acute cholecystitis

1. Welcome to the morning
session

2. Academic case Presentation:
CHOLECYSTITIS.
🦟
🦟 Dr. ANWAR ALAM and DR FAISAL AHMED
Intern Doctor,
💊 Department of SURGERY,
🏥 Tairunnessa Memorial Medical College and Hospital.

3. Particulars of the Patient:
• Name: Mrs Shahnaz
• Age: 40 years.
• Sex: Female.
• Address: Gazipura.
• Occupation: Housewife
• Religion: Islam.
• Marital Status: married.
• Date & Time of Admission: 18/11/2022 @ 8:30 PM
• Date & Time of Examination: 18/11/2022 @ 8.40 PM

4. Chief Complaints:
• Pain in the right upper abdomen for 4 days
• Vomiting 3-4 times for 2 days

5. History of present illness
• According to the statement of the pateint she was well
before 4 days then she developed sudden severe pain in
the right upper abdomen for 4 days .Her abdominal pain
was colicky in nature and aggravated by taking heavy
meals.She also complained of vomiting 3-4 times for 2
days which contained food particles,bile stained and
projectile in nature . Her bladder habit was normal .She
was normotensive and non diabetic.Then she was
admitted to the hospital for better management.

6. Continue...
• Past History - She has no significant history
• Family History: She has total 4 family members and all are at good
health
• Drugs & Treatment History: She no previous drug history
• Personal History: Nothing significant.

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• Allergy & Immunization History: She has no any allergic
history. She has been immunized as per EPI schedule of
Bangladesh.
• Socioeconomic History: She belongs to middle class family
& lives in flat house with good water supply & well sanitization.
• Menstural history : Lmp 09/11/22
• Menstrual cycle & period : Regular & 5days.

8. General Examination:

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• Appearance: Ill-looking.
• Body Build & Nutrition: Average.
• Decubitus: On choice.
• Cooperation: Cooperative.
• Pulse: 112 beats/min
• Blood Pressure: 110/70 mmHg
• Respiratory Rate: 20 breaths/min
• Temperature: 98°F (at examination time)

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• Anaemia: Absent.
• Jaundice: Present
• Cyanosis: Absent.
• Clubbing: Absent.
• Koilonychia: Absent
• Leukonychia: Absent
• Oedema: Absent
• Dehydration: Present.

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• Neck Vein: Not engorged.
• Thyroid Gland: No thyromegaly.
• Lymph Nodes: No lymphedenopathy.
• Bony Tenderness: No bony-tenderness.
• Pigmentation: No pigmentation were seen.
• Body Hair Distribution: Normal as like female pattern according to
age.

12. Systemic Examination:

13. Gastrointestinal System:
• Mouth & Pharynx:
Lips, gums, mouth, tongue and oral cavity- Nothing abnormality
is
detected.

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• Abdomen:
A. Inspection: abdomen is scaphoid in shape, flanks are empty
and there is no visible pulsation, or scar mark.
B. Palpation:
★ Rigidity & tenderness in right hypochondrium.
( Murphy’s sign positive)
★ Liver- not palpable.
★ Spleen- not palpable.
★ Kidneys- not Ballotable.
C. Percussion: Tympanic.
D. Auscultation: Bowel sound present.

15. Respiratory system:
• Inspection: Chest shape is normal, chest movement is symmetrical &
intercostal spaces were full.
• Palpation: Trachea is centrally placed, Chest expandability is normal and
symmetrical, vocal fremitus was normal.
• Percussion: Resonant.
• Auscultation: Breath sound is vesicular and no added sound is found.

16. Cardiovascular System:
• Inspection: There is no visible carotid & epigastric pulsation and
no cardiac impulse were seen.
• Palpation:
★ Apex beat located at left 5th intercoastal space medial to the mid
clavicular line .
★ Thrill- Absent.
★ Palpable P2: Absent
★ Left Parasternal Heave: Absent.
• Auscultation: 1st & 2nd heart sounds were audible at all
auscultatory area of precordium and there is no murmur present.

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• Other systemic examination revels nothing abnormality.

18. Salient Features:
Sahnaz , 40 years old Female hailing from, Gazipura admitted at
this hospital with the complains of sudden severe pain in the right
upper abdomen for 4 days .Her abdominal pain was colicky in
nature and aggravated by taking heavy meals.She also complained
of vomiting 3-4 times for 2 days which contained food particles,bile
stained and projectile in nature . On general examinations, we
found her pulse- 112 beats/min, blood pressure- 110/70 mmHg,
respiratory rate 18 breaths/min and temperature- 98*F and all other
vital parameters were normal.

19. Salient Feature:
On systemic examinations, we found abdomen was scaphoid in
shape and rigidity & tenderness in right hypochondriac region, on
press on tip of 9th coastal cartilage patient feels pain ( Murphy’s
sign positive), bladder is empty. Other systemic examination
reveals nothing abnormalities.
Patient is normotensive, non-diabetic. Her bladder habit is
normal.

20. Provisional Diagnosis:
• Acute cholecystitis .

21. Differential Diagnosis:
-Acute pancreatitis
-Perforated peptic ulcer

22. Investigations:
• CBC ē ESR.
• Liver function test
. USG of whole abdomen
• S. Creatinine.
• S.Lipase ,S.Amylase
• Urine R/M/E
• RBS
• X-ray abdomen in erect posture
•

23. Investigations:
• CBC-
★ HB%:- 12.5 gm/dL
★ ESR:- 29 mm (1st hour)
★ Total WBC:- 6.6 ×103 /uL
Neutrophil:79% Lymphocyte: 16%
★ Platelet count:- 282×103 /uL
• S. Creatinine- 1.0 mg/dL
• AST- 263.80 U/L
• ALT- 675.00 U/L

24. Investigations:
• Urine R/M/E:- Pus cell: 2-3/HPF
Epithelial cell: 0-1/HPF
• RBS:- 4.2 mmol/L
• S Bilirubin 2.1 mg/dl

26. USG of whole
abdomen
Suggestive of
cholelithiasis with
cholecystitis

27. Confirmatory Diagnosis:
- Acute cholecystitis

28. Treatment & Management at ward:
• Order on Admission:
1. Bed rest.
2. Diet: NPO till further order
3. Inf.H/S (2L) +5% DNS (1L) - I/V @30drops/min. stat
4. Inj.Ceftriaxone ( 1gm ) 1 vial I/V ------- stat & BD
Inj Tramadol hydrochloride (100ml) I/M 1amp ----- stat &BD
5. Inj .Tiemonium methylsulphate (5mg) I/V 1amp --stat &
TDS
6.Inj . Ondansetron (8mg) I/v 1 amp ------ stat & TDS
7. Inj .Esomrprazole (40mg) I/v 1 vial -------- stat & BD

29. Treatment on discharge:
Antibiotic-Cap. Cefixime-400mg....1+0+1 for 7 days
Anti ulcerant-Tab. Esomeprazole 20mg...1+0+1 for 2
months
Anti emetic-Tab. Domperidone 10mg....1+1+1 for 7days
Analgesic-Tab. Ketorolac tromethamine 10mg...1+1+1
Antispasmodic-Tab. Tiemonium methylsulphate 50
mg....1+1+1 for 7days

30. Continue...
Advices:
👉🏼 To take good nutritious diet.Avoid fatty food
👉🏼 To take rest & medicine regularly
👉🏼 To intake plenty of fluid.
👉🏼 To report to the hospital if abdominal pain occurs.

31. THANK YOU