FACULTY OF MEDICINE AND HEALTH SCIENCES UNIVERSITI PUTRA MALAYSIA
CASE WRITE-UP
ACUTE CHOLECYSTITIS SECONDARY TO CHOLELITHIASIS
Supervisor :
MR. YAP YOKE YEW
Name
:
TAJUZZAMAN BIN RAZALI
Matric no.
:
159012
Group no.
:
B5
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Identification/Demographic Data Name
: Mr. IA
Age
: 65 years old
Sex
: Male
Race
: Malay
Status
: Married
Address
: Puchong, Selangor
Ward/Bed
: 6C/20
Date of admission
: 13th August 2012
Date of clerking
: 14th September 2012
HISTORY Chief Complaint Mr. IA was presented with right hypochondriac pain for three days associated with vomiting and fever on the day of admission.
History of Presenting Illness Mr. IA, a 65-year old Malay gentleman was admitted to the ward with complaint of pain at the right hypochondrium region on the abdomen for three days. The pain was gradually increased and worsens on the third day. He characterized the pain as burning pain. He experienced intermittent pain for the past three days and the pain did not radiate. The pain lasted for one hour duration but he forgot the frequency of the pain to occur. He also complained that the pain became worse when he was moving or coughing. The pain even affected his daily activities and work and he took medical leave for past three days. He needed to lie down to relieve the pain. The pain was quite severe and he characterized the severity of the pain with a scale of seven out of ten where zero is not in pain and ten is the most severe pain. 2
Regarding the vomiting, he vomited food particles and fluid with no blood or bile, for two times on the day before admission. The amount of the vomitus was the same as the amount of ingested food but it was in particles but not in bolus. He also complained of low grade fever on the day before admission to the ward and the fever. The fever was associated with chills and rigors. He denied any tea-coloured urine and pale stool for the past three days before the admission. He also denied any nausea, diarrhoea, constipation, loss of appetite, loss of weight, alteration of bowel habit, dysphagia or haematemesis.
Systemic Review Cardiovascular System He denied any chest pain, palpitations, orthopnoea, paroxysmal nocturnal dyspnoea or ankle oedema. Respiratory System He complained of coughing. However, he denied any shortness of breath, haemoptysis, wheezing or night sweats. Urinary System He denied any dysuria, passing tea-coloured urine, urinary incontinence, or frequency. Central Nervous System He complained of headache. However, he denied any dizziness, syncope, blurry vision or double vision. Musculoskeletal System He denied any joint pain or back pain.
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Past Medical and Surgical History He went to consult with a general practitioner regarding his pain on the first day of his illness. He was treated as gastritis and was prescribed with magnesium tricarbonate and gastric medication. However, there was no improvement for the pain to relieve. Thus, he came to Emergency Department in Hospital Serdang in the night and referred to Ward 6C. He was diagnosed with asthma for four years and still under medication. His last attack of acute exacerbation was last year. He was a known hypertensive and diabetic mellitus type II patient when he was diagnosed at Klinik Kesihatan Batu 14 last year. He was still on follow-up at the Klinik Kesihatan.
Drug History Regarding his asthma, he was prescribed with metered-dose inhaler ventolin and he only used it if he got acute exacerbation, which occured last year. He was also under medication of perindopril 2mg od for his hypertension and metformin 250 mg bd for his Diabetes Mellitus Type II and he said he had compliance towards his prescription. He denied any medications from pharmacy or traditional medicine. He had no allergy towards any drugs.
Family History He was a single son in his family and his parents died of unknown reason but most probably due to aging. His children were all healthy. There was no family history of hypertension, cardiac disease, diabetes, asthma and malignancy.
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Social and Personal History He lived with his wife who had hypertension and four children. He lived in the first floor of a double-storey terrace house. He never smoked and consumed alcohol.
Diet History He had no allergy to any food. He also denied any abdominal pain or vomiting after taking oily or fatty food. The vomiting was also not associated with heavy post-meal.
Summary Mr. IA, a 65-year old diabetic and hypertensive man was presented with severe burning right hypochondriac pain associated with fever and vomiting 3 days prior to admission. The pain worsens when the patient was moving and coughing. However, he denied that the pain was not aggravated by oily or fatty food. The vomiting contained food particles and the fever was associated with chills and rigors.
PHYSICAL EXAMINATION General Inspection The patient was lying flat comfortably in supine position supported with one pillow. He did not look ill. He was conscious, oriented and alert to time, place and person. He was not in pain or respiratory distress and his hydrational and nutritional status was adequate. There was no muscle wasting, no gross deformity and he was not obese. There was an intravenous line attached to his right wrist.
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General Systemic Examination Vital signs Pulse rate
: 89 beat per minute, normal volume, regular rhythm
Blood pressure
: 136/65 mmHg
Respiratory rate
: 18 breaths per minute
Temperature
: 38.9C
Hands Palms were dry, warm and pink. There was no sign of pallor. There was no presence of palmar erythema. From inspection of the fingers and nails, there was no peripheral cyanosis. There were no finger clubbing, no leuconychia and no koilonychia. Head and Face From inspection of the eyes, the conjunctiva was pink and the sclera was not icteric. From inspection of the mouth and tongue, the tongue was coated. There was no central cyanosis and oral hygiene was good. Neck There was no gross enlargement of thyroid. Jugular venous pressure was not elevated and carotid artery was palpable. There was no carotid bruit heard. Chest Wall and Axillae There was no spider naevi, gynaecomastia and axillary hair loss. Heart sounds revealed dual rhythms sound and no murmur heard. Other abnormality was not found on examination. Lower Limb There was no pitting oedema.
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Specific Abdominal Examination Inspection The abdomen was symmetrical and not distended. There was no abnormal movement found with each respiration. The umbilicus was inverted and centrally located. There were no striae, no surgical scars, no prominent and dilated veins, no skin discolouration, no visible peristalsis, no pulsation and no obvious mass seen. Cough impulse shown right reducible inguinal hernia, measuring 5x5 cm in diametre. Upon further questioning, the patient said that the hernia was noticed ten years ago but he never went to hospital for follow-up. Palpation and Percussion Upon superficial palpation, the abdomen was soft and tender at right hypochondrium and right lumbar region on the abdomen. Upon deep palpation, the liver was palpable with two finger breadths below the costal margin. The spleen was not palpable. The kidney was not ballotable. There was no palpable mass found on the abdomen. Other parts of the abdomen were soft and normal. Upon percussion, the abdomen was resonance except the part where the liver was palpable and at the left iliac region on the abdomen. Murphy’s sign was negative. There was no shifting dullness and fluid thrill was negative. Auscultation There was increased bowel sound heard. There was no renal artery bruit heard. Per rectal examination and genitalia examination were unremarkable. All other systems were unremarkable.
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LABORATORY INVESTIGATIONS Full Blood Count (13/08/2012) Objective:
To check for any sign of anaemia or underlying infection
Type of specimen: Whole blood Results
Normal range
Haemoglobin
13.6 g/dL
13.0 – 18.0
Haematocrit
41.2 %
40.0 – 54.0
Platelet
235 x 109/L
150 – 400
Total White Blood Cells
18.3 x 109/L
4.0 – 11.0
Percentage of Neutrophils
73 %
40 – 75
Total white blood cell count and neutrophils were increased which might be due to infection. Haemoglobin and haematocrit level were slightly low which might be due to anaemia.
Liver Function Test (13/08/2012) Objective:
To rule out any jaundice, liver disease or liver dysfunction
Type of specimen:
Whole blood Results
Normal range
Total Protein
80 g/L
64 – 83
Albumin
40 g/L
35 – 50
Globulin
40 g/L
34 – 50
Albumin/Globulin Ratio
1.00
–
Total Bilirubin
40.3 µmol/L
3.4 – 20.5
Alanine Transaminase
22 U/L
<44
Alkaline Phosphatase
60 U/L
40-150
Total bilirubin was markedly increased which indicates hyperbilirubinaemia. This may lead to jaundice.
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Renal Profile (13/08/2012) Objective:
To monitor level of fluid loss and renal function
Type of specimen:
Whole blood Results
Normal range
Urea
5.1 mmol/L
3.2 – 9.2
Sodium
132 mmol/L
3.2 – 9.2
Potassium
3.7 mmol/L
3.5 – 5.1
Chloride
95 mmol/L
98 – 107
Creatinine
96 µmol/L
62 – 115
Slight low level of chloride indicates there was electrolyte imbalance occurred to the patient.
Other Tests (13/08/2012) Tests
Results
Normal range
Serum Amylase
54 U/L
25 – 125
Calcium
2.19 mmol/L
2.10 – 2.55
Magnesium
1.04 mmol/L
0.85 – 1.05
RADIOLOGICAL INVESTIGATIONS Chest X-ray (13/08/2012) Findings: Minimal right sided perihilar haziness was seen on erect view chest X-ray. There was no perforated gasterointestinal viscus seen and no gas bubbles seen at below of the diaphragm.
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Abdominal X-ray (13/08/2012) Findings: Faecal loaded was seen at the left iliac region. There was no sign of intestinal obstruction.
Ultrasound of Hepatobiliary System (05/09/2012) The liver had a normal homogenous parenchymal echotexture with raised echopattern. There was no focal lesion within the parenchyma. There was no biliary tree dilatation. The portal vein and common bile duct were normal in calibre. However, the gallbladder wall was thickened and blurred in outline. Multiple stones of varying sizes were seen in the gallbladder. The largest stone measured about 2.5 cm in diameter. There was associated pericholecystic fluid denoting underlying inflammation of the gallbladder. The visualised pancreas and the spleen were normal.
TREATMENT AND MANAGEMENT On 13/08/2012, the patient was given intravenous fluid drip 5 pint 3ns 2ds and antibiotics (intravenous Ciprofloxacin 400 mg bd. The patient was kept nil by mouth. Subcutaneous Pethidine 1 mg/kg was given for pain relief. On 12/09/2012, open cholecystectomy was performed on the patient. Histopathology of the gallbladder confirmed acute cholecystitis secondary to gallstones. Post open cholecystectomy also revealed perforated gallbladder empyema with pus collection. There were impacted pigmented stones seen at Hartmann’s pouch with sludge. Until 14/09/2012, the patient was still under follow-up for any post-operative complications.
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DISCUSSION The patient problem lists: I.
Symptoms Positive Findings • • • •
II.
III.
Negative Findings • •
Pain at the right hypochondrium on the abdomen Vomiting Chills Rigors
Signs • Fever
• Anaemia
• Jaundice
• Hepatomegaly
Others • Hypertension
• Diabetes Mellitus Type II
IV.
Coughing Headache
Diagnosis Provisional diagnosis Points for Acute cholecystitis
Points against
Severe burning and colicky pain Hepatomegaly, in the right upper quadrant of coughing abdomen,
vomiting,
fever
associated with chills and rigors, jaundice,
tender
hypochondrium
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right
headache,
Differential diagnosis Differential diagnosis
Points for
Points against
Chronic Cholecystitis
Colicky pain in the right upper Repeated acute cholecystitis quadrant of abdomen, vomiting, and biliary colic, pain worsen jaundice after meals, recurrent flatulence, fatty food intolerance, feeling of distension, heartburn
Ascending cholangitis
Severe pain in the right upper Look very ill, pain worsen after quadrant of abdomen, fever eating spicy or fatty food associated with chills and rigors, vomiting, jaundice
Choledocholithiasis
Colicky pain in the right upper No pale stool, no stone quadrant of abdomen, fever, presented at the bile duct in vomiting ultrasound
Cholangiocarcinoma Pain in the upper abdomen, chills, fever
Hepatitis
right No loss of appetite, no abnormal mass presented at the bile duct in ultrasound
Abdominal pain at upper right quadrant, jaundice, fever, vomiting, hepatomegaly
Final diagnosis Acute cholecystitis secondary to cholelithiasis
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No yellowing of the skin, no ascites, no generalized itching at the body, no loss of apetite
V.
Physiology of bile acids The physiology of bile acid formation can be simplified by the figure below:
Liver
Serum
Cholesterol → Bile acids (0.2–0.6g/24hr)
(2–5µmol/L)
Gallbladder (Bile 5–10mmol)
Renal clearance (Urine 8µmol/24hr)
Intestine (Bacterial degradation & formation of secondary bile acids)
Faeces (0.2–0.6g/hr)
Figure 1: Enterohepatic circulation of bile acids
VI.
Risk factors of gallstones/cholelithiasis • Middle-aged (>40), obese, multiparous women • Familial cholelithiasis in tribes of North Americal Indians because small bile salt pool and Chileans because high cholesterol excretion • High calorie or high cholesterol diets which can produce supersaturated gallbladder bile • Drastic weight reduction and diets to lower cholesterol which can lead to mobilization of cholesterol and increased cholesterol excretion • Disease or resection of terminal ileum which favours cholesterol nucleation by reducing bile salt pool 13
• Drugs such as cholestyramine, oral contraceptive pills, diuretics and clofibrate which give effect of bile salt depletion • Pregnancy can increase bile stasis within gallbladder • Other
metabolic
conditions
such as
diabetes,
cystic
fibrosis,
familial
hyperlipidaemia may increase plasma cholesterol which in turns produce more bile cholesterol
VII.
Pathogenesis of gallstones The pathogenesis of gallstones formation can be explained by the figure below: Formation of cholesterol crystals
‘Cholesterol nucleation’ →due to combination of cholesterol molecules with particles of mucus, bacteria, calcium bilirubinate or mucosal cells
Excessive cholesterol excretion, reduction in amount of bile salt, lecithin available for micelle formation, bile is concentrated in gallbladder (favoured by stasis or decreased gallbladder contractility)
Bile becomes supersaturated with cholesterol
Gallstone formation
Figure 2: Formation of gallstone
VIII.
Acute cholecystitis It is an acute inflammation of gallbladder. It occurs when there is an obstruction at the neck of gallbladder or cystic duct by a stone and is associated with infection and thus causes systemic illness.
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This will cause severe right hypochondriac pain radiating to the right scapular region and to the back. The pain usually associated with other symptoms such as fever, tachycardia, nausea, vomiting, chills and rigors. Upon physical examination, there is often generalized abdominal tenderness and rigidity and most markedly felt over the gallbladder. Murphy’s sign is usually present in patient with very inflamed gallbladder. The results of laboratory investigations may show leukocytosis as a sign of bacterial infection. Raised total bilirubin may indicate obstructive jaundice as presence of gallstones. Based on findings of ultrasound of the abdomen, multiple stones are present usually in the neck of gallbladder or cystic duct. The wall of gallbladder is also thickened with pericholecystic fluid indicating inflammation of gallbladder. Usually, 90% of the case is settled down with conservative treatment by keeping the patient nil by mouth, replacing intravenous fluids, giving antibiotics and painkiller and nasogastric suction is performed if appropriate. However, 10% of the case may develop disease progression with life-threatening complications such as gallbladder empyema, gangrene and perforation which will require surgical intervention such as open cholecystectomy.
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REFERENCES
Subashini CT, Intan NS & Zalinah A. Problem Based Learning: Gallstone. Universiti Putra Malaysia, 2012, 13-21. Zulkhairi A. Physiology of the Bile. Universiti Putra Malaysia, 2011, 7-12. Razana MA. Biliary Tract and the Exocrine Pancreas. Universiti Putra Malaysia, 2011, 7-12. Williams NS, Bulstrode CJK & O’Connell PR. Bailey & Love’s Short Practice of Surgery (25 th ed.). Hodder Arnold, 2008, 1119-1126. Isman H et al. USM History Taking & Physical Examination (2 nd ed.). NADI Corporation, 2006, 95-103. Norman LB, John B, Kevin GB & William EGT. Browse’s Introduction to the Symptoms and Signs of Surgical Disease (4th ed.). Hodder Arnold, 2005, 398-399.
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