----SURGERY CASE PRESENTATION----

CALCULOUS CHOLECYSTITIS

Group Members
CC Deepak Raj
CC SK Ajaharuddin
CC Aparna Viswanath K.V
  Identifying Data
 Chief Complaint
 History Of Present Illness

c
 Review of System
 Past Medical History
ontents  Family Medical History
 Personal and Social History
 OB- Gyne History
 Diet History
 Physical Examination
 Lab Findings
 Diagnosis
 Management
 Discussion
GENERAL DATA
• Name : GM
• Age : 34 y/o
• Gender : Female
• Civil Status : Single
• Address : 32 F. Victor , Pasay City
• Nationality : Filipino
• Religion : Catholic
• Occupation : Production Helper
• Admitted on : January 17, 2024 ( First
Admission)
CHIEF COMPLAINT

RUQ ABDOMINAL PAIN

 HISTORY OF PRESENT ILLNESS

• 4 Years PTC (2020), patient noted sudden onset of RUQ pain graded
5/10, radiating to the right shoulder, squeezing in character. Patient
consulted in the Surgery OPD and got diagnosed with Cholecystitis.
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• No medications taken, no other subjective complaints noted. The pain

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• In the interim , a Whole Abdomen Ultrasound confirmed calculous
Cholecystitis , leading to the recommendation for surgery, and
subsequently, the patient was admitted.
PAST MEDICAL HISTORY

• (-) HTN
• (-) DM
• (-) Allergies
• (-) Previous Surgery
• (-) Accidents/ Traumas
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• (-) Hospitalization
FAMILY HISTORY

• (+) HTN ( Mother)

• (-) DM
• (-) Allergies
• (-) Previous Surgery
• (-) Gall Stones
• (-) Cancer
PERSONAL AND SOCIAL HISTORY

• (-) Smoking
• (-) Alcohol
• (-) Illicit Drugs
• Works 8 hours per day A
• Lives with her Live-in partner

C
OB/GYN HISTORY

• Nulligravid
DIET HISTORY

• Usual Diet: Veggies, Chicken, Rice and Pork (Sometimes)

• Cooks at Home Sometimes
• Uses Open oil From the Market
• Source Of Drinking Water - Mineral Water
• Drinks 2 litters of water everyday
 Review Of System

Cardiovascular Genitourinary Tract

Constitutional (-) Chest Palpitation
(-) Fever ENT (-) Painful Urination
(-) Chest Pain
(-) Headache (-) Hearing loss (-) Incontinence
(+)Weight Loss (-) Tinnitus
(-) Ear Discharge Gastrointestinal
(-) Epistaxis (+)Tenderness (RUQ)
Skin (-) Loss of smell (-) Nausea
(-) Rashes 01 (-) Lymphadenopathy (-) Diarrhea
(-) Jaundice (-) Slurred Speech (-) Constipation

Musculoskeletal
Eye Respiratory System (-) jaundice
(-) Blurring of (-) cough (-) Malaise
Vision (-) Dyspnea
(-) Loss of Vision (-) DOB
02 PHYSICAL EXAMINATION
General Survey Chest & Lungs
• Awake, Alert, Coherent, Not In Cardiopulmonary Distress • Symmetric chest expansion,
• Clear breath sounds
• (-) retraction
Vital Signs
CVS
• BP 110/80 mmHg
• HR 91 bpm • Adynamic precordium
• RR 22 • Normal rate regular rhythm
• T 36.7 C • (-) Tachycardic
• O2 98% • (-) Murmur

Skin Abdomen
• Inspection- Symmetric with no bulging/swelling, no scars
• Good skin turgor, No rashes, No Lesions • Auscultation- Active bowel Sounds
• Percussion- tympanic
• Palpitation- (+) Epigastric Tenderness, (+) RUQ Pain radiating to
HEENT back
• (+) Murphy's sign
• Eyes Anicteric sclera, Pink palpebral conjunctiva
• Ear No ear discharge, (-) tinnitus Extremities
• Nose Symmetric, no nasal discharge • No lesions/scars, no cyanosis, (-) Edema, Full equal pulses,
• Throat Oral mucosa is pink, No tonsillitis • CRT < 2 sec.
LAB FINDINGS

CHEMISTERY 12/11/2023 11/24/2023

TEST RESULTS RESULTS UNIT REFERENCE

RANGE
FBS 5.01 5.17 mmol/L 3.89-5.83

BUN L 1.78 L 2.45 mmol/L 2.50- 6.50

Creatinine 69.10 55.85 mmol/L 44.0- 80.0

SGPT 15.94 1 U/L 0-41.0

SGOT 13.87 U/L 0-40.0

Akaline 53.70 U/L 0.00-115.0

Phosphatase
Lipase H 154.60 U/L 0-38.0

Sodiumm/ NA+ 141.30 145.30 mmol/L 135.0-148.0

Potassium/ K+ 4.47 4.17 mmol/L 3.50- 5.30

Lab Findings: Coagulation Factors
TEST RESULTS UNIT REFERENCE RANGE

PTT

APTT 27.6 Secs. 24.0- 35.0

PT

Protime H 14.2 Secs. 10-14

% Activity 79.85 % 70-120

INR H 1.23 0.64- 1.17

Lab Findings:
Hematology- Complete Blood Count, Differential Count

12/11/2023

RESULTS UNIT REFERENCE

RANGE
Hemoglobin 13.4 g/dL 12.2- 14.3

Hematocrit 39.5 % 38.0- 43.0

RBC 4.73 X10 12/L 4.18- 5.01
WBC 9.77 X10 9/L 5.86-10.73
Neutrophil 60.3 % 49.0- 67.0
Lymphocytes 30.6 % 20.0- 40.0
Monocytes 6.3 % 5.0- 10.0
Eosinophil 2.4 % 0.0- 6.0
Basophil 0.4 % 0.0- 2.0
MCV 83.5 fL 80.0-100.0
MCH 28.3 pg 27.0-32.0
MCHC 33.9 g/dL 32.0-36.0
RDW 11.8 11.5-14.5
MPV 9.8 fL 7.8-11.0
Platelate Count H 468 X10 9/L 150-400
Whole Abdomen Ultrasound

• Calculous Cholecystitis
• otherwise negative whole abdominal
01
ultrasound Keyword

Keyword
04
DIAGNOSIS
Calculous Cholecystitis

MANAGEMENT
Sx Procedure Performed: Open Cholecystectomy on
01/22/2024
DISCUSSION

 Anatomy
 Function
 Types
 Diagnosis
 Treatment
 Complications
 ANATOMY OF GALLBLADDER

 Pear Shaped structure

 Dimension: 7.0 - 10 cm long
 Normal Capacity: About 30-50 mL
 Lies on the underside of the liver at the junction of right and
left lobes of the liver
 Anatomical divisions: a fundus a body and a neck that
terminates in a narrow infundibulum
 Blood supply: Cystic Atrery ( a branch of right hepatic artery)
 ANATOMY OF GALLBLADDER
Calot's Triangle
 HepatobiliaryKeyword
triangle Keyword

 Border
Superior - Inferior Surface of the liver
Lateral - by Cystic duct and the medial
border of the gallbladder
Medial - by the common hepatic duct
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Content
Cystic artery
Lymph node of Lund
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 FUNCTIONS OF GALLBLADDER

 To store and regulate the flow of bile

 Mainly Composed of water, mixed with bile salts and acids
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 Secretion of mucus - approximately 20mL is produced per day
Acute Cholecystitis

 Acute Cholecystitis is associated with gallstones in 90 to 95% of

cases
 Blockage of cystic duct in absence of stone - Acalculous
Cholecystitis
 < 1 % of acute Cholecystitis - tumor obstructing the cystic duct
 In severe cases 5 to 10% of inflammatory process progress and
leads to ischemia and necrosis of the gallbladder wall.
Calculous Cholecysitis
Gallsotnes ( Cholelithiasis)

 Most common biliary pathology

 Asymptomatic in majority of cases (>80%)
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 Approximately 2-3% of asymptomatic patient will develop symptoms requiring
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 Cholecystectomy is one of the most common operations performed by a general
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surgeons
 Complicated gallstone disease - 3.5% of symptomatic patients
 Cholesterol stones

 Contain 51-99% pure cholesterol plus an admixture of calcium salts, bile acids, bile
pigments and phosphoipids

 Altered level of cholesterol, bile acid and lecithin in bile precipitation of inosoluble
cholesterole crystals

 Old age; OCP; obesity; clofibrate - increases cholesterol secretion

 Oestrogen; ileal resection; cholestyramine- reduces the bile salt concentration

Gallbladder Cholesterol Stones
 Pigment Stones
 Stones containing < 20% cholesterol and are dark because of the presence of calcium
bilirubin

 Black pigment stones: usually small, brittle, dark and sometimes speculated
• Formed by super saturation of unconjugated bilirubin within the bile.
• The insoluble unconjugated bilirubin pigment polymer mixed with calcium phosphate and
calcium bicarbonate, forming a stones

 Brown pigment stones: usually <1cm in diameter, brownish-yellow soft and often mushy
• Secondary to bacterial infection and bile stasis.
• Form in the gallbladder or in the bile duct
• Unconjugated bilirubin precipitates with calcium, and along with dead bacterial cell
bodies and forms soft brown stones
Risk Factors
 Elderly
 Obesity
 Cronh's disease
 Pregnancy
 Dietary factrors
 Family history
 Pareatal nutrition
 Sickle cell disease
 Oral contraceptive and estrogen therapy
 Clinical Manifestations
 Right upper quadrant or epigestric pain that less or more than 5 hours
 May radiate to right back and interscapular area
 Crampy colic pain
 Fever
 Nausea and vomiting
 Anorexia
 Tachycardia
 Palpable tender mass at the right upper quadrant
 (+) Murphy's sign- The voluntary arrest of inspiration with deep palpation on the right
costal margin
 Diagnostic Workup
 Lab Findings:
Mild to moderate leukocytosis (12000- 15000/mL)
Mild elevation of serum bilirubin (>4mg/dL)
Mild elevation of alkaline phosphatase, transaminase and amylase
High TLC (>20000/mL) suggest a complicated form of Cholecystitis

 Ultrasonography
Sensitive, inexpensive and reliable tool
85% sensitivity and 95% of specificity
Can show GB wall thickening and pericholecystic fluid

 HIDA ( Hepatobiliary iminodiacetic acid ) Scan

Useful in the diagnosis of atypical cases
Lack of filling of GB after 4hours indicates an obstructed cystic duct
95% of sensitivity and specificity
 Diagnostic Workup

 CT Scan

 Note:
An accurate history and physical examination can
help to rule out the GB stones
 TREATMENT

 IV Fluid administration
 Administration of analgesics
 Administration of antibiotics ( broad- spectrum antibiotics)
 Surgery
Laparoscopic Cholecystectomy
Open Cholecystectomy
 COMPLICATIONS
 Gangrenous Cholecystitis
m/c complication(20% of cases)

 Perforation
Approximately in 10% of cases
often localized by omentum
resulting pericholecystic abscess

 Emphysematous Cholecystitis
Caused by secondary infection of the gallbladder with gas forming organisms

 Cholecystoenteric fistula
Passage of gallstone, usually larger than 2.5 cm through a Cholecystoenteric fistula
which lead to development of mechanical bowel obstruction.
Tokyo Guidelines For Severity Grading Of Acute Cholecystitis
 Grade III - Severe
 Associated with dysfunction of any one of the following organs/systems:
• Cardiovascular dysfunction - Hypotension requiring treatment with dopamine >5
ug/kg/min, or any dose of norepinephrine
• Neurological dysfunction - Decreased level of consciousness
• Respiratory dysfunction - PaO2/FiO2 ratio <300
• Renal dysfunction - Oliguria, creatinine > 2.0 mg/dL
• Hepatic dysfunction - Prothrombin time (PT-INR) > 1.5
• Hematological dysfunction - Platelets Counts < 100,000/mm3
Tokyo Guidelines For Severity Grading Of Acute Cholecystitis
 Grade II- Moderate
 Associated with any one of the following conditions:
• Elevated WBC (>18000/mm3)
• Palpebral tender mass in the RUQ
• Duration of Complaints >72hours
• Marked local inflammation ( gangrenous Cholecystitis, pericholecystic abscess,
hepatic abscess, biliary peritonitis, emphysematous Cholecystitis)
Tokyo Guidelines For Severity Grading Of Acute Cholecystitis

 Grade I- Mild

• Does not meet the criteria of grade II or grade III acute Cholecystitis
• Grade I can also be defined as acute Cholecystitis in a healthy person with no organ
dysfunction and mild inflammatory changes in the gallbladder
• Making cholecystectomy a safe and low- risk operative procedure
 DIFFERENTIAL DIAGNOSIS
 Hepatitis
 Cholangitis
 Peptic ulcer disease
 Pancreatitis
 Appendicitis
 Myocardial Ischemia
 Pneumonia
 References
Schwartz 11th ed.