1. Ryan Em C. DalmanMD MBA - 070070 February 11, 2010

2.  Present a case of Cholelithiasis History and Physical Exam Differentials Diagnostics  Discuss it’s basic concepts of management

3. Patient History

4.  EI  63-year-old  Female  Born on May 22, 1947  Roman Catholic  Informant: Patient, good reliability

5.  Masakit ang tiyan  (abdominal pain)

6.  Abdominal pain, RUQ Mostly felt after eating oily/fatty food, took pain killers with partial relief Intermittent and described as crampy No radiation Pain 5/10 No yellowing of skin, no nausea, no vomiting, no fever, no blood in stool, no history of trauma  Sought consult Diagnosed with cholelithiasis and liver cirrhosis via ultrasound and CT Discharged with pain and other unrecalled medications  Symptoms resolved 3 years PTA No recurrence of symptoms

7.  RUQ pain 10/10 Sudden, episodic, sharp and crampy After eating oily/fatty food  Fever, undocumented  Yellowing of skin  Vomiting 1x Non-projectile, non-bloody, non-bilous  Tea colored urine  No radiation  Consult at a local clinic, given pain medications and was discharged  No nausea, no fever, no acholic stool, no change in bowel movement 1 month PTA Consult Symptoms persisted

8. General: no weight loss, no change in appetite Cutaneous: no lesions,no pruritus HEENT: with occasional headaches no redness no aural/nasal discharge no neck masses no sore throat Cardiovascular: no easy fatigability, fainting spells, no palpitation Respiratory:no cough, colds Genitourinary: no pain in urination, no genital discharge Endocrine: no polyuria, polydypsia, no heat/cold intolerance Muskuloskeletal: no weakness, numbness on all extremities Hematopoietic: no easy bruisability, or bleeding

9. No Hypertension No Diabetes, Asthma No Cancer, Allergies Liver cirrhosis, probably 2 o to schistosomiasis (2008) Previously treated for PTB s/p BTL Not taking any maintenance medications

10.  History hypertension  No heart disease, cancer, stroke, diabetes, asthma, or allergies

11.  Owns a small business  Used to dwell in the rice fields as a kid  Lives with her family  Non-smoker  Occasional alcoholic beverage drinker  No substance abuse

12. Physical Exam

13.  Icteric sclerae Abdomen  Flabby  Direct tenderness RUQ  No murphy’s sign  No rebound tenderness

14.  General Survey Awake, coherent, and not in cardiorespiratory distress  Vital Signs febrile at 37.9 o C 130/80 RR 20 bpm HR 71 bpm Height:162cm weight:53kg BMI: 20.2

15.  Skin Jaundiced No rashes, hemorrhages, scars Moist CRT 1-2 seconds

16. Head no lesions Eyes icteric sclerae, pink palpebral conjunctiva pupils 2-3mm Ears no discharge, tenderness Nose septum medline, moist mucosa Throat mouth and tongue moist no TPC

17. Neck no cervical lymphadonapathy no nuchal rigidity Chest adynamic precordium no heaves, thrills, or lifts, PMI at 5 th ICS MCL regular rate, normal rhythm no murmurs Lungs symmetrical chest expansion, no retractions clear breath sounds

18. Abdomen flat, no scars, no lesions normoactive bowel sounds tympanitic on all quadrants direct tenderness on the RUQ no Murphy’s sign no rebound tenderness no masses, no organomegally no psoas, obturator, and Rovsing’s sign

19. History  63 year old female  Diagnosed with cholelithiasis and liver cirrhosis via ultrasound and CT, 3 years  RUQ pain of 1 month  Vomiting  Fever, undocumented  Tea-colored urine  No history of trauma Physical Exam  Jaundiced skin  Icteric sclerae  RUQ tenderness  Febrile at 37.9 o C

21. Acute calculous cholecystitis Liver cirrhosis probably 2 o schistosomiasis

22.  Cholangitis  Malignancy (biliary, pancreatic, ampullary)  Pancreatitis  Appendicitis  Duodenal ulcer  Diverticulitis

23.  Inflammation of the gallbladder  95% caused by gallbladder stones  Begins suddenly as stones block the cystic duct

24.  Presence of 1 or more calculi in the gallbladder 1 in 17 (5.88%) or 16 million people in USA Prevalence lower in Asians 60 years and above: men (12.9%) women (22.4%)

25.  Cholesterol stones - > 85%  Black pigment stones  Brown Pigment stones  Mixed

26.  Female, Fat, Fertile, Forty  Pregnancy  Oral contraceptives  Hyperlipidemia  Total parenteral nutrition

27. Imbalance or change in composition of bile! Supersaturation… …crystallization… …stone formation Gallbladder sludge... (acalculous cholecystitis)

28. Serum  CBC  Liver function test  Bilirubin  Lipase  Amylase

29.  Plain abdominal film 10-15% of cholesterol 50% of pigment stones  Ultrasonography As small as 2mm can be confidently identified  Oral cholecystography (OCG) Used to assess patency of cystic duct and gallbladder emptying function Replaced by US

30.  CT scans Similar findings as in ultrasound To further characterize complications Good for detection of intrahepatic stones or recurrent pyogenic cholangitis  Endoscopic retrograde cholangiopancreatography (ERCP) Common hepatic duct Common bile duct Pancreatic duct

31. Who can undergo surgery?  Symptoms that affect patient’s daily activites  Presence of prior complication of gallstone disease  Underlying condition predisposing patient to increased risk of gallstone complication  Prophylactic cholecystectomy > 3cm stones

32. Laparoscopic Cholecystectomy Shortened hospital stay Complications 4% Conversion to laparotomy 5% Death <0.1% Bile duct injuries 0.2-0.5%

33. Dissolution of stones  Ursodeoxycholic acid Dissolves 80% of cholesterol stones < 0.5cm  Maybe accompanied by extracorporeal shock waves

34.  Elimination of obesity  Low cholesterol diet  High fiber, high-calcium diet  Ingestion of meals at regular intervals  Vigorous exercise  Ursodeoxycholic acid

35. Ryan Em C. DalmanMD MBA - 070070 February 11, 2010