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Case Management, Presentation, Discussion and Sharing of Information on Non Acute Abdomen

Robelle Joan A.  Peralta, M.D.

First Year Level Resident

General Data

M.O.

32/F

Filipino

Sta. Ana, Manila

 

Chief Complaint:  Epigastric Pain

History of Present Illness

 2 wks PTC – the patient complained of intermittent epigastric pain,  colicky in character associated  with food intake.  The patient consulted with private physician and was diagnosed as Peptic Ulcer Disease.  She was prescribed with a H2 blocker but no relief was noted.

1 wk    PTC – there was noted increase in severity of the epigastric pain that was radiating to the back with associated feeling of bloatedness but there was no fever, jaundice, dysuria, anorexia or vomiting.  The patient decided to again consult.

Past Medical History

No Hypertension

No Diabetes Mellitus

No PTB

No Bronchial Asthma

No previous hospitalizations

No allergies to food/drugs

 

Family History

Denies heredofamilial diseases

Personal and Social History

Non smoker

Non alcoholic beverage drinker

 

Review of Systems

General:  no fever, no anorexia, no weight loss

Skin:  no pruritus, no rashes, no jaundice, no pallor

HEENT:  no headache, no dizziness, no blurring of vision, no doubling of vision, no earache, no tinnitus

Respiratory:       no cough, no dyspnea, no chest pain, no hemoptysis

Cardiac:  no palpitations, no easy fatigability, no orthopnea, no paroxysmal nocturnal dyspnea

Hematologic:  no easy bruisability

Urinary:  no dysuria, no hematuria, no frequency

Endocrine:  no heat/cold intolerance, no polydipsia, no polyuria, no polyphagia

Nervous: no loss of consciousness, no seizures

 

Physical Examination

General Survey:  Conscious, coherent, ambulatory, not in cardiorespiratory distress

Vital Signs:  BP:120/80   CR:85   RR:21    T:37ºC

HEENT:  pink palpebral conjunctiva, anicteric sclerae, supple neck, no cervical lymphadenopathy

Chest and Lungs:  symmetrical chest expansion, no retractions, clear breath sounds

Physical Examination

Heart:  Adynamic precordium, normal rate & regular rhythm, no murmur

Abdomen:  Flabby, NABS, soft, nontender

Extremities:  grossly normal extremities

 

Salient Features

43 /female  

Epigastric pain associated with food intake 

   colicky, radiating to back

   (+) feeling of bloatedness

   not relieved with H2 blockers

   (-)  fever

   (-)  jaundice

 

Algorithm

Clinical Diagnosis

Calculous of the Gallbladder with other cholecystitis

Do I need a para-clinical diagnostic procedure?

Yes, I need a paraclinical diagnostic procedure to increase the certainty of my diagnosis.

Ultrasound Findings

IMPRESSION:      Normal sized liver with moderate diffuse fatty infiltration

Cholecystolithiases

Unremarkable pancreas and spleen.

 

Pre-treatment Diagnosis

Goals Of Treatment

Resolution of the Abdominal Pain

No complications

No recurrence

 

Treatment Options

Treatment of Choice

Open Cholecystectomy

Pre-operative Preparation

Informed consent secured

Psychosocial support provided

Optimized patient’s physical health

Patient screened for any health condition

Operative materials secured

 

Operative Management

Patient supine under GA

Asepsis and antisepsis

Sterile drapes placed

Right Kocher incision

 Operative Management

Muscle splitting

Peritoneum entered

Intraop Findings

          GB measured 6x3 cms with not thickened walls containing bile and one stone 1cm and 1.2 cms in diameter cystic duct 0.3 cms and CBD 0.8 cms with no palpable stones.

Cystic artery clamped and ligated

cystic duct identified and tagged

Gallbladder dissected from liver down to the Cystic duct

Cystic duct clamped and ligated

Washing with NSS

Hemostasis checked

Complete OS count

Abdomen closed

 

Final Diagnosis

Calculous of the Gallbladder with other cholecystitis

s/p cholecystectomy

 

Post operative Care

NPO

Continue Hydration (IVF)

Adequate Analgesia

Early Ambulation

Daily Wound care

 

Outcome

Resolution of the epigastric pain

Live patient

No complications

Satisfied patient

No medico-legal suit

 

Discussion

Acute Non Surgical Abdomen

- Any abdominal condition acute in onset requiring no immediate/urgent surgical intervention or may not need surgery at all

Common acute non- surgical abdomen cases

    - Acute Renal Colic

    - Acute Cholecystitis

    - Peptic Ulcer Disease/ Gastritis

    - Pancreatitis

    - Non Specific Abdominal Pain

    - Acute Gastroenteritis

    - Intestinal obstruction

    - GI Bleeding

Gallstone disease is one of the most common problems affecting the digestive tract.

The prevalence of gallstones is related to many factors including age, gender, pregnancy, dietary factors, ethnicity and others. 

Symptomatic gallstone disease may progress to complications related to gallstones like cholecystolithiasis, choledocholithiasis, cholangitis, gallstone pancreatitis, and gallbladder carcinoma.

Cholelithiasis is the presence of gallstones in the gallbladder.

Cholecystitis is inflammation of the gallbladder from obstruction of the cystic duct.

Choledocholithiasis is the presence of a stone in the common bile duct.

Cholangitis occurs when a gallstone obstructs the biliary or hepatic ducts, causing inflammation and infection.

  

Gallstones form as a result of solids settling out of the solution.

The major organic solutes in bile are bilirubin, bile salts, phospholipids and cholesterols.

They can either be cholesterol (common in Western countries) or pigment stones (common in Asian countries).

Normally, bile acids, lecithin, and phospholipids help to maintain cholesterol solubility in bile.

When bile becomes supersaturated with cholesterol, it crystallizes and forms a nidus for stone formation.

Calcium and pigment also may be incorporated in the stone.

Impaired gallbladder motility, biliary stasis, and bile content predispose people to the formation of gallstones.

Pigment stones, which comprise 15% of gallstones, are formed by the crystallization of calcium bilirubinate.

Diseases that lead to increased destruction of red blood cells (hemolysis), abnormal metabolism of hemoglobin (cirrhosis), or infections (including parasitic) predispose people to pigment stones. Black stones and brown stones exist.

Black stones are found in people with hemolytic disorders. Brown stones are found in the intrahepatic or extrahepatic duct. They are associated with infection in the gallbladder and commonly are found in people of Asian descent.

Gallstone differentiation is an important consideration in management; cholesterol stones are more likely to respond to nonsurgical management than are pigment or mixed stones.

About two-thirds of patients with gallstone disease present with chronic cholecystitis characterized by recurrent attacks of pain.

The pain develops when a stone obstructs the cystic duct, resulting in a progressive increase of tension in the gallbladder wall.

It is located in the epigastrium or in right upper quadrant and frequently radiates to the upper back or between the scapula.

The pain is severe and comes on abruptly, typically during the night or after a fatty meal.

CLNICAL PRESENTATION

1.  Biliary colic type pain (“colic” misnomer �� pain usually episodic/constant

2. Gallstones

• Postprandial only in ~50% of patients

• Pain for 1-5 hrs, relief within 24 hrs

• >24 hrs �� cholecystitis is present.

• N/V in 60-70%, bloating 50%

• PE/Labs: usually completely normal

Asymptomatic pt’s usually don’t need treatment

Ddx: GERD, pancreatitis, PUD, many others

Treatment for symptomatic cholelithiasis:

• Surgery (elective lap chole standard of care)

• Expectant medical management not recommended

Questions

1.   What is the most specific and most sensitive diagnostic test for cholecystitis?

        a.   Ct scan

        b.   Plain Abdominal x-ray

        c.  Ultrasound

        d.  MRI

 

Write a if 1,2,3 are correct

Write b if 1 and 3 are correct

Write c if 2 and 4 are correct

Write d if only 4 is correct

Write e if 1,2,3,4 are all correct

 

2.  Which of the following help maintain cholesterol solubility in the bile?

1. Bile salts

2.  Cholesterol crystals

3.  Lecithin

4.  Vitamins

 

3.  Which of the following are treatment options of cholelithiasis?

1.  open cholecystectomy

2.  appendectomy

3.  laparoscopic cholecystectomy

4.  exploratory laparotomy

 

4.  Which of the following conditions predisposes one to the development of gallstones?

1.  Impaired gallbladder motility

2.  biliary stasis

3.  bile content

4.  Time of day

 

5.  Which of the following are examples of non acute abdomen?

1. Acute Renal Colic

2. Stabwound at the epigastric area

3. Peptic Ulcer Disease

4. Complete Gut Obstruction

 

References

1. Schwartz’s Principles of Surgery 8th ed

2.  Surgical Decision making

3.  Chassin’s Operative Strategy in General Surgery 3rd Edition pg 572-599

4. Cameron,J.L. Current Surgical Therapy 8th Ed; 2004

 

Thank you and good day!

                    

 

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