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    CasePresentation

    Cholelithiasis

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    IntroductionCholelithiasis

    Presence of one or more calculi (gallstones) in thegallbladder

    common health problem, affecting about 1 out of every1,000 people and is the fifth leading cause of hospitalizationamong adults and accounts for 90% of all gallbladder andduct diseases.

    prognosis is usually good with treatment unless infectionoccurs, in which case the prognosis depends on its severityand response to antibiotics.

    Prevalence of cholelithiasis is affected by many factorsincluding;

    Ethnicity

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    Gallstones

    tend to be asymptomatic

    Diagnosis is usually by ultrasonography.

    made of cholesterol, calcium bilirubinate, or a mixture ofcholesterol and bilirubin pigment

    Migration of gallstones may lead to occlusion of the biliaryand pancreatic ducts, causing pain (biliary colic) andproducing acute complications, such as acute cholecystitis,ascending cholangitis, or acute pancreatitis.

    Asymptomatic gallstones

    In patients with asymptomatic gallstones discoveredincidentally, the likelihood of developing symptoms orcomplications is 1-2% per year

    In most cases as m tomatic allstones do not re uire an

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    Biliary colic

    Pain termed biliary colic occurs when gallstones fortuitouslyimpact in the cystic duct during a gallbladder contraction,increasing gallbladder wall tension.

    In most cases, the pain resolves over 30 to 90 minutes asthe gallbladder relaxes and the obstruction is relieved.

    Episodes of biliary colic are sporadic and unpredictable.

    The patient localizes the pain to the epigastrium or rightupper quadrant and may describe radiation to the rightscapular tip.

    From onset, the pain increases steadily over about 10 to 20minutes and then gradually wanes.

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    Predisposing factors

    Age - elderly people are prone to gallstoneformation because of weakened immunesystem and deteriorating body organs.

    Diabetic - are prone to gallstone formationbecause of impaired protein synthesis andfatty acid storage.

    Genetic - family with a history of

    cholelithiasis has a high risk of acquiring thedisease condition.

    Precipitating factor

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    Excess alcohol consumption

    Oral contraceptives.

    High fat, low fiber diet.

    Rapid weight loss.

    Women who have had many children.(multiparity)

    Hemolytic disorders such as sickle cell anemia, hereditaryspherocytosis.

    Liver cirrhosis.

    Diabetes.

    Female gender.

    Inflammatory bowel disease such as crohns.

    Signs and symptoms

    Symptoms usually manifest after a stone, which is greater

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    Cholangitis- If the common bile duct is blocked for aperiod of time, certain bacteria may grow in the

    stagnant bile producing symptoms of cholangitis.

    Jaundice- a yellow pigmentation of the sclerae, skin,and deeper tissues cause by excessive accumulation ofbile pigments in the blood. The accumulation is due to

    the continuous blockage of bile to the intestines whereit is partly excreted as waste.

    Pancreatitis- stones blocking the lower end of thecommon bile duct where it enters the duodenum mayobstruct secretion from the pancreas producing

    pancreatitis.

    Note: Often there are no symptoms.

    Additional symptoms that may be associated withthis disease:

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    heartburn- because of vomiting

    gas/flatus, excessive - decrease in peristalsis because ofdecrease in water in the intestine.

    abdominal indigestion- decrease ability to emulsify fats,intolerance to fatty foods leading to indigestion

    abdominal fullness, gaseous-decrease in peristalsis

    because of decrease in water in the intestine.

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    Complications of gallbladder stones

    Acute cholecystitisoccurs when persistent stone impaction in the cystic duct causesthe gallbladder to become distended and progressively inflamed.

    Chronically, gallstones may cause progressive fibrosis of thegallbladder wall and loss of gallbladder function, termedchronic cholecystitis.

    Gallbladder adenocarcinoma

    an uncommon cancer that usually develops in the setting ofgallstones and chronic cholecystitis.

    commonly invade the adjacent liver and common bile duct,producing jaundice.

    Medical Intervention

    Dissolution Agents (Cholesterol Stones)

    Extracor oreal Shock Wave Lithotri s

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    Personal Data

    NAME: Mrs. Dimakasuka

    ADDRESS: Bgy. Calaocan, Santiago City, Isabela

    BIRTHDAY: January 11, 1968

    BIRTHPLACE: Quezon City

    AGE: 43 years old

    NATIONALITY: Filipino

    DIALECTS SPOKEN: Ilokano, Tagalog

    RELIGION: Roman Catholic

    EDUCATIONAL ATTAINMENT: High School Graduate

    OCCUPATION: Vendor

    DATEOF ADMISSION: June 02, 2011 CHIEF COMPLAINT: fever bod weakness severe abdominal ain

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    History of Past Illness

    She acquired chicken pox and measles when she was young and wasalready twice hospitalized for the delivery of both her children but aside fromthat she was never brought to hospital for conditions which are related to her

    condition now.

    However during the past 5 months (starting January 2011) the patienthas been experiencing pain on her right upper side part of the abdomen whichshe ignored. And she verbalized that it was a tolerable pain and was easilyrelieved by rest and sleep. Due to her work, Mrs. Dimakasuka was not able tohave a check up or medical examinations done. Two months before the

    hospitalization, she experienced an intense abdominal pain accompanied bynausea and vomiting but instead of going to the hospital for checkup she justtook pain medications.

    HISTORY of PRESENT ILLNESS

    Two days prior to admission the patient again experienced severeabdominal pain while at work accompanied by fever (May 31). By 11 pm of June2, 2011 she was admitted at CVAH with chief complaints of fever, bodyweakness, severe abdominal pain, nausea and vomiting He was immediatelyattended by the nurses by taking his vital signs. Her consent was signed. Shewas immediately examined by Dr. JJ with orders made and carried out. The

    patient was inserted with an IVF of D5LRS 1L x 30gtts/min inserted at her lefthand. She had undergone laboratory exams such as, CBC, Urinalysis, HBT

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    LABORATORY AND DIAGNOSTIC EXAMS

    HBTPancreas Ultrasound

    Results:

    Abnormally contracted gallbladder with a lithiasis atthe neck.

    Intrahepatic and extrahepatic ducts are not dilated.

    Unremarkable liver and pancreas.

    (-) for ascites

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    Analysis and Interpretation of

    Results

    Abnormally contracted gallbladderwith a lithiasis at the neck.

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    Physical AssessmentJune 2, 2011 (upon admission, based on the patient's

    chart)

    Patient Is conscious, coherent but in distress with

    steady severe aching pain in the right upperquadrant of the epigastrium radiating to the rightshoulder

    Vital signs:

    BP- 90/60

    T- 38

    P-80

    R-28

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    June 3,2011 (patient's chart)

    Patient is conscious and coherent withIVF of 1L D5LRS regulated at 30

    gtts/min still with (+) jaundice, tolerable

    pain in the right upper quadrant of theepigastrium

    Vital signs:

    BP-100/70T-37.1

    PR-87

    RR-21

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    Sclera: appears yellowish

    Lips: pale:dry

    Skin: yellowish in color

    :warm to touchAbdomen: guarding behavior upon palpation

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    Anatomy and

    Physiology

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    The gallbladder stores bile, which is released when foodcontaining fat enters the digestive tract, stimulating the

    secretion of cholecystokinin (CCK). The bile emulsifies fatsand neutralizes acids in partly digested food. After beingstored in the gallbladder, the bile becomes moreconcentrated than when it left the liver, increasing itspotency and intensifying its effect on fats.

    The liver's cells (hepatocytes) excrete bile into canaliculi,which are intercellular spaces between the liver cells. Thesedrain into the right and left hepatic ducts, after which biletravels via the common hepatic and cystic ducts to thegallbladder. The gallbladder, which has a capacity of 50

    milliliters (about 5 tablespoons), concentrates the bile 10fold by removing water and stores it until a person eats. Atthis time, bile is discharged from the gallbladder via thecystic duct into the common bile duct and then into theduodenum (the first part of the small intestine), where itbegins to dissolve the fat in ingested food.

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    The liver excretes approximately 500 to 1000 milliliters (50to 100 tablespoons) of bile each day. Most (95%) of the bile

    that has entered the intestines is resorbed in the last part ofthe small intestine (known as the terminal ileum), andreturned to the liver for reuse.

    Metabolic functions, such as the maintenance of glucose(blood sugar) levels

    Synthetic functions, such as the synthesis of serum proteinssuch as albumin, blood clotting (coagulation) factors, andcomplement (a mediator of inflammatory responses)

    Storage functions, such as the storage of sugar (glycogen),

    fat (triglycerides), iron, copper, and fat soluble vitamins (A, D,E, and K)

    Catabolic functions, such as the detoxification of drugs

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    Pathophysiology

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    Cholelithiasis

    RUQ colickypain(January, 2011

    June 2011,

    Bile stasis become amedium for bacterial

    growth

    Inflammation

    Endogenous

    pyrogens

    Release of chemicalmediatorsReset of

    hypothalamus

    Fever

    obstruction

    Conjugated bilirubin

    Escape from liver intothe blood stream

    Infection

    Stimulates the gallbladderto produce more bile.

    Stimulates the secretionof Cholecystokinin

    Indigestion of fats