ILA.

02
April 30, 2018
CASE 2 INTEGRATED LEARNING ACTIVITY
Group 2 and 6
3B 2019

CASE PRESENTATION o Most ovarian cysts present little or no discomfort and

 A 25-year old G1P0, 12 weeks AOG, complained of acute are harmless
abdominal pain, of 2 hours duration. She has no fever, nor o The majority disappears without treatment within a few
jaundice. months
 Serum electrolytes were normal. Serum amylase was 3100 o However, ovarian cysts — especially those that have
U/L. Alkaline phosphatase and SGPT were mildly elevated. ruptured — can cause serious symptoms: abdominal
 Ultrasound showed small stones in the gall bladder pain, abdominal distention, shock, etc.
 Most ovarian cysts develop as a result of your menstrual
DIAGNOSIS: G1P0, 12 weeks AOG, Pregnancy, Uterine; cycle (functional cysts)
Threatened Abortion; Acute Gallstone Pancreatitis  Types of functional cysts:
o Follicular cyst - Around the midpoint of the menstrual
SALIENT FEATURES cycle, an egg bursts out of its follicle and travels down
the fallopian tube. A follicular cyst begins when the
follicle doesn't rupture or release its egg, but continues
PERTINENT POSITIVES PERTINENT NEGATIVES to grow.
Health History: Health History: o Corpus luteum cyst - When a follicle releases its egg,
25 years old (-) Fever it begins producing estrogen and progesterone for
G1P0, 12 weeks AOG (-) Jaundice conception. This follicle is now called the corpus
Abdominal pain, 2-hour luteum. Sometimes, fluid accumulates inside the
duration Laboratory Tests: follicle, causing the corpus luteum to grow into a cyst
 Other types of cysts:
Normal serum electrolytes
o Dermoid cysts - Also called teratomas, these can
Laboratory Tests:
contain tissue, such as hair, skin or teeth, because they
Increased serum amylase form from embryonic cells. They're rarely cancerous.
(3100 U/L) o Cystadenomas -These develop on the surface of an
Mildly elevated ALP ovary and might be filled with a watery or a mucous
Mildly elevated SGPT/ALT material.
o Endometriomas - These develop as a result of a
Ultrasound: condition in which uterine endometrial cells grow
Small stones in gall bladder outside your uterus (endometriosis). Some of the
tissue can attach to your ovary and form a growth.
CAUSES OF ABDOMINAL PAIN
Ruptured Ectopic Pregnancy
 There are several causes of abdominal pain in a pregnant
woman, but we focused on these diseases because of the  Ectopic pregnancy is a high-risk condition that occurs in 1.9
manifestations of the patient: percent of reported pregnancies
 The leading cause of pregnancy-related death in the first
SYSTEM DISEASE
trimester
Gynecologic Functional ovarian cysts  If a woman of reproductive age presents with abdominal
Pelvic inflammatory disease pain, vaginal bleeding, syncope, or hypotension, the
Ruptured ectopic physician should perform a pregnancy test
pregnancy o If the patient is pregnant, the physician should perform
Pancreatic Acute pancreatitis a work-up to detect possible ectopic or ruptured ectopic
Pancreatic carcinoma pregnancy
Hepatobiliary Gallbladder polyp o Prompt ultrasound evaluation is key in diagnosing
ectopic pregnancy
Acute cholecystitis
 Equivocal ultrasound results should be combined with
Cholelithiasis, quantitative beta subunit of human chorionic gonadotropin
Choledocholelithiasis levels
o If a patient has a beta subunit of human chorionic
Functional Ovarian Cyst gonadotropin level of 1,500 mIU per mL or greater, but
 Elevated CA125 and ultrasound abnormalities are diagnostic the transvaginal ultrasonography does not show an
of ovarian cysts intrauterine gestational sac, ectopic pregnancy should
 Ovarian cysts are fluid-filled sacs or pockets in an ovary or be suspected
on its surface

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 Diagnostic uterine curettage may be appropriate in patients
who are hemodynamically stable and whose beta subunit of
human chorionic gonadotropin levels are not increasing as
expected
 Appropriate treatment for patients with nonruptured
ectopic pregnancy may include expectant management,
medical management with methotrexate, or surgery
o Expectant management is appropriate only when beta
subunit of human chorionic gonadotropin levels are low
and declining
o Initial levels determine the success of medical
treatment
o Surgical treatment is appropriate if ruptured ectopic
pregnancy is suspected and if the patient is
hemodynamically unstable.
Gallbladder Polyp
 Lesions that project from the gallbladder wall into the
gallbladder interior are called gallbladder polyps (GPs)
 Even though most of the gallbladder polyps are benign in
nature, malignant polyps are present in some cases, and
early detection and appropriate early measure is important
for curative treatment and long-term survival
 The term polypoid lesions of the gallbladder represents a
wide spectrum of findings
 Gallbladder polyps are classified as benign or malignant
o Benign GPs are subdivided into:
 Pseudotumors (cholesterol polyps, inflammatory
polyps; cholesterolosis and hyperplasia)
 Epithelial tumors (adenomas)
 Mesenchymatous tumors (fibroma, lipoma, and
hemangioma)
o Malignant GPs are gallbladder carcinomas
 The presenting symptoms of polypoid lesions of the
gallbladder are nonspecific and vague, and in many cases
asymptomatic
o Polypoid lesions of the gallbladder are often detected
incidentally
 Some patients with gallbladder polyps may suffer nausea,
vomiting, and occasional pain in the right hypochondrium,
due to intermittent obstructions caused by small fragments
of cholesterol that become detached from the gallbladder
mucosa
o Cholesterol polyps may detach and behave clinically as
a gallstone, causing biliary colic, obstruction, or even
pancreatitis
o There are also reports of gallbladder polyps causing
acalculous cholecystitis or even massive hemobilia
 Polyps are sometimes identified on transabdominal
ultrasounds done for right upper quadrant pain
 Abdominal ultrasound is looked upon as the best available
exam for diagnosing gallbladder polyps
o Due to its accessibility and low cost
o Also because of its good sensitivity and specificity
 General features of gallbladder polyps are a non-shadowing
polypoid ingrowth into gallbladder lumen, which is usually
immobile unless there is a relatively long pedunculated
component
 Echogenicity varies with the size
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ILA Case 2
o Small polyps appear echogenic but non-shadowing
o Larger cholesterol polyps tend to be hypoechoic
 Generally, polyps in the gallbladder are demonstrable on US,
only when they are over 5 mm in diameter
o Sonographic differentiation between benign and
malignant polyps (and calculous disease) relies greatly
on the size of a single nonmobile lesion within the gall
bladder
o A gallstone impacted within the gallbladder wall may be
easily mistaken for a polyp on ultrasound scanning
Acute Cholecystitis
 Acute inflammation of the gallbladder wall, in 90-95% of
cases, is due to cystic duct obstruction by a stone
 Pregnancy and being female, which are seen in the case, may
have contributed to development of gallstones
o During pregnancy, physiological changes increase the
likelihood of gallstone formation
 Increased gallbladder stasis
 Increased bile production by approximately 50%,
elevated levels of cholesterol
 Reduced levels of the bile acid chenodexycholic
acid
o Among females, estrogen increases biliary secretion of
cholesterol and progesterone reducing bile acid
secretion by increasing gallbladder stasis
 Inflammatory response can be evoked by three factors:
o Mechanical inflammation produced by increased
intraluminal pressure and distention with resulting
ischemia of the gallbladder mucosa and wall;
o Chemical inflammation caused by the release of
lysolecithin (due to the action of phospholipase on
lecithin in bile) and other local tissue factors, and
o Bacterial inflammation, which may play a role in 50–
85% of patients with acute cholecystitis
 The organisms most frequently isolated by culture
of gallbladder bile in these patients include
 Escherichia coli
 Klebsiella spp.
 Streptococcus spp.
 Clostridium spp,
 The diagnosis of acute cholecystitis is usually based on a
characteristic history and physical examination
o The triad of sudden onset of RUQ tenderness, fever, and
leukocytosis is highly suggestive
 Characteristically, acute cholecystitis pain is steady
and severe
 May also radiate to the right shoulder or back
o Associated complaints may include nausea, vomiting,
and anorexia
o There is often a history of fatty food ingestion about one
hour or more before the initial onset of pain
 During physical examination, patients with acute
cholecystitis are usually ill appearing, febrile, and
tachycardic, and lie still on the examining table of associated
local parietal peritoneal inflammation that is aggravated by
movement
o Abdominal examination usually demonstrates
voluntary and involuntary guarding
 ILA Case 2

 Elicitation of "Murphy's sign" may be a useful diagnostic  Amylase or lipase levels at least 3 times above the reference
maneuver range are generally considered diagnostic of acute
 Typically, leukocytosis in the range of 10,000–15,000 cells pancreatitis
per microliter with a left shift on differential count is found o Serum amylase determinations are routinely available,
 About one-fourth have modest elevations in serum but serum lipase determination yield more specific
aminotransferases (usually less than a fivefold elevation) result
 Elevation in the serum total bilirubin and alkaline  An ultrasound of the abdomen is often indicated in
phosphatase concentrations are not common in pancreatitis to evaluate biliary causes of pancreatitis
uncomplicated cholecystitis o Ultrasonography may provide evidence of a dilated
o Biliary obstruction is limited to the gallbladder common bile duct, presence of gallstones, and swelling
o If present, they should raise concerns about of the pancreas
complicating conditions such as cholangitis, o However, it is often difficult to visualize the pancreas
choledocholithiasis, or the Mirizzi syndrome (a itself with this study, and further investigation is often
gallstone impacted in the distal cystic duct causing needed
extrinsic compression of the common bile duct) o An advantage is that an ultrasound is inexpensive and
 Amylase levels are also typically mildly elevated in non-invasive
cholecystitis. However, in this case, the values are more than  Electrolyte abnormalities seen in pancreatitis are often
three times the upper limit of normal amylase levels associated with dehydration, prolonged vomiting, and
(Normal range: 20-96 U/L) which is highly suggestive of calcium deposits in pancreatic fat
pancreatitis and not cholecystitis (Longo et al., 2015). o Serum potassium and BUN elevations may suggest
 Ultrasound will demonstrate calculi in 90–95% of cases and hypovolemia and should be monitored and treated with
is useful for detection of signs of gallbladder inflammation fluid resuscitation and electrolyte replacements if
including thickening of the wall, pericholecystic fluid, and indicated
dilatation of the bile duct o One particular electrolyte, calcium, is very important in
o However, the mere presence of gallstones is not a sine monitoring the progress of the disease process
qua non for acute cholecystitis, since asymptomatic  Normal calcium value is 8.5-10.1 g/dL for patients
cholelithiasis is a common condition in the general who have a normal serum albumin (3.3 -5.2 g/dL)
population  For patients who have a low serum albumin, the
o Thus, confirmation of the diagnosis must still be based calcium level must be corrected based upon their
upon a combination of physical findings, laboratory serum albumin concentration
studies, and imaging tests
Masyadong mahaba? Check the differentials, baka eto lang
Cholelithiasis ang itanong sa exam.
 Pain termed biliary colic occurs when gallstones or sludge
fortuitously impact in the cystic duct during a gallbladder DIFFERENTIAL DIAGNOSES
contraction, increasing gallbladder wall tension Functional Ovarian Cyst
o In most cases, the pain resolves over 30 to 90 minutes
RULE IN RULE OUT
as the gallbladder relaxes and the obstruction is
relieved 25 years old Asymptomatic during
 An elevated alkaline phosphatase is possibly the most G1P0, 12 weeks AOG pregnancy
sensitive and specific indicator of biliary disease. (+) Abdominal pain, 2-hour (+) Serum amylase: 3100
o However, the ALT and AST may become elevated before duration U/L
the alkaline phosphatase (-) Fever (+) Mildly elevated ALP
 Normal value of alkaline phosphatase is 50-100 U/L and (-) Jaundice (+) Mildly elevated
normal ALT levels ranges at 5-30 U/L SGPT/ALT
(-) Elevated CA125
Acute Gallstone Pancreatitis DECISION: RULED OUT
 The cardinal symptom of acute pancreatitis is abdominal
pain, which is characteristically dull, boring, and steady Ruptured Ectopic Pregnancy
o Usually, the pain is sudden in onset and gradually
RULE IN RULE OUT
intensifies in severity until reaching a constant ache
o Most often, it is located in the upper abdomen, usually 25 years old (-) Vaginal bleeding
in the epigastric region, but it may be perceived more G1P0, 12 weeks AOG (-) Pain on bimanual
on the left or right side, depending on which portion of (+) Abdominal pain, 2-hour examination
the pancreas is involved duration (+) Serum amylase = 3100
o The pain radiates directly through the abdomen to the (-) Fever U/L
back in approximately one half of cases (-) Jaundice (+) Mildly elevated ALP
 Normal range for amylase is 40-140 U/L

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 ILA Case 2

(+) Mildly elevated (+) Mildly elevated

SGPT/ALT SGPT/ALT
No changes in serum β- (+) Serum amylase: 3100
hCG levels and serum U/L
progesterone (+) Small stones in gall
DECISION: RULED OUT bladder
DECISION: RULED IN
Gallbladder Polyp
RULE IN RULE OUT PATHOPHYSIOLOGY
25 years old (+) Small stones in gall  Pregnancy and parity are two important risk factors for the
(+) Abdominal pain, 2-hour bladder formation of cholesterol gallstones in women
duration (+) Possible acoustic  Increased levels of female sex hormones during pregnancy
(+) Serum amylase: 3100 shadowing induce a variety of metabolic changes in the hepatobiliary
U/L system
(+) Mildly elevated ALP o Will ultimately cause bile to become supersaturated
with cholesterol and enhance cholelithogenesis
(+) Mildly elevated
 In the liver, there is “estrogen-ERα-SREBP-2” pathway that
SGPT/ALT
promotes cholesterol biosynthesis and hepatic
DECISION: RULED OUT hypersecretion of biliary cholesterol in response to estrogen
 The circulating estrogen activates the hepatic ERα
Acute Cholecystitis o ERα, then in turn, inhibits the negative feedback
RULE IN RULE OUT regulation of cholesterol biosynthesis while stimulating
the activity of sterol regulatory element-binding-
25 years old (-) Fever
protein-2 (SREBP-2) effecting on cholesterol formation
G1P0, 12 weeks AOG (+) Serum amylase: 3100
 Consequently, the hepatic ERα could also stimulate the
(+) Abdominal pain, 2-hour U/L
activity of ATP-binding cassette (ABC) ABC G5/G8
duration (-) Leukocytosis transporters on the canalicular membrane of the hepatocyte
(+) Mildly elevated ALP and promote biliary cholesterol hypersecretion
(+) Mildly elevated o It is also possible that ERα inhibits the expression levels
SGPT/ALT of ABC11, thereby inducing biliary bile acid
(+) Small stones in gall hyposecretion
bladder
DECISION: RULED OUT Mechanism of Abdominal Pain
 High levels of estrogen and progesterone induce smooth
Cholelithiasis muscle relaxation with subsequent impaired gallbladder
motility functions
RULE IN RULE OUT o Leading to gallbladder stasis and ultimately promoting
25 years old (+) Serum amylase: 3100 gallstone formation in pregnant women
G1P0, 12 weeks AOG U/L  Aside from the estrogen effects, it is also well-known that
(+) Abdominal pain, 2-hour progesterone also is a potent inhibitor of hepatic acyl-
duration coenzyme A: cholesterol acyltransferase (ACAT)
(+) Mildly elevated ALP o Responsible for the hepatic formation of cholestyl
(+) Mildly elevated esters that presumably allows more free cholesterol to
SGPT/ALT enter the intrahepatic pool for biliary secretion
(+) Small stones in gall  Pregnancy also has an effect in bile acid synthesis
bladder characterized by a decreased proportion of
chenodeoxycholic acid (CDCA), thereby reducing the ability
DECISION: CANNOT BE TOTALLY RULED OUT
to solubilize cholesterol thus favoring solid cholesterol
crystals
Acute Gallstone Pancreatitis  All these mechanisms ultimately lead to gallstone formation
RULE IN RULE OUT and its subsequent duct obstruction  ABDOMINAL PAIN
25 years old Normal serum electrolytes
G1P0, 12 weeks AOG Mechanism of Abnormal Liver Function Tests
(+) Abdominal pain, 2-hour  Duct obstruction due to gallstone and ampullary obstruction
duration cause:
(+) Mildly elevated ALP o Pancreatic interstitial edema
o Impaired blood flow leading to ischemia,
o Eventually acinar injury

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 The acinar cell injury in turn would activate proteolysis, fat
necrosis, interstitial inflammation, edema and haemorrhage
 ACUTE PANCREATITIS
 There are two well-known theories that explain its
occurrence:
o Due to reflux of bile into the pancreas due to
obstruction at Ampulla of Vater
o Intraductal hypertension due to outflow blockade at
pancreatic duct
o Penetration of secretion into interstitial tissue
 There are changes in the serum profiles expected in
pregnancy, however, in the majority of published studies,
serum alanine transaminase (ALT) and aspartate
transaminase (AST) activity levels do not change during
pregnancy or remain within the normal limits established in
non-pregnant women
 There are three proposed mechanisms to explain the liver
enzyme elevation after an obstructive process
1) Regurgitation of transaminases from clogged biliary
canaliculi to the liver sinusoids
2) Increased production of the enzymes, and
3) Secretion of transaminases by hepatocytes in response to
increased intrabiliary pressure
 All this would lead to the apparent mild increase in ALT and
ALP
 To note that ALP is a sensitive test for ductal obstruction and
elevation in pregnancy starts at 15 weeks AOG to peak at the
third trimester
Fetal Effects
 Perinatal mortality due to increased toxicity and high
enzyme levels
 Fetal distress, threatened preterm labour, prematurity, in
utero fetal death
 First trimester: lowest likelihood of achieving a term
pregnancy and were highly associated with fetal
complications (pre-term delivery) and mortality
 Term pregnancy is relatively low in the first trimester as
compared to pregnant women on their second and third
trimester.
 Low birth weight, spontaneous abortion and preterm
delivery were observed to occur in any trimester.
 Fetal detrimental effects were prominent during the first
trimester because fetal development is most vulnerable.
 Higher complications in moderately severe and severe acute
pancreatitis than mild acute pancreatitis
 Progression of severity of acute pancreatitis in pregnancy
increases the incidence of fetal distress and fetal loss
 Hypovolemic shock, hypercoagulable state, inflammation
due to pancreatitis, placental abruption and profound
metabolic disturbance > acidosis > changes in the fetal acid-
base status > fetal hypoxemia > compensatory mechanisms >
blood redistribution to cerebrum and myocardium > severe
and sustained hypoxemia > decompensation > fetal demise
Effects on Pregnancy
 Cholelithiasis - Almost always the predisposing condition
for acute pancreatitis
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ILA Case 2
 Characterized by:
o Epigastric pain
o Nausea and vomiting
o abdominal distention
 Hyperemesis - most common misdiagnosis of pancreatitis
in women presenting with severe nausea and vomiting in the
first trimester
 Serum amylase levels of three times upper normal values
confirms the diagnosis of the disease
 Serum lipase activity is also increased and usually remains
elevated with continued inflammation.
 There is usually leukocytosis, and 25% of patients have
hypocalcemia.
 Elevated serum bilirubin and aspartate aminotransferase
levels may signify gallstone disease
 Maternal and fetal mortality rates are declining due to
earlier diagnosis and greater treatment options, which have
improved management of pancreatic symptoms that can
cause preterm labor.
 Possible complications:
o As many as 10 percent have systemic inflammatory
response syndrome, which causes endothelial activation
and can lead to acute respiratory distress syndrome.
o Development of gestational diabetes mellitus
o Preterm delivery
o Short gestational age
o Jaundice
o intrauterine fetal death
 Prognostic factors (If three of the first four features are
documented, survival is only 30 percent):
o Respiratory failure
o Shock
o Need for massive colloid replacement
o Hypocalcemia < 8 mg/d
o Dark hemorrhagic fluid removed with paracentesis
MANAGEMENT
Initial Supportive Care
 Resting the digestive tract by not eating (NPO), pain control
(intravenous administration of meperidine) and aggressive
fluids given through an IV line are essential
 Prevention of hypoxemia and ensure adequacy of fluid
resuscitation is a critical component in the care of patients
with acute pancreatitis
 Aggressive IV fluid replacement is of critical importance to
counteract hypovolemia caused by third space losses and
greater vascular permeability caused by inflammatory
mediators.
 Hypovolemia
o Compromises the microcirculation of the pancreas
o Major contributor to the development of necrotizing
pancreatitis
 Resuscitation involves administration of several liters of
fluid as a bolus, followed by continuous infusion at a rate of
250-500 mL/h
 Clinically, the adequacy of fluid resuscitation should be
monitored by vital signs, urinary output (>0.5 mL/kg/h),
and decrease of hematocrit at 12 and 24 h after admission
 ILA Case 2

 Careful attention should be paid to signs of overhydration,

such as pulmonary edema causing hypoxia
 Consequently, fetal monitoring must also be of utmost
importance ensure stability of both the mother and the fetus.

Management of Underlying Cause

 According to the Society of American Gastrointestinal and
Endoscopic Surgeons, regardless of trimester, laparoscopic
cholecystectomy is the treatment of choice in the pregnant
patient with symptomatic gallbladder disease.
 However, early surgical management is recommended up to
date
 Rates of spontaneous abortion and preterm labor decreased
after laparoscopic cholecystectomy
 Delaying cholecystectomy until after delivery results to high
rates of recurrent symptoms, emergency department visits,
and recurrent hospitalizations.
 Second trimester is the best period for surgery
o Organogenesis is complete
o Uterus is not big enough to obliterate the surgical view
for laparoscopic approach
 The patient in this case is entering the second trimester of
her pregnancy and considering that she and the fetus have
been stabilized in the initial management, the treatment of
choice now is laparoscopic cholecystectomy
 Emphasis on fetal heart monitoring is very important in
the perioperative management.
 Prophylactic use of tocolytics is not recommended
o However, when signs of preterm labor are present, this
should be considered perioperatively

GUYS, take note: Dr. Turingan suggested that we can perform

ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP) for this case

See Appendix for the Guidelines in the management of Acute

Gallstone Pancreatitis

LET’S GO BATCH 2019! 100% PROMOTION!

#2019KAKAYANIN

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 ILA.02
April 30, 2018
CASE 2 INTEGRATED LEARNING ACTIVITY
Group 2 and 6
3B 2019

APPENDIX

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