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“ Middle-aged Stoner” A Case Discussion

“ Middle-aged Stoner” A Case Discussion. Ryan Em C. Dalman MD MBA - 070070. February 11, 2010. Objectives. Present a case of Cholelithiasis History and Physical Exam Differentials Diagnostics Discuss it’s basic concepts of management . Case Presentation. Patient History.

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“ Middle-aged Stoner” A Case Discussion

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  1. “ Middle-aged Stoner”A Case Discussion Ryan Em C. Dalman MD MBA - 070070 February 11, 2010

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

  3. Case Presentation Patient History

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

  5. Chief Complaint Masakitangtiyan (abdominal pain)

  6. History of Present Illness 3 years PTA No recurrence of symptoms • 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 cholelithiasisand liver cirrhosis via ultrasound and CT • Discharged with pain and other unrecalled medications • Symptoms resolved

  7. History of Present Illness 1 month PTA Consult Symptoms persisted • 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

  8. Review of Systems General: no weight loss, no change in appetite Cutaneous: no lesions,nopruritus 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. Past Medical History No Hypertension No Diabetes, Asthma No Cancer, Allergies Liver cirrhosis, probably 2o to schistosomiasis (2008) Previously treated for PTB s/p BTL Not taking any maintenance medications

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

  11. Personal and Social History 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. Case Presentation Physical Exam

  13. Physical Exam (ER) Ictericsclerae Abdomen Flabby Direct tenderness RUQ No murphy’s sign No rebound tenderness

  14. Physical Exam (floors) • General Survey • Awake, coherent, and not in cardiorespiratory distress • Vital Signs • febrile at 37.9oC • 130/80 • RR 20 bpm • HR 71 bpm • Height:162cm weight:53kg BMI: 20.2

  15. Physical Exam • Skin • Jaundiced • No rashes, hemorrhages, scars • Moist • CRT 1-2 seconds

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

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

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

  19. Salient Features 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 • Ictericsclerae • RUQ tenderness • Febrile at 37.9oC

  20. Case Discussion

  21. Primary Impression Acute calculouscholecystitis Liver cirrhosis probably 2oschistosomiasis

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

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

  24. Cholelithiasis • 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. Etiology Cholesterol stones - > 85% Black pigment stones Brown Pigment stones Mixed

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

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

  28. Diagnostics/Workup Serum CBC Liver function test Bilirubin Lipase Amylase

  29. Diagnostics/Workup • 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. Diagnostics/Workup • CT scans • Similar findings as in ultrasound • To further characterize complications • Good for detection of intrahepatic stones or recurrent pyogeniccholangitis • Endoscopic retrograde cholangiopancreatography (ERCP) • Common hepatic duct • Common bile duct • Pancreatic duct

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

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

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

  35. “ Middle-aged Stoner”A Case Discussion Ryan Em C. Dalman MD MBA - 070070 February 11, 2010

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