamins A, D, E, & K.
 May exhibit deficiencies of these vitamins.

 If biliary obstruction has been prolonged (eg,


bleeding caused by vitamin K deficiency, which in-
terferes with normal blood clotting)
ASSESSMENT & DIAGNOSTIC
FINDINGS
 Abdominal ultrasound
 Ultrasonography

 Radionuclide imaging or cholescintigraphy

 Cholecystography

 Endoscopic retrograde
cholangiopancreatography
 Percutaneous transhepatic
cholangiography
ABDOMINAL ULTRASOUND
 Ifgall bladder stone is suspected, an abdominal
x- ray may be obtained to exclude other causes
of symptoms. However, only 10 to 15% gall
stone are calcified sufficiently to be visible on
such x - ray studies.
ULTRA SONOGRAPHY
 Replaced cholecystography as the diagnostic
procedure of choice
 Does not expose patients to ionizing radiation.

 Most accurate if the patients fasts overnight so that the


gall bladder is distended.
 Detect calculi in the gall bladder or a dilated
common bile duct with 90% accuracy.
 Obesity, ascites & distended bowel may be difficult to
examine satisfactorily with an ultrasound.
 Stones are acoustically dense & produce an
acoustic shadow. Stones also move with
changes in position.
 Polyps may be calcified & reflect shadows, but do
not move with change in posture.
 Thickened gallbladder wall & local tenderness
indicate cholecystitis.
 When a stone obstructs the neck of the gallblad-
der, the gallbladder may become very large, but
thin walled.

A contracted, thick-walled gallbladder indicates
chronic cholecystitis .
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
 Permits direct visualization of structures that
could once be seen only during laparotomy.
 Examination of the hepatobiliary system is carried
out via a side-viewing flexible fiberoptic endo-
scope inserted into the esophagus to the descend-
ing duodenum.
 Multiple position changes are required during the
procedure, beginning in the left semiprone posi-
tion to pass the endoscope.
 Fluoroscopy & multiple x-rays are used.
MANAGEMENT
 Nutritional& supportive therapy
 Pharmacologic therapy

 Nonsurgical removal

 Surgical management
COMPLICATIONS GALL
STONES
 Chronic cholecystitis
 Acute cholecystitis

 Choledocholithiasis

 Cholangitis,

 Gallstone pancreatitis,

 Gallstone ileus,

 Perforation of the gallbladder

 Gallbladder carcinoma
PATIENT EDUCATION
Managing Pain
 Sitting upright in bed or a chair or walking may ease the discomfort.
 Analgesic medications as needed & as prescribed
Resuming Activity
 Light exercise (walking) immediately.
 Shower or bath after 1 or 2 days
Resuming Eating
 Resume normal diet.
 Low intake fatty food
 Eat more fiber food/serat
THANKYOU