its all about surgery...

1. Welcome
to
the Morning Session
Dr. Sharmin
Intern Doctor
Department Of Surgery
Tairunnessa Memorial Medical College and
Hospital,Gazipur

2. A LONG CASE ON
•CHOLELITHIASIS

3. Particularsofthepatient:
Name: Moynesa Khatun
Age: 45 years
Sex: Female
Occupation: Housewife
Marital status: Married
Religion: Islam
Present Address: Kunia, Targach, Gazipur
Permanent Adress: Mymensingh
Date of admission : 03.11.2019 at 12.30 pm
Date of examination: 03.11.2019 at 01.00 pm

4. Chief complaints:
1. Pain in right upper abdomen for 3
days.
2. Discomfort In upper abdomen for
1month.
3.Nausea for same duration

5. Historyofpresentillness:
• According to the statement of the patient she was reasonably
well 1month back then she developed right hypochondriac
discomfort which was recurrent and was associated with
nausea. Patient stated that the discomfort was more
pronounced after the consumption of fat containing foods. On
further inquiry patient gave history of 2 episodes of sudden
excruciating right hypochondriac pain which was colicky,
radiating to right shoulder, associated with vomiting that was
followed by intake of oily fried food. Pain had no periodicity
and was not associated with fever with chills and rigors. Her
stool is normal and has no history of steatorrhea. She is non
Diabetic, Non-Hypertensive. With these complains she is
admitted to department of surgery of this Hospital for her
better management.

6. Historyof pastillness:
• She has No significant past medical and
surgical history.
Drug history:
• She has History of taken pain killer but she
couldn’t mention name
Family history:
• All other family members of her family are
apparently healthy.
• Personal History:
She is nonsmoker and non betel nut chewer .

7. Menstrual history:
Her menstrual cycle is regular .
Occupational history:
She is a Housewife.
Socioeconomic status:
She belongs to a middle class family.
Immunization history:
She is not fully immunized as per EPI
schedule of her time.

8. General examination:
•Appearance : Ill looking
• Body built : Average
• Co-operation : Co-operative
• Decubitus : On choice.
• Nutrition : Average
•Anemia : Mild
• Jaundice : Present

9. •Cyanosis : Absent
•Edema : Absent
•Dehydration : Absent
•Clubbing : Absent.
•Koilonychia : Absent.
•Leukonychia : Absent
•Neck vein : Not engorged.
•Pulse : 84 beats/min

10. .
•Blood pressure : 120/80 mmHg.
•Temperature : 98°F.
•Respiratory rate : 18
breaths/min.
•Jugular venous pressure : Not
raised.
•Lymph node : Not palpable.
•Thyroid gland : Not enlarged.
•Weight : 50kg

11. Alimentary system:
Inspection:
Oral cavity : normal
Lips, mouth : normal
Tongue : normal.
SystemicExamination

12. Abdomen proper:
Inspection:
Shape of abdomen : Shape was scafoid
shaped, had normal hair distribution and
wear no visible impulses.
Movement of the abdomen :Moves
with respiration.
Umbilicus : centrally placed,
Inverted and vertical slit
Visible pulsation : Absent
Visible peristalsis : Absent
Scar mark : Absent

13. Palpation:
Superficial palpation:
Temperature : Normal
Tenderness :Soft and slight tender
in Right Hypochondrium
Any mass : Absent
Deep palpation:
Liver : not palpable
Spleen : not palpable
Kidney : not ballotable
Urinary bladder : not palpable

14. Percussion:
Percussion note : Tympanic
Upper border of liver dullness :
Right 5th intercostal space
Shifting dullness : Absent
Auscultation:
Bowel sound : Present
No Hepatic bruit, splenic rub or
renal bruit.

15. Respiratorysystem.
Inspection:
Shape of the chest : Normal
Deformity : Absent
Movement of chest : Normal
Respiratory rate : 18 breaths/min
Any scar marks : Absent
Visible impulse & engorged vein : Absent

16. Position of trachea : Centrally placed
Apex beat : Felt in left 5th intercostal
space just medial to the
midclavicular line.
Chest expansibility : Normal
Vocal fremitus : Normal
Palpation:

17. Percussion:
• Percussion note : resonant
• Upper border of liver dullness : in
right
5th intercostal space in
midclavicular
line.
Auscultation:
• Breath sounds : Vesicular
• Added sounds : absent
• Vocal Resonance : Normal.

18. Cardiovascularsystem:
Inspection:
Deformity of chest : Absent
Visible Cardiac impulse : Absent
Any Scar marks : Absent
Palpation:
Apex beat : Felt in left 5th intercoastal
space just medial to the midclavicular line
Thrill : Absent
Left parasternal heave : Absent
Palpable P2 : Absent
Epigastric pulsation : Absent

19. Auscultation:
Heart sound : 1st and 2nd heart
sounds are audible in all auscultatory
area.
Murmur : Absent
Added sound : Absent

20. Nervoussystem:
Higher psychic function: Intact
Cranial nerve examination: all cranial nerves are
intact
Signs of meningeal irritation:
Neck rigidity: Absent
Kernig’s sign: Negative
Brudzinski’s sign: Negative
Motor function: Normal
Sensory function: Normal
Cerebellar function: Intact

21. Salient Feature:
Mrs Moynesa Khatun, 45 years old
muslim female hailing from kunia targach
,Gazipur was admitted at TMMC&H on
the date 03.11.2019 with complains of
recurrent Right upper abdominal
Discomfort, fatty food intolerance and
nausea since last 1month

22. . On further inquiry she had 2 episodes of
sudden excruciating Right Hypochondriac colicky
pain, radiating to right shoulder, associated with
vomiting which was followed by intake of oily
fried food. Pain has no periodicity and was not
associated with fever with chills and rigors,
patient has no history of steatorrhea. She is non
diabetic.On general examination showed that
patient is non obese while her abdominal
examination revealed that there was slight
tenderness in Right Hypochondrium.

23. .
On general examination, she is co
operative,anaemic and
icteric.Her dehydration,
oedema,cyanosis,clubbing
absent.her pulse 84/m,bp
100/80mmhg,tem 98 F.
Now she is admitted to this
hospital for better management.

24. Provisionaldiagnosis:
Cholelithiasis

25. Differentialdiagnosis:
1. PUD
2. Cholecystitis

26. INVESTIGATIONS
• 1.CBC WITH ESR
• 2.HB%
• 3.BLOOD GROUPING
• 4.URINE R/E
• 5.USG OF W/A
• 6.XRAY OF ABDOMEN
• 7.ECG

34. Confirmatory diagnosis:
Cholelithiasis

35. Plan:
• Laparoscopic Cholecystectomy
under General Anesthesia

36. Treatment:
During admission
Bed rest
Diet: Normal with avoidance of fatty food.
Inf Hartman solution (2L)+5% DNS(1L)
I/V @ 20 drops/min
Tab. Algin (50mg)/Tiemonium methyl sulfate
1+1+1
Tab. Anadol (50mg)/Tramadol hydrocloride
1+0+1- sos
Tab. Maxpro (20mg)/Esomeprazole magnesium trihydrate
----------------------1+0+1 (Before meal)
Tab. Emistat (8mg)/Ondansetron
1+0+1
Tab Rivotril(0.5mg)/Clonazepam
1tab P/O-Sips of water

37. CONSERVATIVE TREATMENT:
• Bed test
• Diet: NPO(TFO)
• Inf H/S(1litre)
• I/V @20drps/min
• Inj Axon/ Ceftriaxone(1gm)
I/V ----stat
Inj Pantobex(40mg)/Pantoprazol Sodium
Sesquihydrate
1vial i/v---stat

38. Definitive treatment:
• Bed rest
• Diet: NPO for 6 hours,then sips of water-semisolid-
solid
• Inf 5%DA(1L) +5%DNS(1L)
• I/V@ 20drps/min
• Inj Axon(1gm)/Ceftriaxone
• 1vial I/V -8hourly
• Inf Flamyd(500mg/100ml)/Metronidazole
• 1bag i/v--8hourly

39. • Inj Torax(30mg)/ketorolac tromethamine
• 1 vial I/M—12 Hourly
• Inj Pantobex(40mg)/Pantoprazol Sodium
Sesquihydrate
1vial I/V---12hourly
• Inj Anset(8mg)/Ondansetron
• 1amp I/V—SOS
• Supp Voltaline(50mg)/Diclofenac Sodium
• 1 stick P/R---SOS
• Supp Napa (500mg)/Paracetamol
• 1stick P/R----S0S
• O2 inhalation—SOS
• Nebulization--sos

40. DURING DISCHARGE;
• 1.Tab Cef-3(200mg)/Cefixime
1+0+1—7days
2.Tab Torax(10mg)/Ketorolac Tromethamine
1+0+1 if pain,after meal -3days
3.Tab Maxpro(20mg)/Esomeprazol Magnesium
Trihydrate
1+0+1 (30 min before meal)-14 days
4.Tab Omidon(10mg)
1+1+1 –5days

41. Advice:
oTake medicines regularly.
oAvoid fatty food.
oYou will have dietary food habits and have
also Vit C enriched fruits except Tamarind.
oIntake plenty of water.
oMaintain proper hygiene

42. Followup
* You will come at 3RD POD for
DRESSING at surgery ward.
• You will come at 6th POD for stitch
off .
•If any complications arise,
consult in OPD of Surgery.

44. SHORT TOPIC ON :
•CHOLELITHIASIS

45. Cholelithiasis
• Cholelithiasis is
derived from the
Greek word
‘CHOL’ means
“Bile” and “LITH”
means ‘Stone’.
• Presence of stones
in the gallbladder
is reffered to as
cholelithiasis.

46. Types of Gallstone
• There are three types of gallstone which is given
below:
• CHOLESTEROL STONES( 80% cholesterol by weight)
vary in color from light yellow to dark green or
brown and are oval 2to 3cm in length,often having a
tiny dark center spot.

47. • PIGMENT STONES are small,dark stones
made of bilirubin,calcium salts and 20%
cholesterol that are found in bile.
• MIXED GALLSTONES typically contain 20-
80% cholesterol.Other common
constituents are calcium
carbonate,palmitate phosphate ,bilirubin
and other bile pigments.Because of their
calcium content,they are other
radiographically visible.

49. Pathophysiology:
• Cholesterol gallstones develop
when bile contains too much
cholesterol and not enough bile
salt.
• Two other factors are important in
causing gallstones are:
• Incomplete and Infrequent
emptying of the gallbladder may
cause the bile to become
overconcentrated and contribute
to gallstone formation.

50. •The second factor is the
presence of proteins in the
liver and bile that either
promote or inhibit cholesterol
crystallization into gallstones.

51. ETIOLOGY:
• Fat
• Forty
• Female
• Fertile
• Drugs
• Heriditary
• Bile stasis

53. Signs and symptoms:
• Gallstones may be asymptomatic,even for
years.These gallstones are called “silent
stones” and do not require treatment.
• Symptoms commonly begin to appear once the
stones reach a certain size(>8mm)
• A characteristic symptom of gallstones is a
“gallstone attack”, in which a person may
experience intense pain in the upper right
side of the abdomen.

54. •Often,attacks occur after a
particularly fatty meal and
almost always happen at
night.
•Abdominal bloating.
•Intolerance of fatty foods.
•Belching.
•Gas
•Indigestion

55. INVESTIGATIONS:
•USG of HBS
•LFTs
•ERCP/MRCP
•AXR
•CT Scan

57. TREATMENT:
•Conservative treatment for acute
condition.
•SURGERY:
•Open cholecystectomy
•Laparoscopic cholecystectomy(the
gold standard for treating
symptomatic cholelithiasis

58. •Medical treatment:
•1.expectant incase of
asymptomatic
•2.Chemical ddissolution:
•By Chenodeoxycholic acid
(when gall stone<2cm nd
GALL BLADDER –normal
function)

59. •3.Fragmentation by
ESWL(extra corporial shock
wave lithotripsy.
•Percutaneous
cholecystolithotomy.

60. COMPLICATIONS:
•Cholecystitis
•Choledocholithiasis
•Perforated gallbladder
•Gallbladder cancer
•Cholangitis
•Pancreatitis
•Gangrene or abscesses

61. REFERENCES
• 1.Bailey and love’s Short Practice on Surgery,
26th edition
• 2.Robbins and Cotran Pthologic Basic Of
diseases
• 3.Wikipedia

63. THANK YOU
HAVE A NICE DAY