SURGERY CASE

PRESENTATION

PEREZ, REN GAEBE

PEREZ, REINA ROSE
PERSONA, GIANN ROINA
GENERAL DATA

Patient B.L. 39/F

Roman Catholic,Married
From Marikina
ABDOMINA
L PAIN

CHIEF
COMPLAINT
PATIENT’S MEDICAL
HISTORY
● Sudden onset of intermittent right
upper quadrant pain
● Not relieved by position change,
1 YEAR food intake
PTC ● Colicky in character, radiating to the
back
● Graded as 7/10
● 2 episodes of vomiting, watery and
non-bilious approximately ½ cup per
bout
● No medications taken and no
consult done
PATIENT’S MEDICAL
HISTORY
● Still with RUQ pain
● Not relieved by position change and
11
MONTHS food intake
PTC ● Colicky in character
● Now with Jaundice as noticed by the
relatives
● Consult at private MD; given liver
supplement
On interim, the patient was apparently taking the
supplement prescribed. No consult was done and no other
medications were taken.
PATIENT’S MEDICAL
HISTORY
● Sudden onset of intermittent
epigastric and RUQ pain
● Not relieved by position change, food
3 weeks intake
● Colicky in character and radiating to
PTA the back, graded as 9/10
● 3 episodes of vomiting
● Fever (39°C)
● Sought ER consult and was advised
for possible scheduling of procedure;
given pain medications which offered
slight to moderate relief.
PATIENT’S MEDICAL
HISTORY
● Still with persistence of RUQ pain;
On continued intake of prescribed
medications which offered slight to
interim
moderate relief.
 PATIENT’S MEDICAL
HISTORY
● Patient still with aforementioned
Few symptoms
hours ● Sought OPD consult, given pain
PTA medications which offered slight to
moderate relief; advised for ER
consult hence admission.
 PAST MEDICAL HISTORY

● (-) Hypertension, Diabetes Mellitus, Asthma, Kidney, Heart and

Thyroid diseases
● (-) Tuberculosis
● (-) Cancer
● (-) No known food and drug allergy
● (-) Previous Hospitalization and surgery
● (-) Blood transfusion
● (-) History of chronic NSAID use and/or intake of high-dose NSAIDs
FAMILY HISTORY

● Hypertension - Mother
● Diabetes Mellitus - Sister
● Cholelithiasis - Sister
● (-) Asthma
● (-) Kidney, Heart, Thyroid diseases
● (-) Tuberculosis
● (-) Cancer
 OB AND GYNE
● HISTORY
Last Menstrual Period: October 23, 2019
● G3P3 (3003)
○ M – 13 y/o
○ I - Regular menstrual cycle occurring monthly
○ D - 3-4 days
○ A - 2-4 moderately soaked pads daily
○ S - No dysmenorrhea, no headache and no breast
tenderness
● (+) OCP use - 15 years
SEXUAL HISTORY

● Sexually active
● Coitarche was at 16
● Had a total of 2 sexual partners
● Has no dyspareunia and post-coital bleeding
● Has no history of sexually transmitted infections
 PERSONAL AND SOCIAL HISTORY

● Lives with her family

● Works as a businesswoman
● Diet: Food preference to salty and fatty food
● Previous 7.2 pack-year smoker
● Occasional alcoholic beverage drinker
○ 3-4x a week
○ 2 bottles of 500ml beer
● Denies illicit drug use
Review of Systems
General (-) anorexia, (-) weight loss, (-) malaise, (-) easy
fatigability, (-) night sweats

Skin (-) lesions, (-) rashes, (-) jaundice, (-) cyanosis, (-)
pallor

HEENT (-) headache, (-) blurring of vision, (-) epistaxis, (-)

sore throat, (-) hoarseness, (-) neck pain and
stiffness

Respirator (-) dyspnea, (-) cough, (-) hemoptysis

y
Review of Systems
Cardiovascul (-) chest pain, (-) orthopnea, (-) palpitations, (-)
ar PND, (-) edema

Gastrointest (-) constipation (-) diarrhea

inal

GU (-) flank pain, (-) dysuria, (-) nocturia

Musculoskel (-) joint pain or swelling, (-) muscle pain, (-)

etal stiffness
Review of Systems
Endocrine (-) polyuria, (-) polydipsia, (-) polyphagia, (-)
heat/cold intolerance

Neurologic (-) tingling sensation on all extremities, (-)

occasional numbness on all toes
Physical Examination
General Survey: Awake, cooperative, bed-bound, not in cardiorespiratory distress

Vital Signs:

BP - 110/80mmHg Height - 158cm

PR - 112bpm Weight - 55kg

RR - 20 cpm BMI - 22 (within normal range)

Temp - 37°C
Skin: Warm to touch, good skin turgor. (-) pallor (-) cyanosis (-) jaundice (-) rashes (-)
bruises

Head: (-) head injury or trauma. Hair with average texture. Scalp without lump or lesion.

Eyes: (-) discharge (-) lesions (-) ptosis (-) exophthalmos, (-) enopthalmos. Pink palpebral
conjunctiva, icteric sclera. Pupils are equally round, reactive to light and
accommodation.
Ears: Symmetrical, (-) drainage, (-) swelling (-) lesions,

Nose: Patent, pink mucosa, septum at the midline. (-) sinus tenderness (-) discharge

Mouth/ Throat: (+) Icteric ventral surface of the tongue and

frenulum. Tongue and uvula at the midline.

Neck: Neck supple. Trachea at the midline. No cervical lymphadenopathy. Thyroid gland
was not palpable
Respiratory: (-)chest deformities. symmetric chest expansion, Symmetric tactile fremitus.
Vesicular breath sounds, no adventitious breath sounds.

Cardiovascular: Adynamic chest. (-) cyanosis , no visible jugular pulsations, (-) distended
neck veins. (-) heaves (-) thrills line. Apex beat at 5th ICS, Regular rhythm with distinct S1
and S2. No murmurs or extra sounds
Abdomen & Back: Non distended. No lesions and visible masses upon inspection. With
normoactive bowel sounds. Tympanitic on percussion. Soft upon palpation
(-) Hepatomegaly. (+) tenderness on epigastric and right upper
quadrant. (+) Murphy's sign, (-) Goldflam test

DRE: (-) hemorrhoids, (-) anal fissure, (-) palpable mass, empty rectal
vault, smooth anal canal with good sphincter tone, non-bloody per
examining finger

Musculoskeletal: (-) joint deformities. Good range of motion in hands, wrists, elbows,
shoulders, spine, hips, knees, ankles.
Neurology: 5/5 muscle strength of all extremities. Intact sensory and cranial nerves.

Extremities: Warm. No edema. Calves supple, nontender. Capillary refill < 2 seconds,
symmetric brachial and dorsalis pedis pulse +2
Salient Features
Salient Features: History
Pertinent Positives Pertinent Negatives
39/ F (-) hematochezia
Sudden onset of RUQ pain radiating to the back, not (-) melena
relieved by position change and food intake
(+) Colicky pain, RUQ (-) fatigue
(+) Vomiting (-) History of chronic NSAID use and/or intake of high-
dose NSAIDs
(+) Fever
Food preference: salty and fatty food
(+) Family history of cholelithiasis
Salient Features: PE
Pertinent Positives Pertinent Negatives
(+) Icteric sclera and icteric ventral surface of tongue Normal DRE findings
(+) Murphy’s sign (-) Goldflam test
(+) tenderness on epigastric and RUQ areas (-) LUTS
(-) Hepatomegaly
 Ascending Cholangitis
Secondary to Obstructive
Jaundice Probably
secondary to
Choledocolithiasis
PRIMARY WORKING IMPRESSION
Differential Diagnosis
CHRONIC CHOLECYSTITIS
● Chronic cholecystitis is characterized by repeated attacks
of pain (biliary colic) that occur when gallstones
periodically block the cystic duct.
● In chronic cholecystitis, the gallbladder is damaged by
repeated attacks of acute inflammation, usually due to
gallstones, and may become thick-walled, scarred, and
small.
CHRONIC CHOLECYSTITIS
POINTS IN FAVOR POINTS AGAINST

● (+) Abdominal pain Cannot be totally ruled

● (+) Murphy's Sign out
● (+) Jaundice
● (+) vomiting
● (+) Fever
ACUTE VIRAL HEPATITIS

● Acute viral hepatitis is a systemic infection affecting the liver

predominantly.
● Almost all cases of acute viral hepatitis are caused by one of
five viral agents: hepatitis A virus (HAV), hepatitis B virus (HBV),
hepatitis C virus (HCV), the HBV-associated delta agent or
hepatitis D virus (HDV), and hepatitis E virus (HEV).
HEPATITIS
POINTS IN FAVOR POINTS AGAINST
● (+) Right Upper ● (-) Hepatomegaly
Quadrant Pain ● (-) Fatigue
● (+) Jaundice ● Cannot totally rule
● (+) History of Fever out
PEPTIC ULCER DISEASE
● Focal defects in the gastric or duodenal
mucosa which extends to the submucosa or
even deeper
● Imbalance between the action of acid and
mucosal defense
PEPTIC ULCER DISEASE
POINTS IN FAVOR POINTS AGAINST
● (+) Abdominal pain ● No history of chronic NSAID
● (+) Not relieved by food use or intake of high-dose
intake NSAIDs
● Age of the patient
DIAGNOSTIC PLAN
Complete Blood Count (10/21/2019-Noninstitutional )
WBC 7.30 5-10
Neutrophils 0.570 0.400-0.600
Lymphocytes 0.380 0.200-0.400
Eosinophils 0.020 0.010-0.030
Monocytes 0.030 0.020-0.050
RBC 4.16 4.20-5.60
Hemoglobin 130 119-159
Hematocrit 0.40 0.370-0.470
Platelet 333 150-400
Pancreatic Enzymes (October 21, 2019-
Noninstitutional )
Lipase 144.0 0-90 IU/L
Amylase 200.3 10-150
IU/L
Pancreatic Enzymes (October 27, 2019-
QMMC)
Lipase 1697.43
Amylase 486.73
Clinical Chemistry (10/21/2019-
Noninstituional)
Alkaline
35.00-123.0
Phosphatas 324 U/L
U/L
e
Total 5.000-21.00
8.7 umol/L
Bilirubin umol/L
BUN 5.45 mmol/L 2.1 – 7.1 mmol/L
Creatinine 67.46 umol/L 53 – 115 umol/L
HEPATITIS PROFILE (October 26,2019)
OCTOBER 25, 2019 NON REACTIVE
HBsAg
Anti-Hbs 2.0 NONREACTIVE
HbeAg 0.116 NONREACTIVE
Anti-Hbe 1.40 NONREACTIVE
Anti-Hbc IgM 0.291 NONREACTIVE
Antii-HAV IgM 0.038 NONREACTIVE
Anti-HCV 0.283 NONREACTIVE
Blood Chemistry (October 21, 2019-
Noninstitutional)

Sodium 137.1
Potassium 3.37
Chloride 109.70
Whole Abdomen Ultrasound (October
22, 2019 Noninstitutional)
● The liver is normal in size and parenchymal echogenicity. No discrete mass or
calcification is noted. The portal vein and its tributaries are unremarkable.
● The gallbladder is normal in size and echo. The wall is of normal
thickness with comet tail shadowing. Dilated Common Bile
Duct. It is measured is measured 0.47cm. A strong echo with
distal acoustic shadowing is noted within the mid common
bile duct and it is measured 1.13 x 0.92cm.
● The pancreas is normal in size and echo. No discrete mass or calcification is noted .
Peripancreatic areas are unremarkable.
● The spleen is of normal size and echo. No discrete mass or calcification is noted.
Perisplenic areas are unremarkable.
Whole Abdomen Ultrasound (October
22, 2019 Noninstitutional)
● Both kidneys show normal parenchymal thickness and echo pattern with distinct
corticomedullary junction. They measured as follows:
● Right Kidney: 8.67 x 4.72 x 3.72cm Parenchymal Thickness: 1.60cm
● Left Kidney: 9.29 X 5.26 X 3.83 cm Parenchymal Thickness: 1.80cm
● No discrete mass or calcification is noted. Renal outline is smooth and regular. The
pelvocalyces and ureter of both kidneys are not dilated. No lithiasis is seen. Perianal
and pararenal spaces are unremarkable.
● The urinary bladder has a prevoid volume of 6.11cc of urine with normal echo.
Whole Abdomen Ultrasound (October
22, 2019 Noninstitutional)
Impression:
● Normal Liver
● Choledocholithiasis
● Hyperplastic cholecystosis of the gallbladder wall
● Dilated common bile duct
● Normal Pancreas and spleen
● Normal kidneys and underfilled urinary bladder
Other Laboratory Tests and Diagnostics
done OCTOBER 25, 2019

CHEST X-RAY: NORMAL CHEST

ECG: NORMAL SINUS RHYTHM

 Biliary Pancreatitis
Probably Secondary
to Choledocolithiasis
THERAPEUTIC PLAN
PLAN OF MANAGEMENT
OPEN CHOLECYSTECTOMY WITH INTRAOPERATIVE
CHOLANGIOGRAM

● Cholecystectomy - removal of the gallbladder

● Standard treatment for symptomatic gallbladder
stones.
● After the cystic artery and cystic duct have been
identified, the gallbladder is dissected free from
the liver bed, starting at the fundus.
● The dissection is carried proximally toward the
Intraoperative Cholangiogram

● Bile Ducts are visualized under fluoroscopy by

injecting contrast through a catheter placed in the
CD
● Size can then be evaluated, the presence or
absence of common bile duct stones assessed, and
filling defects confirmed, as the dye passes into
the duodenum.
● Detected stones in 7% of patients
Intraoperative Cholangiogram

● Selective intraoperative cholangiogram: history of

abnormal liver function tests, pancreatitis,
jaundice, a large duct and small stones, a dilated
duct on preoperative ultrasonography, and if
preoperative endoscopic cholangiography for the
above reasons was unsuccessful.
COURSE IN THE WARD
Pre Op Findings
Pre Operative October 26 and 27, 2019 (Day 1 & Day
2)Subjective Objective Assessment Plan Comment

Abdominal pain Abdominal Acute Pancreatitis For Open Agree

Tenderness on secondary to Cholecystectomy with Main indication of
RUQ Choledocolithiasis Intraop Cholangiogram treatment for
symptomatic
gallstones
Murphy’s sign Diagnostics:
CBC, Na, K, Cl, BUN,
Increased Crea, Amylase, Lipase, For CP clearance
Lipase and Alk Phos, Total Bilirubin,
Amylase PT, PTT, CXR, 12L-
ECG, Hepa profile

Icterus and Secure ‘2u’ pRBC

Jaundice properly typed and
matched
Pre Operative October 26 and 27, 2019 (Day 1 & Day
2) Subjective Rationale/ Comment
Objective Assessment Plan
Right upper quadrant Vital Signs: Visceral Pain Omeprazole 40mg IV Agree
squeezing radiating to BP- 110/80 OD
the back PR-112 HNBB 10mg IV q 8 To decrease pain
sensation
RR-20 RTC
Temp- 37 Paracetamol 500mg
IV RTC
PS-7/10 Tramadol 50mg IV q8
PRN
 Pre Operative October 26 and 27, 2019 (Day 1 & Day
2)Subjective Objective Assessment Plan Comment
No subjective Normal BMI Nutrition NPO This dogma is offered
complaints because of the concern
that food intake will
stimulate pancreatic enz
yme release in an
already inflamed
pancreas

Good skin turgor Hydration PLR 1L x 150cc/hr For electrolyte

320cc for 8 hours Monitor vital signs every 4 replacement and also for
hours mild malnutrition due to
Monitor Urine Output prior surgery
Pre Operative October 28, 2019 Day 3
Subjective Objective Assessment Plan Comment

Right upper Abdominal Acute HNBB 10mg IV q 8 Agree

quadrant colicky Tenderness Pancreatitis RTC
radiating to the Paracetamol 500mg IV
back
Murphy’s sign Gallstones RTC
Tramadol 50mg IV q8
Increased Lipase PRN
and Amylase
For Open
VAS-7/10 Cholecystectomy with
Intraop Cholangiogram
Pre Operative October 28, 2019 Day 3
S O A P C

Normal BMI Nutrition Low salt low fat Agree

diet
LSLF diet can
reduce the
symptoms of
gallstones

Good skin turgor Hydration D5LR 1L x Agree

Urine output- 150cc/hr Use to replace
350cc for 8 Monitor vital fluid
hours signs every 4
hours
Monitor Urine
output
Pre Operative October 29, 2019 Day 4
Right upper Abdominal For Open NPO To prevent pulmonary
quadrant squeezing Tenderness on Cholecystectomy aspiration of stomach
radiating to the back RUQ with Intraop
contents during general
Cholangiogram
Murphy’s sign anesthesia

Increased Lipase Therapeutics: Pre-operative antibiotic

and Amylase 1. Cefoxitin 2g/IV prophylaxis (DOH
2. Omeprazole National Antibiotic
40mg/IV OD while Guidelines for Surgical
Icterus and Prophylaxis, 2016)
NPO
Jaundice To reduce gastric fluid
acidity during surgery
VAS-6/10 that may cause
pneumonitis

For CP clearance
To help the patient and
health care providers
weigh the benefits and
risks of the surgery and
optimize the timing of
the surgery.
PreOperative
Pre Operative October
October 29, 2019 29, 2019 Day 4
S O A P C

Good skin Hydration D5LR 1L x 8hrs Agree

turgor once on NPO Use to replace fluid,
BP- 110/80 for acute blood loss
HR- 95 plus additional
180cal.

No subjective K-3.37 Hypokalemia 10meqs KCl in Agree

complaints 90cc PNSSx 1 Best initial treatment
hour for 3 cycles for hypokalemia
Intraoperative Findings Hepatic Ducts
(Left & Right)

Common
Hepatic Duct

Cystic duct
stump

Commo
n Bile
Duct

Duodenu
m
Intraoperative Findings
Intraoperative Findings
Post-Fluoro
Intraoperative Findings
INTRAOPERATIVE FINDINGS

6X3cm gallbladder, non thickened wall with no

intraluminal stones. Dilated cystic duct.

No filling defect, dilated common bile duct and

intrahepatic ducts with complete regress of
contrast medium into the duodenum.
Obstructive Jaundice secondary
to Biliary Pancreatitis secondary
to Choledocholithiasis
S/P Open cholecystectomy with
Intraoperative cholangiogram
FINAL DIAGNOSIS
Post Operative October 29, 2019 (Day 1)
S O A P C

(-) flatus (-) bowel Nutrition NPO Agree

sounds Oral feeding is usually
started once peristalsis
starts or usually 8 hours
post-op

(-) signs Good skin Hydration B fluids 1Lx 12 hours for 2 cycle Provision of amino acids,
of turgor once at ward electrolytes, due to
dehydrati UO = 350cc inadequate oral intake, and
on for 8 hours before and after surgery
Post-op VAS 6-7/10 Somatic Ketorolac 30mg IV q6 x 2 doses Agree
site pain pain ANST Patient still in PACU hence
Butorphanol 1mg via epidural given via epidural catheter
catheter q12 x 2 doses
Post Operative October 30, 2019 (Day 2)

S O A P C

(+) flatus (+) Nutrition May have soft diet to DAT Agree
bowel Oral feeding is usually started
sounds once peristalsis starts or usually
8 hours post-op

(-) signs of Good Hydration B fluids 1Lx 12 hours for 2 Provision of amino acids,
dehydration skin cycle once at ward electrolytes, due to inadequate
turgor oral intake, and before and after
surgery

Post-op site 2/10 Somatic HNBB 10mg IV q

pain pain Paracetamol 500mg IV RTC
Tramadol 50mg IV q8 PRN
Post Operative October 31, 2019 (Day 3)

S O A P C

(+) Bowel Normoactive Nutrition DAT Agree

movement bowel sounds

Post-op site BP – 120/80 Somatic May go home Pain medications

pain HR – 88 pain Paracetamol 500mg every 6 hours
RTC x 2 days then PRN
VAS 2/10 Tramadol 50mg 1 tablet TID RTC

Good skin healing Dry wound Wound Daily wound care To monitor the
(-) fever (-) Redness healing Follow up at OPD after 1 week patient and for
Temp – 36.4C removal of sutures
Discussion
Pathophysiology
● Inflammation due to activation of pancreatic enzymes within the pancreas.
● Ranges from self-limiting inflammation to critical phase characterized by
pancreatic necrosis, multiple organ failure and increased mortality.
● Autodigestion: currently accepted pathogenic theory.
● Common etiologies include:
○ Gallstones (most common cause; 70%)
○ Alcohol (2nd most common; 10%)
○ Others: Hypertriglyceridemia, iatrogenic, drugs, direct trauma, tumors

Source: Hazem Z.M. (2009) Acute Biliary Pancreatitis: Diagnosis and Treatment. Saudi J Gastroenterol.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841412/?report=printable
Epidemiology
● Risk of developing acute pancreatitis in patients with gallstones is greater in
men; however, more women develop this disorder since gallstones occur
with increased frequency in women.

Source: Hazem Z.M. (2009) Acute Biliary Pancreatitis: Diagnosis and Treatment. Saudi J Gastroenterol.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841412/?report=printable
Clinical Manifestations of Acute
Pancreatitis
● Shock
● Abdominal tenderness
● Bowel sounds
● Jaundice
● Pulmonary findings (rales, atelectasis, or pleural effusion)
● Cullen’s sign
● Grey-Turner’s sign
Clinical Manifestations of Acute
Pancreatitis
● Abdominal pain (Epigastric and/or periumbilical region) - major symptom
○ Steady and boring
○ Radiation to the back, chest, flanks or lower abdomen
○ Aggravated when lying supine
○ Relieved upon sitting with the trunk flexed and knees drawn up
● Other symptoms: nausea, vomiting and abdominal distention
● General PE: hypotensive, tachycardic and with low-grade fever
Revised Atlanta Classification: Phases
● Early (< 2 weeks)
○ Defined by clinical parameters
○ Most exhibit SIRS; predisposed to organ failure
○ Persistent organ failure (>48 hours): correlates with severity
● Late (≧ 2 weeks)
○ May require imaging to evaluate local complications
○ Persistent organ failure is still an important clinical parameter
○ Need for supportive measures (dialysis, ventilator support, TPN)
Revised Atlanta Classification: Severity
● Mild
○ Without local complications or organ failure
○ Self-limited; subsides within 3-7 days after treatment is instituted
○ Resumption of oral intake (normal bowel function, no n/v, and hungry)
● Moderately Severe
○ Transient organ failure (resolves in <48 hours) or
○ Local/systemic complications in the absence of persistent organ failure
● Severe
○ Persistent organ failure (>48 hours)
○ Imaging warranted to assess for necrosis or complications
Acute Biliary Pancreatitis
● Result of transient obstruction of the bile duct and
pancreatic duct, which results in bile reflux or
increased hydrostatic pressure in the pancreatic duct.
● Defined by fulfillment of at least 1 of the ff:
○ Gallstones or biliary sludging on imaging
○ Dilated CBD on imaging
○ ALT elevated more than 2x the upper limit
● However, most cases are self-limiting and improve
with conservative treatment since most gallstones
spontaneously pass the duodenum.

Source: Lee HS, Chung MJ, Park JY, Bang S, Park, SW, Song SY, et al. (2018) Urgent endoscopic retrograde cholangiopancreatography
Diagnostics
● Lipase and Amylase
○ Gold standard for diagnosis; increased 3-fold should raise suspicion
○ Lipase: remains elevated for 7-14 days; more specific
○ Amylase: remains elevated for ~36 hours
● CBC
○ Reveals leukocytosis with neutrophilia
○ Hemoconcentration (> 44% Hct)
● Serum chemistry
○ Disturbance in electrolytes usually seen secondary to third spacing
○ Hyperglycemia may be due to B-cell destruction
Diagnostics
● Alanine Aminotransferase (ALT)
● More than 2x the upper limit of normal
● Abdominal CT Scan
○ Useful in indicating severity and aids in evaluation of complications
● Transabdominal Ultrasound
○ First imaging utilized for evaluation
○ Of use to evaluate gallbladder if gallstone disease is suspected
Management
● Conventional measures
○ Fluid resuscitation with BUN and Hct monitoring
○ Analgesics for pain
○ Placed on NPO and bowel rest
○ Vital signs monitoring
Thank You!