CASE PRESENTATION

Asparo, Lagansoa, Lamis, Lotayco,

Mejica, Mondia, Opina, Ortiz
CASE PRESENTATION
GROUP 4B
 TABLE OF CONTENTS

OBJECTIVES METHODOLOGY
01 You can describe the
topic of the section here
02 You can describe the
topic of the section here

RESULTS CONCLUSIONS
03 ANALYSIS
You can describe the
topic of the section here
04 You can describe the
topic of the section here
 01
General Data, History & PE, Salient
points
 GENERAL DATA
Patient D.C.
74 year old
Female
Filipino
Married
Bacolod City
Roman Catholic
 Chief complaint

EPIGASTRIC PAIN
 History of Present Illness

2 yrs PTA 1 yr PTA In the interim

● (+) on and off epigastric
pain
● Patient tolerated
● No consult done
● No meds taken
● Persistence of ● Persistence of
symptoms waxing and waning
● Omeprazole 40mg epigastric pain
● With noted relief
 History of Present Illness

1 mon PTA 7 hrs PTA In the interim

● (+) epigastric pain (PS ● Persistence of ● Persistence of
5/10) symptoms waxing and waning
● Radiating to the back ● Whole abdomen epigastric pain
● (+) postprandial ultrasound -
vomiting
● Omeprazole- temporary
relief
 Past Medical Family Medical Personal/Social
(+) Diabetes Mellitus No known heredofamilial Non smoker
Metformin 500mg illnesses Non alcoholic beverage drinker
Denies illicit drug use
(+) Hypertension Occupation: Retired what???
Amlodipine 5mg OD

(+) Food and drugs allergy

Penicillin and Raw carrots
 General Survey

NEPTUNE
Neptune is the farthest
planet from the Sun
 Physical Examination

NEPTUNE
Neptune is the farthest
planet from the Sun
RESEARCH RESOURCES

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here
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here
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here
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here
 SALIENT FEATURES

NEPTUNE SATURN
Neptune is the farthest It has several rings. It's
planet from the Sun. It's composed of hydrogen
really cold there and helium

MERCURY VENUS
Mercury is the closest Venus has a beautiful
planet to the Sun and the name and is the second
smallest one planet from the Sun
 02
Differential Diagnoses
 DIFFERENTIAL DIAGNOSES
DDX 1 DDX 2 DDX 3 CHRONIC
MOST LIKELY: MOST LIKELY: MOST LIKELY: CHOLECYSTITIS

MOST LIKELY:
● Recurrent attacks of
LEAST LIKELY: LEAST LIKELY: LEAST LIKELY: epigastric pain
● Pain that radiates to the
back
● (+) Nausea & Vomiting
● RUQ Tenderness

LEAST LIKELY:
 03
Working Impression

Obstructive Jaundice secondary to

Choledocholithiasis
ADMITTING IMPRESSION
 04
Course in the Wards
 Despite being red, Mars is
RESEARCH 1 actually a cold place. It's full
of iron oxide dust
Mercury is the closest planet
to the Sun and the smallest
one in the Solar System
2 EXPERIMENTAL
Neptune is the farthest planet
RESULTS 3 from the Sun. It's also the
fourth-largest object
Venus has a beautiful name
and is the second planet from
the Sun. It’s terribly hot
4 CONCLUSIONS
 PATIENT DC
74/F

● Waxing & Waning of Epigastric Pain

● From nonradiating to radiating to the back
● Postprandial vomiting
● (+) Epigastric tenderness
● (+) RUQ Tenderness
● (-) Murphy’s

Salient Points
 TRIAL TIMELINE
Despite being red, Mars is
RESEARCH 1 actually a cold place. It's full
of iron oxide dust
Mercury is the closest planet
to the Sun and the smallest
one in the Solar System
2 EXPERIMENTAL
Neptune is the farthest planet
RESULTS 3 from the Sun. It's also the
fourth-largest object
Venus has a beautiful name
and is the second planet from
the Sun. It’s terribly hot
4 CONCLUSIONS
 05
CASE
DISCUSSION
ANATOMY
ANATOMY OF BILE DUCTS
SPHINCTER OF ODDI
ANATOMIC VARIANTS
ANATOMIC VARIANTS IN ARTERIAL BLOOD SUPPLY
 GALLBLADDER FUNCTION

● Concentrate, store and regulate the flow of bile

● Secretion of bile

● Bile pH regulation

● Absorption of certain vitamins in our body

● Neurohormonal regulation of the Vagus Nerve

HORMONES & PEPTIDES
BILE FORMATION AND COMPOSITION
 DIAGNOSTIC STUDIES

1. BLOOD TEST
a. Complete blood Count
b. Liver function tests

2. TRANSABDOMINAL
ULTRASOUND

3. COMPUTED TOMOGRAPHY

4. MAGNETIC RESONANCE
IMAGING
a. MRI w/ MRCP  preferred
 DIAGNOSTIC STUDIES

5. Endoscopic Retrograde Cholangiopancreatography

6. Endoscopic Choledochoscopy

7. Endoscopic Ultrasound

8. Percutaneous Transhepatic Cholangiography

 GALLSTONE DISEASE
● “CHOLELITHIASIS”
● most common afflictions of the digestive tract
● Women 3X > men
● First-degree relatives of patients with gallstones have a twofold
greater prevalence
● Most patients are ASYMPTOMATIC
● Symptomatic patients experiences typical symptoms of postprandial
right upper quadrant pain (biliary colic)
● May progress to complications  acute cholecystitis,
choledocholithiasis, cholangitis, gallstone pancreatitis, gallstone
ileus, and gallbladder cancer
 PREVALENCE

 Diet  Surgeries
 Age  Terminal ileal
 Gender resection
 BMI  Gastric surgery
 Ethnic background  Duodenal surgery
 Pregnancy  Rapid weight loss
 Non HDL  Bariatric surgery
hyperlipidemia  Lifestyle changes
 Crohn’s dieases  Medications
 Hereditary  Somatostatin
spherocytosis analogues
 Sickle cell disease  Estrogen containing
 Thalassemia OCPs
 GALLSTONE
DISEASE

Prevalence and Incidence

- Present in between 10% and 15% of adults
- Prevalence of gallstones is related to many factors
- 6Fs: Female, Fat, Forty, Fertile, Family history, Fair
- Pregnancy
- non-HDL hyperlipidemia
- Crohn’s disease
- Blood dso: hereditary spherocytosis, sickle cell
disease, and thalassemia
- Terminal ileal resection and gastric/duodenal surgery
- Rapid weight loss following bariatric surgery
- Medications: somatostatin analogues and estrogen-
containing oral contraceptives
 GALLSTONE
FORMATION

- Major organic solutes in bile

- Bilirubin
- Bile salts
- Phospholipids
- Cholesterol

- Classified by cholesterol content

- Cholesterol stones
- Pigment stones (black or brown)
 GALLSTONE
FORMATION

- Cholesterol stones
- Pure cholesterol (10%) - single large stone
with smooth surface
- Mixed (70%) - multiple, variable in size, may
be hard and faceted or irregular,
multilobed, and soft, colors range from
whitish yellow to green or black

- The primary event in the formation of

cholesterol stones is supersaturation of bile
with cholesterol.
- Cholesterol hypersecretion either through
increased intake or dysfunctional processing.
 GALLSTONE
FORMATION

- Pigmented stones
- <20% cholesterol
- dark due to the presence of calcium bilirubinate

● Black pigment stones

- small, brittle, dark and sometimes spiculated
- supersaturation of unconjugated bilirubin
● Brown pigment stones
- <1 cm in diameter, brownish-yellow, soft, and often
mushy
- Secondary to bacterial infection and bile stasis
 SYMPTOMATIC
GALLSTONES

● Symptomatic Cholelithiasis
- Pain develops when a stone obstructs the cystic duct
- Chief symptom: postprandial RUQ or epigastric pain
(biliary colic)
- Frequently radiates to the right upper back or
between the scapulae
- Pain is severe and comes abruptly during the night or
after a fatty meal
- Pain is constant and increases in severity
- Can last 1 to 5 hours
- Associated with nausea and sometimes vomiting
 SYMPTOMATIC
GALLSTONES

● Symptomatic Cholelithiasis
- Abdominal UTZ is the standard diagnostic test for
gallstones
- Surgical cholecystectomy offers the best long-term
results for patients with symptomatic gallstones
- Laparoscopic approach
- proven to be safe and effective
- Standard of care for symptomatic gallstone
 SYMPTOMATIC
GALLSTONES
● Acute Cholecystitis
- Infection of the gallbladder
- Associated with gallstones in 90-95% of cases
- Gallbladder distention, inflammation, and
edema
- Unremitting RUQ or epigastric pain, more
severe, does not subside and may persist for
several days
- Febrile episodes, anorexia, nausea and
vomiting
- PE: tenderness and guarding, Murphy’s sign is
characteristic
 SYMPTOMATIC
GALLSTONES

● Acute Cholecystitis
- Ultrasonography considered most useful -
documents presence or absence of stones,
gallbladder wall thickening and pericholecystic
fluid
- Cholecystectomy is the definitive treatment and
laparoscopic approach is the procedure of
choice for acute cholecystitis
 SYMPTOMATIC
GALLSTONES

● Choledocholithiasis
- CBD stones are found in 6-12% of patients with
gallstones
- Incidence increases with age

● Primary CBD stones

- Form in the bile duct itself, usually brown pigment
type
● Secondary CBD stones
- Form within the gallbladder and migrate down the
cystic duct, usually cholesterol stones
 SYMPTOMATIC
GALLSTONES

● Choledocholithiasis
- Typical pain similar to biliary colic associated with
nausea and vomiting
- PE may be normal but mild epigastric or RUQ
tenderness as well as mild icterus are common
 SYMPTOMATIC
GALLSTONES

● Choledocholithiasis
- Ultrasonography is useful in documenting gallstones
and CBD size.
- Dilated CBD (>8mm in diameter) on UTZ in a patient
with gallstones, jaundice, and biliary pain is highly
suggestive of CBD stones.
- MRCP provides excellent anatomic detail for detecting
choledocholithiasis
- ERCP is highly effective at diagnosing
choledocholithiasis
 SYMPTOMATIC
GALLSTONES

● Choledocholithiasis
- For symptomatic gallstones and suspected CBD
stones, bile duct clearance and cholecystectomy are
indicated
- Safely achieved either with ERCP or by going directly
to surgery - both approaches are considered safe and
effective, no formal recommendation exists
 SYMPTOMATIC
GALLSTONES
● Cholangitis
- Ascending bacterial infection associated with
partial or complete obstruction of the bile
ducts
- Mechanical hindrance to bile flow facilitates
ascending bacterial contamination from the
bowel
- Combination of both significant bacterial
contamination and biliary obstruction is
required for its development (mc of obstruction:
gallstones)
 SYMPTOMATIC
GALLSTONES
● Cholangitis
- Most common in older and female patients
- Charcot’s triad: fever, epigastric or RUQ pain,
and jaundice
- Reynold’s pentad: fever, jaundice, RUQ pain,
septic shock, mental status changes
- Leukocytosis, hyperbilirubinemia, and elevated
alkaline phosphatase and transaminases are
common
- Initial treatment includes broad-spectrum IV
antibiotics to cover enteric organisms and
anaerobes, fluid resuscitation, and rapid biliary
decompression.
 SYMPTOMATIC
GALLSTONES

● Gallstone Pancreatitis
- Provoked by transient or persistent obstruction of the
pancreatic duct by a stone passing the ampulla.
- Increased ductal pressures cause leakage of
pancreatic enzymes into the glandular tissue
- Initial management is supportive including admission
for bowel rest, IV hydration and pain control
- Antibiotics are not indicated in the absence of signs
of infected pancreatic necrosis
 SYMPTOMATIC
GALLSTONES

● Gallstone Ileus
- Large gallstones erode through the gallbladder wall
directly into the intestine via a choledochoenteric
fistula until they reach an area of fixed obstruction
- Proximal stones can become impacted in the pylorus
or proximal duodenum causing gastric outlet
obstruction (Bouveret syndrome)
- Distal stones may become lodged at surgical
anastomoses or the ileocecal valve causing small
bowel obstruction
 SYMPTOMATIC
GALLSTONES

● Gallstone Ileus
- Patients present with symptoms of obstipation,
nausea, and abdominal pain
- Management of gallstone ileus focuses on relieving
the intestinal obstruction and removing the stone
 SYMPTOMATIC
GALLSTONES

● Cholangiohepatitis
- AKA recurrent pyogenic cholangitis
- Affects both sexes and occurs most frequently in 3rd
and 4th decades of life
- Bacterial contamination of the biliary tree (E. coli,
Klebsiella species, Bacteroides species, or
Enterococcus faecalis, Clonorchis sinensis,
Opisthorchis viverrini, and A. lumbricoides)
- Usually presents with RUQ or epigastric pain, fever
and jaundice
- Relapsing symptoms are one of the most
characteristic features
 PROCEDURAL
INTERVENTIONS FOR
GALLSTONE DISEASE

● Percutaneous Transhepatic Cholecystostomy

Tubes
- Placed into the gallbladder to decompress and drain
a distended, inflamed, hydropic, or purulent
gallbladder
- PTC tubes are most often pigtail catheters inserted
percutaneously under ultrasound guidance