acute cholecystitis
TRANSCRIPT
ACUTE CHOLECYSTITIS
Pableo, Rachel M.
General data
• C.D• 43 y.o.• Female• Married• Roman Catholic• August 4, 1966• Solana,Cagayan• July 29, 2010
Chief complaint
• Right upper quadrant pain
History of Present Illness
• 1 year PTA - recurrent RUQ colicky pain• UTZ – cholecystolithiasis• 3 months PTA - consulted a PMD and
Omeprazole was prescribed• Still with RUQ pain - admission
Past Medical History
• August 2009 – surgery due to a laryngeal cyst at SPH
Family History
• unremarkable
Personal and Social History
• Non-cigarette smoker• Non-alcoholic beverage drinker
Review of Systems
• Integumentary: (-) pruritus• CNS: (-) seizure, (-) h/a, (-) dizziness• Cardiorespiratory: (-) cough, (-) chest pain• GIT: (-) vomiting, (-) diarrhea, (-) constipation• GUT: (-) oliguria, (-) hematuria, (-) dysuria
• Hematologic: (-) gum bleeding, (-) easy bruisability
• Muskuloskeletal: (-) myalgia, (-) arthralgia• Endocrine: (-) weight loss, (-) loss of appetite,
(-) fever
Physical Examination:
• General Survey: Px is conscious, coherent and not in cardiorespiratory distress
Vital Signs:• BP: 120/90• CR: 98 bpm• RR: 20 bpm• Temp: 36.8 C
• Skin: (-) pallor, good skin turgor• HEENT: pink palpebral conjunctiva• Chest and Lungs: (-) rales, (-) wheezes• Heart: AP, NRRR, (-) murmur• Abdomen: flabby, (+) Murphy’s sign• Extremities: (-) edema, FEP
Impression
• Acute Cholecystitis
Date Diagnostics IVF/Meds
7/29/10 11:45 am CBC, UA, UTZ, Na, K, creatinine, RBS, CXR, 12L ECG Sodium : 149 mmol/L (138-145) Potassium: 4.06 mmol/L (3.5-5.4)Glucose : 5.36 mmol/L (4.10 – 5.90) Creatinine: 60 umol/L (53 – 115)Chloride: 104 mmol/L (96 – 110) ALT: 15 u/L (9 – 72)ALKP: 82 u/L (38 – 126)
•Admit to surgery ward•Secure consent for admission and management•NPO•IVF D5LRS 1L q 8 hrs•Medicines: Ampi-Sulbactam 1.5 mg q 12 hrs ANST• Ranitidine 50 mg IV q 12 hrs• Ketorolac 30 mg IV q 8 hrs•For “E” cholecystectomy•Refer to Medicine for eval’n prior to cholecystectomy
Date Diagnostics IVF/ MedsCBC:Hgb: 109 g/L (120-160)Hct: 0.33 (0.38 – 0.47)Erythrocyte no. conc.: 4.9 (4.5 to 6.0 x 109/L)Thrombocyte no. conc.: 243 (150-400 x 109/L)WBC Diff. Ct.: Neutrophils – 38.4 (35-65)Lymphocytes – 41.3 (20-40)Monocytes – 19.3 (2-8)Eosinophils – 0 (0-5)Basophils – 1 (0-1)U/A:Yellow, sl. TurbidpH 6.0SG 1.030(-) chemical testWBC – 12-15/hpf, RBC 6-9 Bacteria - few
Date Diagnostics IVF/ Meds
7/29/10 3:45 pmBP: 130/90, HR: 81 bpm, RR: 18 bpm
UTZ of of Hepatobiliary tree and PancreasResult: CholelithiasisCXR: no cardiomegaly, no infiltration12L ECG : sinus rhythm, non-specific ST-T wave changes
Patient seen and examinedPatient was referred for eval’n due to cholecystectomyA: stable cardiopulmonary status at the time of examinationP: no absolute CI for the contemplated procedure
Date Diagnostics IVF/ Meds7/30/10 1:00 am Post –op orders
Status post cholecystectomyNPOMonitor VS q 15 mins. Until stableOR @ 5-6 pm via face maskIVF: Plain NSS x 30 gtts/ min , D5LRS x 30 gtts/minMeds: Intrathecal morphine given Ketorolac 30 mg IV q g hrs after negative skin testTramadol 50 mg IV PRN - moderate to severe painRanitidine 50 mg IV q 8 hrs while on NPO
Date Diagnostics IVF/ Meds7/30/10 8:50 am
7/31/10 (+) BMSoft, non tender
Soft dietIVF: D5LRS 1L q 8 hrsContinue medsProbable discharge tomorrow D/C TramadolMGHDulcolax 2 adult suppository nowBladder draining prior to dischargeHome Meds:Cefuroxime 500 mg TID for 7 daysKetomed 10 mg 1 tab TIDOmeprazole 20 mg BIDFollow-up - Aug. 5, 2010Discharge
GALLSTONE DISEASE
Discussion
Prevalence and Incidence
• one of the most common problems affecting the digestive tract
• Factors : -age- gender- ethnic background
Predisposing conditions:
- Obesity- pregnancy- dietary factors- Crohn's disease- terminal ileal resection
- gastric surgery- hereditary spherocytosis- sickle cell disease- thalassemia
Prevalence and Incidence
• 3x more in women than men• first-degree relatives - twofold greater
prevalence
NATURAL HISTORY
• asymptomatic throughout life• Some progress to a symptomatic stage, with
biliary colic caused by a stone obstructing the cystic duct - may progress to complications related to the gallstones.
• Approximately 3% of asymptomatic individuals become symptomatic per year.
• Complicated gallstone disease develops in 3 to 5% of symptomatic patients per year.
Gallstone Formation
• result of solids settling out of solution• major organic solutes in bile are:
*bilirubin*bile salts* phospholipids*cholesterol
• classified by their cholesterol content as either:* cholesterol stones * pigment stones – black or brown
CHOLESTEROL STONES
• single large stones with smooth surfaces
• contain variable amounts of bile pigments and calcium, but are always >70% cholesterol by weight
• Most cholesterol stones are radiolucent
• Whether pure or of mixed nature: common primary event in the formation of cholesterol stones is supersaturation of bile with cholesterol.
PIGMENT STONES
• contain <20% cholesterol • dark because of the presence of calcium
bilirubinate• Black pigment
stones are usually small, brittle, black,
and sometimes spiculated
• formed by supersaturation of calcium bilirubinate, carbonate, and phosphate
• Brown stones are usually <1 cm in diameter, brownish-yellow, soft, and often mushy
• usually secondary to bacterial infection caused by bile stasis
• major part of the stone: *Precipitated calcium bilirubinate *bacterial cell bodies
ACUTE CHOLECYSTITIS
• secondary to gallstones in 90 to 95% of cases• Obstruction of the cystic duct by a gallstone
is the initiating event that leads to gallbladder distention, inflammation, and edema of the gallbladder wall
• It is an inflammatory process, probably mediated by:* lysolecithin*bile salts* PAF
CLINICAL MANIFESTATIONS
• Attack of biliary colic - unremitting and may persist for several days
• Usually right upper quadrant or epigastrium• Radiate to the right upper part of the back or
the interscapular area - more severe
CLINICAL MANIFESTATIONS
• Febrile• Complains of anorexia, nausea, and vomiting • Reluctant to move
• Focal tenderness (RUQ)• A Murphy's sign, an
inspiratory arrest with deep palpation in the right subcostal area, is characteristic of acute cholecystitis
Laboratory Findings
• mild to moderate leukocytosis (12,000 to 15,000 cells/mm3
• high WBC (above 20,000) - gangrenous cholecystitis, perforation, or associated cholangitis
• mild elevation of serum bilirubin, < 4 mg/mL, with mild elevation of ALP, transaminases, and amylase
• Severe jaundice is suggestive of common bile duct stones or obstruction of the bile ducts
• by severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the gallbladder that mechanically obstructs the bile duct (Mirizzi's syndrome)
DIAGNOSIS
• Ultrasonography is the most useful radiologic test for diagnosing acute cholecystitis
TREATMENT
• IV fluids, antibiotics, and analgesia• Gram (-) aerobes, anaerobes• Typical regimens:
* 3rd generation cephalosporin with good anaerobic coverage * 2nd generation cephalosporin combined with metronidazole
TREATMENT
• aminoglycoside with metronidazole – if the patient is with allergies
• Cholecystectomy – definitive treatment for acute cholecystitis
Laparoscopic cholecystectomy - procedure of choice for acute
cholecystitis
• When patients:* present late (after 3 to 4 days of illness)*unfit for surgery- they can be treated with antibiotics with laparoscopic cholecystectomy scheduled for approximately 2 months later
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