Case History Surgery Chole Cystitis

7/28/2019 Case History Surgery Chole Cystitis

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First Moscow State Medical University

MEDICAL FACULTY

Division of Foreign Students with Instruction Conducted in English

Department of Surgery

CASE HISTORY

By Mardiana Kamal

Medical Faculty, English Medium, Group 93

Supervisor: , MD PhD

MOSCOW 2012


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Personal data of the patient

Name :

Age : 80 years old

Date of birth : 11.11.1931

Sex : Female

Weight : 60 kg

Height : 156 cm

Occupation : Pensioner

Marital status : Married

Department : Surgery

Date of Admission : 11.03.2012

COMPLAINTS

The patient complained of feeling heaviness in region of under right costal arc, periodically appeared

pain after eating fatty food.

ANAMNESIS MORBIThe patient, , was admitted to the 79th Hospital on 11.03.2012 with the

complaints of feeling heaviness in region of in region of under right costal arch, already 5 years. On the

same day, she went to the polyclinic, was asked to go to the hospital and she was admitted.

Investigations were performed: Ultrasound investigation of abdominal cavity revealed concrement in

gall bladder.

ANAMNESIS VITAE

Anamnesis familiae

The patient is widowed and has 1 child. Her daughter was also admitted to the hospital two years ago

with the same complaints.

Physical abnormalities: The patient grew normally without any physical abnormality.

Previous medical history

The patient had never been admitted to any hospitals before. Although, she has diagnosed previous

case of ARVI, Ischemic Heart Disease, Arterial Hypertension, and Chronic Obstructive Pulmonary

Disease. No information on usage of medical preparations.

Epidemiological anamnesis: She does not have any current infection. She seldom has tonsilits.

Harmful habits: Patient does not smoke or drink

Previous blood transfusion: Patient had previous no blood transfusion

Allergic history: There is no known allergy in this patient.

STATUS PREASENS

The patients condition is satisfactory. She is well and alert. She is coherent and fluent.


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CONSTITUTION

The patient had a normal constitution.The external features of the body correlates to her age.

POSTURE

The patient was normal and active. She did not have any discomfort during inspection and was not

assuming a forced position.

Height 1.56 m, weight 60kg.

BMI = 23 - normal

SKIN

The patient got a clear pink skin. There were no hyperpigmentations of the skin. The skin was evenly

colored with no jaundice. There were no abnormal discolorations of the mucous membranes. The skin of

the patient was dry.

SUBCUTANEOUS FAT

Patients subcutaneous fats are uniformly distributed. There is no excessive fat accumulation. Wasting

was also not noticed in this patient.

EDEMA

No edema was visible in this patient. The eye lids appear normal with no narrowing of the slits. The

patients ankle and legs were checked and there was no pitting edema. Acsites was absentand no

generalized form of edema was found in this patient (anasarca).

LYMPH NODES

Regions Visual inspection Palpation Characters

Submandibular Not visible Palpable, not enlarged

(0.5cm)

Mobile without

skin attachment

Cervical Not visible Palpable, not enlarged(0.5cm)

Mobile withoutskin attachment

Supraclavicular Not visible Not palpable -

Axillary Not visible Palpable, not enlarged

(0.5cm)

Mobile without

skin attachment

MUSCULAR SYSTEM

There were no local atrophies of the skeletal musculature observed in this patient. There was no

functional skeletal muscle dysfunction (cramps).

BONESThe bones of the skull, chest, spine and extremities were normal without any abnormal bulge or

deformities. Patients general bone configuration is normal. There is no abnormal growth or elongation

(gigantism) of the patients bone structures.


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RESPIRATORY SYSTEM

Inspection of the chest

The patient was examined in an upright sitting position in her room. The patients clavicles and the

shoulder blades are at the same level and the supra-clavicular fossa and the sub-clavicular are equally

pronounced on each sides.

Respiratory movements:

The respiratory movements of the patient were normal since the patient was not assuming a forced

position and there was no evidence of involvement of the accessory respiratory muscles.

Respiratory type: The respiratory type was thoraxic breathing.

Respiratory rate: 15 breaths per minute.

Respiratory rhythm: Rhythmic of uniform depth and equal length of the inspiration and expiration.

Constitution: The patient had a normostenic constituition. The costal angle is not more than 90 degrees.

Pain and tenderness:

Pain and tenderness (both local and diffuse) are absent in the patients thoracic region.

Elasticity (resilience):

The patients chest is of normal decreased elasticity.

Vocal fremitus:Vocal fremitus normal in this patient. The vocal fremitus was about the same intensity with no changes

in symmetrical parts of the thoracic cavity.

Percussion of the chest:

Comparative percussion:

Pulmonic sound with an admixture of tympani. The so-called hyper-resonant sound is heard in

symmetrical points of patients thoracic cavity.

Topographic percussion:

Upper borders of the lungs:

Borders of the lungs Right lung Left lung

Upper anterior border 3 cm above the clavicle 3 cm above the clavicle

Upper posterior border Spinous process of the 7th

cervical vertebra

Spinous process of the 7th

cervical vertebra

Kroenigs area normal normal

The lower borders of the lungs:

Topographic lines Right lung Left lung

Linea parasternalis 5th

intercostals space -

Linea midclavicularis 6th

rib -

Linea axillaris anterius 7th rib 7th rib

Linea axillaries medius 8th rib 8th rib


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Linea axillaris posterius 9th rib 9th rib

Linea scapularis 10th rib 10th rib

Linea paraspinalis Spinous process of the 11th

thoracic vertebra

Spinous process of the 11th

thoracic vertebra

Mobility of the lower lung borders:

Mobility of the lower lung borders are without any peculiarities, with normal parameters.

Auscultation of the lungs:

Vesicular breathing:

The patient had clear vesicular breathing with normal inspiration and expiration phases.

Bronchial breathing:

Bronchial breathing is heard over the larynx, and trachea.

Bronchophony:

Normal bronchophony. The loud whispering voice of the patient is audible on both side of the chest in

symmetrical points.

CARDIOVASCULAR SYSTEM

General inspection of the cardiovascular system:

Patient appears calm with no signs of breathlessness, anxiety or discomfort.

Examination of the neck region:

No carotid shudder is felt.

Neck veins are not visible.

Arterial blood pressure: 140/80 mmHg

Pulse Rate : 78 beat per minute

Palpation of the apex beat: Apex beat in this patient was not palpable.

Palpation of the pulse:

Carotid artery:

- Pulse not visible, but felt- Regular pulse with regular resistance and strengthAxillary artery:

- Pulse not visible, but felt- Regular pulse with regular resistance and strengthInguinal artery:

- Pulse not visible, but felt- Regular pulse with regular resistance and strengthPopliteal artery:

- Pulse not visible, but felt- Regular pulse with regular resistance and strengthTibialis posterior:

- Pulse not visible, but felt- Regular pulse with regular resistance and strengthDorsalis pedis:

- Pulse not visible, but felt- Regular pulse with regular resistance and strength


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Palpations of apex beat: palpated 2cm medial to the left midclavicular line.

Auscultation:

Points S1 S2 S3 S4

1st

point Normal Normal _ _

2nd point Normal Normal _ _

3rd point Normal Normal _ _

4th point Normal Normal _ _

Botkin-erbs point Normal Normal _ _

Auscultatory findings: No pathologies were found

Percussion of the heart:

Relative heart dullness:

Relative borders of the heart Dullness levels

Right border 3 cm laterally to the right edge of the

sternum

Left border 1 cm medially from the midclavicular line

Upper border 3rd

intercostals space

Absolute heart dullness:

Absolute borders of the heart Dullness levels

Right border Left edge of the sternum

Left border 1 cm from the relative heart dullness

Upper border 4th

intercostals space

Configuration of the vascular bundle:

The configuration of the vascular bundle is without any peculiarities.

Configuration and assessment (shape) of the heart dullness:The heart dullness is relatively normal with no mitral or aortic (so-called sitting duck or boot shaped)

configuration of the heart dullness.


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URINARY SYSTEM

Inquiry:

Patient had no complains. She has no pain or any discomfort in her lumbar region. The patients

micturation is normal with no pain of discomfort during this process.

Physical examination:

Inspection:

There are no physical signs of fetor uremicus. There is no abnormal swelling or protrusion in the

patients loin region.

Palpation:

The kidneys were impalpable. No tenderness over renal

ENDOCRINE SYSTEM


Inspection:

Patients general outlook does not indicate any endocrinal abnormalities.Patients mental and

emotional state was normal. Her sleeping patterns have not changed.

CENTRAL NERVOUS SYSTEM

Inquiry:

Consciousness : conscious and alert

Headache : absent

Dizziness : absent

Sleeping disorders : absent

Memory status : Normal

STATUS LOCALIS (Digestive system)

Physical examination of the gastrointestinal tract:

Inspection:The general appearance of the patient is satisfactory and there is no evidence of poor nutritional state

or cachexia.

Oral cavity: no foul smell or any other unpleasant odor.

State of the teeth : no cavities were present.

State of the gums: pink color without hemorrhages, no ulceration and no purulent inflammation.

State of the tongue: the tongue is clean and moist with visible papillae.

Palpation of the Stomach: soft, without pain

Schutkin-Blumberg sign : Negative

Peritoneal signs : Negative

Ortner sign : Negative

Auscultation : normal bowel sounds


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LIVER AND THE GALL BLADDER


The inspection was carried out during the day in a room with proper light settings. The habitusof the patient was normal. No icteric of the sclera. Normal pinkish colour of all parts of the tongue,

palms and soles.

Skin:

No abnormal discoloration of the skin. Few scratch marks were revealed during inspection. No hemorrhagic diathesis. No spider angiomatas.Percussion of the liver:

Topographic lines Superior liver borders Inferior liver borders

Linea axillaris anterior

dextra

7th rib 10th rib

Linea midclavicularis dextra 6th rib Arcus costalis

Linea parasternalis dextra Superior edge of the 6th

rib 2 cm below the interior

edge of the right costal arch

Lines mediana anterior _ 3 cm below the base of the

xiphoid process

The left border of the liver dullness was on the linea parastenalis sinistra.

Palpation of the liver and gallbladder:

Palpation of the liver: Palpation was not performed due to post-operative drainage at right hypogastric

region.

Gall bladder

Murphys sign Negative

Otners sign Negative

Georgivsky- de musses sign Negative

Spleen

Palpation of the Spleen:

The spleen was impalpable.

Percussion of the spleen:

Axis Measurements

Transverse axis 5.5 cm

Long axis 7 cm


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PRESUMPTIVE DIAGNOSIS

Chronic Cholecystitis.

Methods of investigations

Common blood count Biochemical blood test Common urine test Prothrombin index HBs Ag, antiHCV, HIV test Ultrasound examination Oesophagogastroduodenoscopy ECGInstrumental and laboratory methods

General analysis of the blood

Date of the sample: 13.03.2012

Parameters Obtained results

WBC 11.1 10^9 /l

RBC 4.21 10^12 /l

HGB 116 g/l

Hematocrit 37.4

Platelet 182 10^9/l

Mean Corpuscular Volume 89 fl

Mean Corpuscular Hemoglobin 27.5 pg

MCHC 311 g/l

Lymphocyte 26 %

Monocyte 6 %

Granulocyte 69 %

Biochemical Analysis of the Blood

Date: 13.03.2012

Parameters Results

Total Protein 63 g/l

Albumin 38g/l

Urea 6.3 mmol/l

Total bilirubin 9.9 micromol

Iron 6.6 mmol.l

Creatinine 101.1 micromol/l

Cholesterin 6.1 mmol/l

Tryglyceride 1.04 mmol/l


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AST 46 E/l

ALT 38 E/l

a-Amylase 27 E/l

Alkaline Phosphotase 160 E/l

Glucose 4.1 mmol/l

General analysis of patients urine sample

Date of sample: 14.09.2011

Properties Results

Color yellow

Transparency clear

Urine pH 6.0 - acidic

Reactivity to blood negative

Protein 0.5 g/l

Ketone body 4 mmol/l

Bilirubin Pigments 8.5 umol/l

Urobilin 34 umol/l

Leucocytes 250 Leu/uL

Prothrombin index (13.03.2012) : 84%

HBs Ag test : Negative

antiHCV test : Negative

HIV test : Negative

ULTRASONOGRAPHY INVESTIGATIONSDate 11.03.2012

Concrement in gall bladder. Chronic calculous cholecystitis, bile duct not dilated.

Date : 13.03.2012

Separated from subdiaphragmatic peritoneum on the right and left, obstructive, near the spleen in the

lateral left and right canals. In pelvic cavity, no peculiarities identified.

Intrahepatic bile ducts are not dilated. In region of gallbladder, fluid delineated structures are not

identified. Hepaticocholedochus : 5.5 6mm

Liver:Parenchyma : Changed

Focal changes : None

Intrahepatic duct : Poor

Gallbladder:

Deformed, Size increased, wall is without changes. Contents are non-homogenous. Palpation in region

of gallbladder is without pain. Common bile duct is without changes.


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Pancreas:

Normal value, not dilated, no focal changes

Spleen :

No significant changes

Conclusion : Cholelithiasis. Chronic Calculous Cholecystitis.

ENDOSCOPIC INVESTIGATIONS

Esophagogastroduodenoscopy:

Date: 12.09.2011

Patients throat was anesthetized with 10 % of lidocaine. There was no obstacle in the passage of the

fiberscope. The esophageal lumen was free. The opening at the esophagealgastric junction not

deformed. Mucosa is pale-pink. There are no pathogenic changes in the esophagus. Cardiac sphincter

does not close completely. Evacuation from oesophagus is normal. Empty stomach with mucous. Folds

in normal form, during insufflation of air expanded satisfactorily. Peristalsis symmetrical. Mucosal focal

hyperaemia. Angle of stomach, antral part without peculiarities. Evacuation is normal. Duodenum iswithout peculiarities. Mucosal layers is without defect. Postbulbar part is normal.

Conclusion : Chronic Gastroduodenitis

ELECTROCARDIOGRAPHIC INVESTIGATIONS

Sinus rhythm with no signs of current attact of coronary heart disease.

CLINICAL DIAGNOSIS

Chronic Calculous Cholecystitis

LAPAROSCOPIC CHOLECYSTECTOMY

Under endotracheal anaesthasia, impositioned pneumoperitoneum and administrated trocar in typical

points.

Video revision : No effusion in peritoneal cavity. Gall bladder normal size. Wall is thickened, fused and

sealed to duodenum. Bile duct is visually not dilated. Fusion is dissected, removed bladder duct and

artery, clipping and separately crossed. Bladder is separated from position with coagulation after.

Hemostasis in course of operation. Bladder is extracted from peritoneal cavity through paraumbilical

puncture. Peritoneal cavity drained. Removed pneumoperitoneum. Suture on punctures.

MEDICATION

1. Ketorol 1.0 / D2. Ceftriaxone 1.0 2x/D3. Analgia 50% 2.0 (if pain arises)


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CONCLUSION

The patient was diagnosed with chronic calculous cholecystitis.

The diagnosis in this patient was confirmed through instrumental investigation by ultrasonography of

the right hypochondriac region. Diagnosis was also achieved with relation to patients symptom of

feeling heaviness in region under costal arch.

During ultrasonography on 11.03.2012, concrement in gall bladder was revealed. Chronic

calculous cholecystitis was the presumptive diagnoses. During ultrasonography on 13.03.2012, signs of

Intrahepatic bile ducts are not dilated. In region of gallbladder, fluid delineated structures are not

identified. Hepaticocholedochus : 5.5 6mm. The was also an increase of urobilin in her urine test.

Patients with choledocholithiasis may be completely asymptomatic; symptoms occur

when the stones obstruct the CBD. The ultrasonography confirmed the diseases.

In the hospital, the patient had undergone laparoscopic cholecystectomy under

anesthesia as treatment.

DIFFERENTIAL DIAGNOSIS

Acute gastritis Amoebic hepatic abcess Appendicitis Biliary colic Cholangitis Cholangiocarcinoma Acute pancreatitis Nephrolithiasis Gastric ulcer Peptic ulcer disease


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CHRONIC CALCULOUS CHOLECYSTITIS

Chronic cholecystitis is gallbladder

inflammation that has lasted a long time. It

almost always results from gallstones. It is

characterized by repeated attacks of pain

(biliary colic). In chronic cholecystitis, the

gallbladder is damaged by repeated attacks of

acute inflammation, usually due to gallstones,

and may become thick-walled, scarred, and

small. The gallbladder usually contains sludge

(microscopic particles of materials similar to

those in gallstones) or gallstones that block its

opening into the cystic duct or reside in the

cystic duct itself.

PATHOPHYSIOLOGY

Gallstones result from supersaturation of cholesterol in the bile, which acts as an irritant, producing

inflammation in the gallbladder, and which precipitates out of bile, causing stones. Risk factors include

gender (women four times as like to develop cholesterol stones as men), age (older than age 40),

multiple parity, obesity, use of estrogen and cholesterol-lowering drugs, bile acid malabsorption with GI

disease, genetic predisposition, rapid weight loss. Pigment stones occur when free bilirubin combines

with calcium. These stones occur primarily in patients with cirrhosis, hemolysis, and biliary infections.

Acute cholecystitis is caused primarily by gallstone obstruction of the cystic duct with edema,

inflammation, and bacterial invasion. It may also occur in the absence of stones, as a result of major

surgical procedures, severe trauma, or burns.

Chronic cholecystitis results from repeated attacks of cholecystitis, presence of stones, or chronic

irritation. The gallbladder becomes thickened, rigid, fibrotic, and functions poorly.


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CLINICAL PRESENTATION

Recurrent episodes of biliary pain in the right upper abdomen, sometimes in epigastrium, often with

irradiation to the right scapular region. Biliary pains may be in the right hypochondrium, frequently or

occasionally, of different intensity and duration, related to intake of fatty meals.

1. In addition, a biliary pain may occur with one or more of the following symptoms:a. regular or periodical feeling of bitter tasteb. nausea, sometimes vomitingc. regular or periodical abdominal bloating and borborygmusd. unstable stool with constipation or diarrhea prevailing2. Impaired gallbladder emptying.3. According to ultrasound examination, thickening of the gallbladder wall up to 3-4 mm and presenceof gallstones in the gallbladder lumen.


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Chronic cholecystitis on ultrasonography

MEDICATION

For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, analgesia, and

intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy with a single broad-

spectrum antibiotic is adequate.

The current Sanford guide recommendations include

piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or meropenem (Merrem, 1 g IV q8h).In severe life-threatening cases, the Sanford Guide recommends

imipenem (500 mg IV q6h) third-generation cephalosporin plus Flagyl (1 g IV loading dose followed by 500 mg IV q6h).Pathogenetic treatment of patients with chronic calculous cholecystitis

Accordingly, treatment of chronic calculous cholecystitis (with biliary pain) aiming for prophylactics of

the acute calculous cholecystitis, duodeno-gastral reflux, antral atrophic (bile-acid-dependent) gastritis

and chronic biliary pancreatitis includes:

1. Celecoxib - 100 mg, 2 times a day after meal for 5-7 days, after which2. Ursodeoxycholic acid - 750 mg, once a day (in the evening) for 3 month.Celecoxib is a selective inhibitor of COX-2. Inhibiting COX-2 activity in the smooth muscle cells of thegallbladder wall and cystic duct it brings relief of the biliary pain within 3-5 days, restoration of the

evacuation function of the gallbladder and the gallbladder-dependent output of biliary cholesterol,

active and passive passage of the hepatic bile into the gallbladder, and decrease in the gallbladder-

independent enterohepatic circulation of bile acids, biliary cholesterol and biliary bilirubin.

Celecoxib, a selective inhibitor of COX-2, inhibiting COX-2 activity in the epithelial cells of the gallbladder

mucosa causes inhibition of the glycoprotein mucin hypersecretion into the gallbladder lumen,


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concentration of glycoprotein biliary mucin in gallbladder bile and viscosity of gallbladder bile, which

prevents formation of biliary sludge.

Low COX-2 activity in the epithelial cells of the gallbladder mucosa helps restoring the absorption

function of the gallbladder (absorption of water and biliary cholesterol from phospholipid vesicles),

which results in increase of concentration of total bile acids and decrease of concentration of biliary

cholesterol in the gallbladder bile. Also, low COX-2 activity in the epithelial and smooth muscle cells of

the gallbladder infundibulum helps lowering the risk of development of acute calculous cholecystitis.

Ursodeoxycholic acid, is a hydrophilic hepatoprotective bile acid. It helps in dissolving the cholesterol

monohydrate crystals in the gallbladder, decrease of lithogenicity of gallbladder and hepatic bile,

disappearance of the chronic bland intrahepatic cholestasis (i.e. results in the restoration of the

accumulation and excretion functions of liver) and in some patients helps in dissolving cholesterol

gallstones.

Celecoxib and Ursodeoxycholic acid, blocking main pathogenetic mechanisms of gallstones formation,

help in slowing down the growth of cholesterol gallstones and lower the risk of acute calculous

cholecystitis. In some patients the chronic calculous cholecystitis can transfer into the gallstone disease(without biliary pain) or the silent gallstones group.

Estimated effectiveness is 95%.

Remission period is 18-24 months.

Contraindications for Celecoxib:

allergic reactions (nettle-rash, bronchial spasm) to acetylsalicylic acid or other NSAIDs (inanamnesis);

3rd trimester of pregnancy; high sensitivity to sulphonamides; high sensitivity to any component of the preparation.Contraindications for Ursodeoxycholic acid: high sensitivity to the preparation; acute inflammatory diseases of the gallbladder and the bile ducts; ulcerative colitis; Crones disease.

MANAGEMENT

Patients should be fasted, rehydrated with intravenous fluids, and given oxygen therapy and adequate

analgesia. Indometacin (25 mg three times daily for a week) can reverse the inflammation of the gallbladder and the contractile dysfunction seen in the early stages (first 24 hours) of cholecystitis. The

prokinetic action of indometacin will also improve postprandial emptying of the gall bladder in patients

with gallbladder disease. A single intramuscular dose of diclofenac (75 mg) may substantially decrease

the rate of progression to acute cholecystitis in patients with symptomatic gall stones.Because of the

risk of superimposed infection, intravenous antibiotics should be started empirically if the patient has

systemic signs or if no improvement is seen after 12-24 hours. A second generation or newer

cephalosporin should be used (for example, cefuroxime 1.5 g every 6-8 hours) with metronidazole (500


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mg every 8 hours). Non-operative managementsolvent dissolution therapy or extracorporeal

shockwave lithotripsyhas been used with variable results to treat chronic cholecystitis in patients unfit

for surgery, but it has no place in the management of acute cholecystitis.

TREATMENT

For patients with symptomatic gallstones and suspected common bile duct stones, either preoperative

endoscopic cholangiography or an intraoperative cholangiogram will document the bile duct stones. If

an endoscopic cholangiogram reveals stones, sphincterotomy and ductal clearance of the stones is

appropriate, followed by a laparoscopic cholecystectomy. An intraoperative cholangiogram at the time

of cholecystectomy will also document the presence or absence of bile duct stones.

Laparoscopic

common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be

retrieved in the same setting (see Choledochal Exploration). If the expertise and/or the instrumentation

for laparoscopic common bile duct exploration are not available, a drain should be left adjacent to the

cystic duct and the patient scheduled for endoscopic sphincterotomy the following day. An open

common bile duct exploration is an option if the endoscopic method has already been tried or is, for

some reason, not feasible. If a choledochotomy is performed, a T tube is left in place. Stones impacted in

the ampulla may be difficult for both endoscopic ductal clearance as well as common bile duct

exploration (open or laparoscopic). In these cases the common bile duct is usually quite dilated (about 2

cm in diameter). A choledochoduodenostomy or a Roux-en-Y choledochojejunostomy may be the best

option under this circumstance.


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OPERATIVE APPROACH

Surgery is indicated if the patient's condition deteriorates or when generalised peritonitis or

emphysematous cholecystitis is present. These features suggest gangrene or perforation of the gall

bladder.

Cholecystectomy

Patients with cholecystitis who undergo early laparoscopic cholecystectomy (before symptoms have

lasted 72-96 hours) have lower complication rates and lower conversion rates than open

cholecystectomy and shorter hospital stays than those undergoing interval surgery.

Surgery for cholecystitis also has a lower conversion rate than delayed surgery (which is

performed during the index admission after conservative management and after symptoms have lasted

3-5 days). Early surgery also avoids complications when conservative treatment fails. A long time

between onset of symptoms and presentation is associated with advanced disease.

Early laparoscopic surgery is safe and feasible in patients with acute or chronic cholecystitis. If early

interventionless than 72 hours after symptoms startedcan be achieved, oedema planes present

during this period allow the gall bladder to be dissected laparoscopically. Although it is desirable tooperate within this time period, it is often difficult to do so in clinical practice. By the time inflammation

has been present for more than 72 hours, features of chronic inflammation (such as fibrosis)

predominate and make it more difficult to dissect the gall bladder.

Contraindications for laparoscopic cholecystectomy include the following:

High risk for general anesthesia Morbid obesity Signs of gallbladder perforation, such as abscess, peritonitis, or fistula Giant gallstones or suspected malignancy End-stage liver disease with portal hypertension and severe coagulopathy


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Percutaneous cholecystostomy

Percutaneous cholecystostomy is a minimally invasive procedure that can benefit patients with serious

comorbidity who are at high risk from major surgery. Percutaneous cholecystostomy can be performed

at the bedside under local anaesthetic and is suitable for patients in intensive care units and those with

burns. It is the definitive treatment in patients with acalculous cholecystitis or it may be used as a

temporising measureto drain infected bile and delay the need for definitive treatment.

Percutaneous cholecystostomy. A pigtail catheter has been placed through the abdominal wall, the right

lobe of the liver, and into the gallbladder.


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Percutaneous cholecystostomy gives clinical improvement in about three quarters of patients. Mortality

after this procedure is related to comorbidity (for example, pneumonia or myocardial infarction) or pre-

existing sepsis. An incomplete or poor response to cholecystostomy within the first 48 hours may

indicate causes of sepsis other than cholecystitis, inadequate antibiotic coverage, possible complications

(such as dislodgement of the drainage tube), or necrosis of the wall of the gall bladder.

Patients can undergo cholecystectomy after percutaneous cholecystostomy. In patients unfit to be given

a general anaesthetic, the drain can be left in place for more than six weeks to allow radiological

extraction of calculi at a later date.

Risks

The overall risk of laparoscopic gallbladder surgery is very low. The most serious possible complicationsinclude:

Infection of an incision. Internal bleeding. Injury to the common bile duct. Injury to the small intestine by one of the instruments used during surgery. Risks of general anesthesia.Recovery is much faster and less painful after laparoscopic surgery than after open surgery.

The hospital stay after laparoscopic surgery is shorter than after open surgery. People generally gohome the same day or the next day, compared with 2 to 4 days or longer for open surgery.

Recovery is faster after laparoscopic surgery. You will spend less time away from work and other activities after laparoscopic surgery (about 7 to10 days compared with 4 to 6 weeks).


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POSTCHOLECYSTECTOMY SYNDROME

Postcholecystectomy syndrome sometimes occurs when abdominal symptoms develop after surgery to

remove the gallbladder(cholecystectomy). Between 5% and 40% of people who have

thegallbladder removed may experience this syndrome.

Symptoms of postcholecystectomy syndrome may include: Upset stomach, nausea, and vomiting. Gas, bloating, and diarrhea. Persistent pain in the upper right abdomen You can ease diarrhea by taking the medicine cholestyramine. If pain continues, you may have a problem caused by something other than the gallbladder ora gallstone. Other possible causes of abdominal pain include irritable bowel syndrome, stomach (peptic)

ulcers, pancreatitis, or abdominal pain from an unknown cause.

COMPLICATIONS

(1) Gangrenous cholecystitisGangrenous cholecystitis occurs in 2-30% of cases of acute cholecystitis. Men aged over 50 with a

history of cardiovascular disease and leucocytosis (>17 000 leucocytes/ml) have the highest risk of

gangrene of the gall bladder.Gangrene occurs most commonly at the fundus because the vascular

supply often becomes compromised. Urgent laparoscopic cholecystectomy should be considered in

patients at high risk of gangrene, and the surgeon should have a low threshold for conversion to open

cholecystectomy during the procedure.

(2) Gallbladder perforationThe gall bladder is perforated in 10% of cases of acute cholecystitisusually in patients who sought

medical attention after a delay or in those who do not respond to conservative management.

Perforation most commonly occurs at the fundus. After the gall bladder has perforated, patients may

experience transient relief of their symptoms because the gall bladder decompresses, but peritonitis

then develops.

Free perforation presents with generalised biliary peritonitis and is associated with a mortality of 30%.

Localised perforation, with the formation of pericholecystic abscesses, is more common, because the

adherent viscera adjacent to the perforation tend to localise spillage of the contents of the gall bladder.

A mass may be palpable in patients with localised perforation, and computed tomography is the most

useful investigation.

(3) Cholecystoenteric fistulasAn acutely inflamed gall bladder may create a cholecystoenteric fistula by adhering to and causing aperforation in other parts of the gastrointestinal tract. The most common sites for fistulas are the

duodenum and the hepatic flexure of the colon. Decompression of the gall bladder because of a fistula

may cause resolution of the acute cholecystitis. Air in the biliary tree (pneumobilia) can be seen on

abdominal radiographs, and imaging enhanced with contrast agents may show fistulas.

(4) Gallstone ileusGallstone ileusobstruction of the small intestine caused by a gall stone passing from the biliary tract

into the intestinal tract through a fistulashould be considered in elderly patients with no obvious


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cause for the intestinal obstruction. Patients may not have a history of cholecystitis. Mortality (15-20%)

is attributed to delays before surgery is performed or to coexisting medical illnesses. Classic findings on

abdominal radiographs include pneumobilia, intestinal obstructions, and gall stones in unusual sites.

PROGNOSIS

For uncomplicated cholecystitis, the prognosis is excellent, with a very low mortality rate. In patients who are critically ill with cholecystitis, the mortality rate approaches 50-60%, especially inthe setting of gangrene or empyema.

Once complications such as perforation/gangrene develop, the prognosis becomes less favorable. Inpatients who are critically ill with acalculous cholecystitis and perforation or gangrene, the mortality rate

can be as high as 50-60%.

TREATMENT FOR PATIENT

Laparoscopic cholecystectomy was done to remove inflamed choledocus. It was successful to stop

patients complaints and to prevent complications in the future.

POSTOPERATIVE PERIOD

Patient spent his post-operative period in the surgical ward. Her general condition was good with

disappearance of main complaints. Prognosis is good with no post-operative complication and she will

be discharge on 19/03/2012.

RECOMMENDATION

1. Patient should be managed and monitored with correction of fluid and electrolyte abnormalities,Antibiotics for complicating infections, performing imaging studies as appropriate (eg, ultrasound, HBS)

and lab data for follow-up care.

2. Patient should maintain healthy life style

Documents

Case History Surgery Chole Cystitis