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!
