clinical

1. CLINICAL MEETING
ON
“Recurrent CBD obstruction following
ERCP & the diagnostic dilemma.”
ORGANIZED BY-
DEPARTMENT OF SURGERY,
UNIT-I, MMCH

2. CHAIRPERSON:
PROF. M.I.M. NASIM SOBHANI KHONDKER
PROFESSOR & HEAD
DEPARTMENT OF SURGERY, MMCH.
SPEAKER:
DR.S.M.SUFI SHAFI-UL-BASHAR
Assistant Registrar, Surgery Unit – I, MMCH.

3. Particulars of the patient :
 Name: Mrs.Gita Rani
 Age: 54 years
 Sex: Female
 Religion: Hindu
 Occupation: Housewife
 Marital status: Married
 Address: Kishorgonj
 Cabin no. - 08, Bed No.-A
 Reg. no.- 33275/3
 Date of admission(in medicine ward): 29/03/2015
 Date of examination(in surgery ward): 04/04/2015

4. Chief complaints:
 Intermittent Upper abdominal pain for
two years.
 Occasional Vomiting for same duration.
 Fluctuating Yellow colouration of
sclera,skin for one year.
 Fever for one day.

5. History of present illness:
According to the statement of the
patient she was reasonably well 2years
ago then she had an attack of upper
abdominal pain which radiated to back
typical of biliary colic.This subsided with
medication.Thereafter she developed
occasional right upper abdominal pain which
was more severe for last one day prior to
admission.

6. History of present illness(contd.):
Pain was situated in right upper
abdomen, severe colicky in nature,
non radiating associated with nausea
& vomiting, not associated with heart
burn or regurgitation, aggravated by
taking fatty food and not totally
relieved by taking medication.

7. History of present illness(contd.):
Patient also complained about occasional
vomiting for same duration,which was non-
projectile,moderate in volume. Vomitus
contained partly digested food particles &
no blood & bile was present.
On the day prior to admission she had
vomiting for several times.

8. Patient had noticed yellow colouration of
skin,sclera and urine for last one year which
was intermittent in nature associated with
generalized itching and pale coloured stool.
She also had fever for one day prior to
admission which was lowgrade,intermittent,
not associated with cough,chest pain, and
chills & rigor,relieved by taking medicine.
History of present illness(contd.):

9. History of present illness(contd.):
She also gave history of loss of
appetite, generalized weakness,
fatigue during the last 1year.

10. History of present illness (cotd.):
She had no history of significant weight
loss or abdominal lump.
Her bowel and bladder habit is normal.
She is a known case of hypothyroidism
for 2 years.
She is normotensive and non diabetic.

11. History of present illness(contd.):
one year later she decided to undergo
laparoscopic cholecystectomy. But then
she was diagnosed as a case of
choledocholithiasis by USG.

12. History of present illness(contd.):
Then MRCP was done on 19/04/14
for confirmation.It revealed –
cholelithiasis with choledocholithiasis.
On 27/04/14 ERCP was done and
comments were- choledocholithiasis
with cholelithiasis . Papillotomy and
stone extraction done and patient
advised for laparoscopic cholecystectomy.

13. History of present illness(contd):
Following ERCP on 30/04/14 (4 days
later) repeat USG was done and it was
found that gallbladder was normal in size,
shape, position and wall thickness with no
sign of inflammation or calculus but CBD
was dilated (23mm).One bright echogenic
structure was seen within the CBD.Then
patient was advised to take oral medication
for stone dissolution.

14. History of present illness(contd):
Fig: stone extraction by ERCP

15. History of past illness:
Six months after ERCP she felt severe
chest pain and was admitted in Heart
Foundation with features of shock.
During treatment, she had iatrogenic
injury of pleura and blood vessels during
setting of central venous line.
Then patient’s condition deteriorated &
was eventually shifted to square hospital
ICU.

16. History of past illness(contd.):
VATS was done to evacuate intrathoracic
Haematoma.
Thereafter patient gradually came round.

17. Drug history:
History of taking
 PPI
 Anti spasmotic
 Thyroxine (for 2 years)
 Ursodeoxycholic acid (after ERCP)
 Patient is not known to be allergic
to any drug or food.

18. Personal history:
She is a post menopausal lady.
She had no h/o abnormal menstrual
bleeding. She is a mother of 2 children.
She is non smoker,non-alcoholic,
no history of drug abuse. She used to
take normal bangladeshi diet.

19. Family history:
None of her family members
sufferred from such kind of illness.
No family history of DM,HTN,
TB and IHD.

20. Immunization history:
She is not immunized as per
EPI schedule.

21. Socio-economic history:
She comes from a middle
class family and She maintains
good sanitation & hygiene.

22. General examination:
 Appearance : Ill-looking
 Intelligence : Intelligent
 Body built &
nutritional status : Average
 Co-operation : Co-operative
 Decubitus : On choice
 Anemia : Absent
 Jaundice : Mild
 Cyanosis : Absent
 Dehydration : Mild

23. General examination(contd):
 Koilonychia : Absent
 Leukonychia : Absent
 Clubbing : Absent
 Pulse : 65beats/min,
regular
 BP : 110/70 mmHg
 Respiration : 18 breaths/min
 Temperature : 98°F at the
 time of examination
 Neck vein : Not engorged

24. General examination(contd):
 Thyroid gland : Not enlarged.
 Lymph node : Not palpably
enlarged.
 Skin condition : Few scratch
marks were present.

25. Systemic examination:
Examination of Alimentary System:
 Mouth, tongue and Pharynx:
Normal
 Per abdominal examination
Inspection
Abdomen was normal in size ,shape &
Complexion. Umbilicus was in normal
position, inverted. Flanks are not full.

26. inspection contd.
There were no scar but few scratch marks
on the skin.
There were no visible peristalsis,engorged
veins, visible pulsation and pigmentation.
Hernial orifices are intact.
External genitalia – Normal.

27. Palpation:
The local temperature was raised.
Tenderness present in right
Hypochondrium.
There was no palpable lump,liver
and spleen were also not palpable.
No other organomegaly present.
Fluid thrill absent.
Murphy’s sign was negative.

28.  Percussion: Tympanic all over
the abdomen.
shifting dullness absent.
 Auscultation: Normal bowel
sound present.

29. Digital rectal examination:
 There was no anal fissure, fistula,
swelling,hemorrhoid, excoriation
of perianal skin.
 Perianal sensation & anal tone intact.
Rectum empty, rectal mucosa
free.There was no secondary deposit
in the recto-vesical pouch. The finger
is not stained with pus, mucous or
blood.

30. Other systemic examinations:
 Respiratory System:
There was no chest deformity,
Trachea centrally placed, breath
sound vesicular with no added
sounds.
 Genito-urinary System:
External genitalia normal, Urinary
bladder was not palpable &
Kidneys are not ballotable.

31.  Cardiovascular system:
All pulses were present.
Precordium normal, heart sound
audible in all areas, no murmur.
 Nervous system:
Higher psychic function is normal,
All cranial nerves are intact. Muscle
bulk, tone & power are normal. All
jerks are normal.sensory intact.

32. Salient features:
Mrs. Gita Rani 52 yrs old female,
hindu,housewife,normotensive non
diabetic hailing from kishorgonj
admitted in this hospital with the
complaints of severe colicky pain in right
hypochondrium, non projectile vomiting
for several times,fluctuating jaundice &
fever.She also had itching for few days.

33. Salient feature(contd.)
She had no history of anaemia,
significant weight loss,
generalized swelling or
pigmentation.Her bowel &
bladder habit is normal. She is a
known case of Hypothyroidism.
About 2 years back she was
diagnosed as a case of biliary
colic.Then she was on
medication & after 1 year she
was diagnosed as a case of
Choledocholithiasis.

34. Salient Feature(contd.)
Then MRCP & ERCP were done
respectively.A stone was removed from CBD &
another was found in gallbladder. Patient was
advised to do cholecystectomy.
But post ERCP ultrasonography reveals
Choledocholithiasis with dilated CBD.Then she
was advised to take oral medications in an
attempt to dissolve the aftercoming stone &
patient continued it until admitted
in this hospital.

35. Salient Feature(contd.)
 On G/E-
Patient was ill looking,mildly
icteric,mildly dehydrated. Oedema
was absent. Her pulse was 65
b/min, BP- 110/70 mmHg, R/R-
18 breaths/min, Temp-98ºF.
There was no lymphadenopathy.

36. Salient feature(contd.)
P/A/E- size& shape of the abdomen
was normal, umbilicus was in normal
position & inverted, flanks were not
full. Local temp.was raised, tenderness
present at the rt. hypochondrium.
Murphy’s sign was negative.

37. Salient feature(contd.)
No ascites , no organomegaly
present. Percussion note was
tympanic all over the abdomen.
Normal bowel sound was present.
Others Systemic examination
revealed no abnormalities.

38. Provisional diagnosis:
?
• Post ERCP obstructive jaundice due
to recurrent choledocholithiasis
and Hypothyroidism

39. Differential diagnosis:
1. Post ERCP Obstructive jaundice due to
retained stone in CBD and
Hypothyroidism .
2. Post ERCP Obstructive jaundice due to
aftercoming stone in CBD and
Hypothyroidism .
3. Post ERCP Obstructive jaundice due to
stricture of common bile duct and
Hypothyroidism.
4. Post ERCP Obstructive jaundice due to
periampullary carcinoma and
Hypothyroidism .

40. Investigations:
Investigations for Diagnosis :
USG OF Whole Abdomen:
From Nuclear Med.& Ultrasound( 29.03.2015):
Liver appears normal in size and shows
normal tissue echotexture.
Intrahepatic biliary tree is not dilated.
GB is distended with thick wall.
About 8.5x 4 cm choledochal cyst is seen.
There appears 2 adjoining stones (1.4cm
and smaller) in terminal part of CBD.

41. Investigations(contd.):
USG OF Whole Abdomen:
Pancreas appear normal in size and
tissue echotexture.
Spleen shows normal in size and homogeneous
tissue echotexture.
Comment:
Choledocholithiasis
Choledochal cyst .

42. Investigations(contd.):
Phothgraph of USG

43. Investigations(contd.)
Suggested investigation.
 ERCP : Advised but not done.
 MRCP: Not done.

44. Other Investigations to diagnose the
patient (contd.):
*S. Bilirubin: 2.3 mg/dl
*SGPT(ALT): 63 IU/L
*ALP: 568 IU/L
*Prothombin time:15 sec.
*I.N.R: 1.25

45. Other Investigations to assess the patient:
*Blood for TC-8500/cumm ,
DC (N-66%,L-26%M-5.%,
E-3%)
HB% -13.1 gm/dl.
ESR -50 mm in 1st
hour
PLT-1,15000/cumm.

46. Other Investigations to assess the patient
(contd.):
*CXR P/A View-Cardiomegaly
* ECG- Normal.
*Echocardiography-Normal study
with good LV function.
LVEF=61%

47. Other Investigations to assess the patient
(contd.):
*RBS-6.8mmol/L
*S. Creatinine-0.8 mg/dL
*Blood Group- A +ve.
*TSH-0.795 uIU/ml (with Thyroxine
replacement)
*HBsAg –Negative.
*Urine R/M/E- albumin- nil,
sugar- nil
pus cell- 1-3/HPF

48. Confirmed Diagnosis (Before
operation)
 Post ERCP Obstructive jaundice due
to choledocholithiasis with choledochal
cyst and Hypothyroidism.

49. Some important points in preoperative
preparation
 Inj. Konakion 10mg-1ampule i/v daily
for 5 days.
 Nothing per oral for 3 days prior to
surgery.
 3L of fluid daily for 3 days.
 10%DA is given in preoperative night.

50. TREATMENT
Surgical Treatment:
Operation note:
Date: 19/04/2015
Time: 10:00 a.m.
Name of the operation: Laparotomy
Indication: Post ERCP Obstructive
jaundice due to choledocholithiasis
with choledochal cyst.
Anaesthesia:General Anaesthesia
Incision : Upper right paramedian

51. Operation note(continued):
Findings: After laparotomy CBD was
found dilated about 3.5cm & no
choledochal cyst was found. The callot’s
triangle was identified.Cystic duct and
cystic artery was identified and ligated.
Then cholecystectomy was done. An
incision was given at mid-level of CBD.

52. Operation note(continued):
A stone was removed measuring
about 2cm in diameter.After
removing the stone a metalic
dilator was inserted in CBD.Both
right and left hepatic duct were
found normal.Dilator could not
be passed through ampulla into
duodenum.

53. Operation note(continued):
Choledochoduodenostomy was
done. Then abdomen was closed
layer by layer keeping a drain tube in
sub hepatic space.

54. Resected gallbladder & CBD stone:

55. Confirmed diagnosis (after
operation)
 Post ERCP Obstructive jaundice due
to Choledocholithiasis with stricture
of papilla and Hypothyroidism.

56. THANK YOU
ALL