1. CLINICAL CASE PRESENTATION
GERNERAL SURGERY, GROUP 1
Adriana Palacio Giraldo, Internship year FUSM

2. ACTIVITIES
1. CLINICAL CASE
2. THEME REVIEW

3. HISTORY OF PRESENTATION
A 25-year-old female presented to the emergency room with a 4-day history of right upper quadrant pain that radiated to the right upper part of the back, the pain was dull and constant on his nature, of moderate intensity, all these symptoms associated with jaundice, general malaise, dark urine and decrease appetite.
REVIEW OF SYSTMES
She stated also that her stool weren't light-colored
MEDICAL HYSTORY
She didn’t have relevant pathology, allergic or toxycologic history
She had 2 caesarean in the past

4. Alert and oriented to person, place and time, calm, well hydrated
PHYSICAL EXAMINATION
Alert and oriented to person, place and time, calm, well hydrated
BP120/75, HR 82, RR 18
Moist mucous membranes in oropharynx, scleral icterus
Lungs - Clear to auscltation, no use of acessory muscles, no crackles or wheezes.
Abdomen soft, flat, pain to palpation on the right hypochondrium, non-tender non- distended, no masses palpable
No lower extremity edema, capillary refill less than 2 sec
But pressure 120 over 75

5. WHAT DO YOU THINK IS THE PROBABLE DIAGNOSIS AND WHICH EXAMS WOULD YOU ASK FOR¿¿

6. ADMISSIONS LABORATORY RESULTS BT: 6.1 BD: 4.32 GGT: 494 Alk phos194
Amylase149 PCR 2.37
WBC 9560 N 65% Hb 12.5.
Mild Leukocytosis without a left shift
Elevation of the total and direct Bilirubin
Elevated alkaline phosphatase that assays common bile duct obstruction.
Elevated Amylase (evaluate the presence of pancreatitis and a mild elevation could be present cholecystitis)
Elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis.

7. IMAGING
Conclusion:
intra and extrahepatic dilated biliary ducts. Cholelthiasis. It should be role out a distal obstruction of the common bile duct.
Echography:
Enlarged intrahepatic biliary ducts in both lobes. Dilated common bile duct measured at 10 mm. Gallbladder distension measured at 7cm with sludge and a 10mm Gallstone inside. Negative sonographic Murphy sign.

8. AND NOW…
WHAT WOULD YOU DO??

9. An Endoscopic Retrograde Cholangiopancreatography (ECPG) was performed
An Endoscopic Retrograde Cholangiopancreatography (ECPG) was performed. It was found a Gallstone of 1.5cm at the distal common bile dict and finally it was removed.
A laparoscopic cholecystectomy was performed with the following findings:
Gallbledder with fibrous, thicked wall over 3 mm. Cistic duct of 10mm aprox. Dilated bile duct. The procedure was made without complications.

10. CLINICAL EVOLUTION
The day after the surgery the patient stated to have no pain and to tolerate food
PHYSICAL EXAMINATION
Hydrated, alert, oriented in person, time and space
HR 88 RR 18
CP: Regular rate and rhythm, no murmurs, rubs or gallops. Normal breath sounds, No wheezes, rales, or rhonchi
ABD: soft, pain to palpation on right hypochondrium, mesogastrium and right lumbar region, non-tender, no sigs of peritoneal irritation. Covered surgical wounds.
EXT: without edema
The patient was discharged with alarm sings and symptoms

11. Choledocholithiasis

12. INTRODUCTION
Choledocholithiasis refers to the presence of gallstones within the common bile duct.
The most cases of choledocholithiasis are secondary to the passage of gallstones from the gallbladder into the common bile duct.
Primary choledocholithiasis is less common and typically occurs in the setting of bile stasis.

13. CLINICAL MANIFESTATIONS
Occasionally the patients are asymptomatic
Patients typically present with biliary type pain
Laboratory testing reveals a cholestatic pattern of liver test abnormalities
Elevated bilirubin and alkaline phosphatase
Typically have a normal complete blood count and pancreatic enzyme levels.

14. Uncomplicated choledocholithiasis
Symptoms
Right upper quadrant or epigastric pain:
More prolonged than is seen with typical biliary colic
Resolves when the stone is removed.
Nausea, and vomiting.
Physical examination
Right upper quadrant or epigastric tenderness.
Patients may also appear jaundiced.
Laboratory tests
Serum ALT and AST concentrations are typically elevated early.
Later, liver tests are typically elevated in a cholestatic pattern
Increases in serum bilirubin, alkaline phosphatase, and gammaglutamyl transpeptidase exceeding the elevations in serum ALT and AST.
Most patients with choledocholithiasis are symptomatic, although occasional patients are asymptomatic.
The pain is often more prolonged than is seen with typical biliary colic (which typically resolves within six hours).

15. Complicated choledocholithiasis
The two major complications are pancreatitis and acute cholangitis.
Patients with biliary pancreatitis typically present with nausea, vomiting, elevations in serum amylase and lipase and/or imaging findings suggestive of acute pancreatitis.
Patients with acute cholangitis often present with Charcot's triad (fever, right upper quadrant pain, and jaundice) and leukocytosis.
In severe cases, bacteremia and sepsis may lead to hypotension and altered mental status (Reynolds' pentad).

16. DIAGNOSIS A combination of laboratory tests and imaging studies.
The first imaging study is a transabdominal ultrasound.
Additional testing may include:
Magnetic resonance cholangiopancreatography (MRCP)
Endoscopic ultrasound (EUS)
Endoscopic retrograde cholangiopancreatography (ERCP)
Diagnostic approach — Patients are often suspected of having choledocholithiasis when they present with right upper quadrant pain with elevated liver enzymes in a primarily cholestatic pattern (disproportionate elevation of the alkaline phosphatase, gammaglutamyl transferase, and bilirubin). In a patient suspected of having choledocholithiasis based on the history, physical exam, and laboratory testing, we start by obtaining a transabdominal ultrasound. If not already done, we also obtain a complete blood count to look for leukocytosis (which may suggest acute cholangitis has developed) and pancreatic enzyme levels.

17. Risk assessment
In a 2010 guideline, the American Society for Gastrointestinal Endoscopy (ASGE) proposed the following approach to stratify patients based on their probability of having choledocholithiasis.

18. High risk Intermediate risk Low risk
Proceed to ERCP with stone removal followed by elective cholecystectomy.
Proceed to preoperative EUS or MRCP, or they proceed to laparoscopic cholecystectomy with intraoperative cholangiography
Proceed directly to cholecystectomy without additional testing
If a stone is found preoperatively, patients should proceed to ERCP with stone removal, followed by elective cholecystectomy, provided gallstones or sludge were seen on preoperative imaging.

19. Imaging test Transabdominal ultrasound ERCP EUS MRCP
A dilated common bile duct on transabdominal ultrasound is suggestive of, but not specific for, choledocholithiasis. A cutoff of 6 mm is often used to classify a duct as being dilated. However, using a cutoff of 6 mm may miss stones.

20. DIFFERENTIAL DIAGNOSIS
Uncomplicated gallstone disease
Acute cholecystitis
Sphincter of Oddi dysfunction
Functional gallbladder disorder
Liver disease
Hematologic disorders
Biliary obstruction from any cause
BILIARY COLIC
JAUNDICE
Choledocholithiasis can typically be differentiated from these other entities based on the patient's history, laboratory tests, and abdominal imaging.

21. MANAGEMENT The mainstay is removal of the common bile duct stone:
Endoscopically
Surgically.
To identify and treat the complications of choledocholithiasis:
Pancreatitis
Acute cholangitis
The mainstay of the management of choledocholithiasis is removal of the common bile duct stone either endoscopically or surgically. It is also important to identify and treat the complications of choledocholithiasis, such as acute pancreatitis and acute cholangitis

22. The approach to stone removal depends on when the stone is discovered.
If the stone is detected before or after cholecystectomy:
ERCP
If the stone is detected during surgery includes:
Intraoperative ERCP
Intraoperative common bile duct exploration
Laparoscopic
Open
Postoperative ERCP.
Intraoperative common bile duct exploration is performed selectively, based on surgeon preference and local expertise. Open common bile duct exploration is more widely available than laparoscopic common bile duct exploration but is associated with significantly more complications

23. Thanks…

24. CLINICAL CASE PRESENTATION
GERNERAL SURGERY, GROUP 1