First Moscow State Medical University

MEDICAL FACULTY Division of Foreign Students with Instruction Conducted in English

Department of Surgery

CASE HISTORY

By Mardiana Kamal Medical Faculty, English Medium, Group 93 Supervisor: , MD PhD

MOSCOW 2012

Personal data of the patient Name : Age : 80 years old Date of birth : 11.11.1931 Sex : Female Weight : 60 kg Height : 156 cm Occupation : Pensioner Marital status : Married Department : Surgery Date of Admission : 11.03.2012 COMPLAINTS The patient complained of feeling heaviness in region of under right costal arc, periodically appeared pain after eating fatty food.

ANAMNESIS MORBI The patient, , was admitted to the 79th Hospital on 11.03.2012 with the complaints of feeling heaviness in region of in region of under right costal arch, already 5 years. On the same day, she went to the polyclinic, was asked to go to the hospital and she was admitted. Investigations were performed: Ultrasound investigation of abdominal cavity revealed concrement in gall bladder.

ANAMNESIS VITAE Anamnesis familiae The patient is widowed and has 1 child. Her daughter was also admitted to the hospital two years ago with the same complaints. Physical abnormalities: The patient grew normally without any physical abnormality. Previous medical history The patient had never been admitted to any hospitals before. Although, she has diagnosed previous case of ARVI, Ischemic Heart Disease, Arterial Hypertension, and Chronic Obstructive Pulmonary Disease. No information on usage of medical preparations.

Epidemiological anamnesis: She does not have any current infection. She seldom has tonsilits. Harmful habits: Patient does not smoke or drink Previous blood transfusion: Patient had previous no blood transfusion Allergic history: There is no known allergy in this patient.

STATUS PREASENS The patients condition is satisfactory. She is well and alert. She is coherent and fluent.

CONSTITUTION The patient had a normal constitution.The external features of the body correlates to her age. POSTURE The patient was normal and active. She did not have any discomfort during inspection and was not assuming a forced position. Height 1.56 m, weight 60kg. BMI = 23 - normal SKIN The patient got a clear pink skin. There were no hyperpigmentations of the skin. The skin was evenly colored with no jaundice. There were no abnormal discolorations of the mucous membranes. The skin of the patient was dry. SUBCUTANEOUS FAT Patients subcutaneous fats are uniformly distributed. There is no excessive fat accumulation. Wasting was also not noticed in this patient. EDEMA No edema was visible in this patient. The eye lids appear normal with no narrowing of the slits. The patients ankle and legs were checked and there was no pitting edema. Acsites was absent and no generalized form of edema was found in this patient (anasarca). LYMPH NODES Regions Submandibular Cervical Supraclavicular Axillary Visual inspection Not visible Not visible Not visible Not visible Palpation Palpable, not enlarged (0.5cm) Palpable, not enlarged (0.5cm) Not palpable Palpable, not enlarged (0.5cm) Characters Mobile without skin attachment Mobile without skin attachment Mobile without skin attachment

MUSCULAR SYSTEM There were no local atrophies of the skeletal musculature observed in this patient. There was no functional skeletal muscle dysfunction (cramps). BONES The bones of the skull, chest, spine and extremities were normal without any abnormal bulge or deformities. Patients general bone configuration is normal. There is no abnormal growth or elongation (gigantism) of the patients bone structures.

RESPIRATORY SYSTEM Inspection of the chest The patient was examined in an upright sitting position in her room. The patients clavicles and the shoulder blades are at the same level and the supra-clavicular fossa and the sub-clavicular are equally pronounced on each sides. Respiratory movements: The respiratory movements of the patient were normal since the patient was not assuming a forced position and there was no evidence of involvement of the accessory respiratory muscles. Respiratory type: The respiratory type was thoraxic breathing. Respiratory rate: 15 breaths per minute. Respiratory rhythm: Rhythmic of uniform depth and equal length of the inspiration and expiration. Constitution: The patient had a normostenic constituition. The costal angle is not more than 90 degrees. Pain and tenderness: Pain and tenderness (both local and diffuse) are absent in the patients thoracic region. Elasticity (resilience): The patients chest is of normal decreased elasticity. Vocal fremitus: Vocal fremitus normal in this patient. The vocal fremitus was about the same intensity with no changes in symmetrical parts of the thoracic cavity. Percussion of the chest: Comparative percussion: Pulmonic sound with an admixture of tympani. The so-called hyper-resonant sound is heard in symmetrical points of patients thoracic cavity. Topographic percussion: Upper borders of the lungs: Borders of the lungs Upper anterior border Upper posterior border Right lung 3 cm above the clavicle Spinous process of the 7th cervical vertebra normal Left lung 3 cm above the clavicle Spinous process of the 7th cervical vertebra normal

Kroenigs area The lower borders of the lungs: Topographic lines Linea parasternalis Linea midclavicularis Linea axillaris anterius Linea axillaries medius

Right lung 5th intercostals space 6th rib 7th rib 8th rib

Left lung 7th rib 8th rib

Linea axillaris posterius Linea scapularis Linea paraspinalis

9th rib 10th rib Spinous process of the 11th thoracic vertebra

9th rib 10th rib Spinous process of the 11th thoracic vertebra

Mobility of the lower lung borders: Mobility of the lower lung borders are without any peculiarities, with normal parameters. Auscultation of the lungs: Vesicular breathing: The patient had clear vesicular breathing with normal inspiration and expiration phases. Bronchial breathing: Bronchial breathing is heard over the larynx, and trachea. Bronchophony: Normal bronchophony. The loud whispering voice of the patient is audible on both side of the chest in symmetrical points. CARDIOVASCULAR SYSTEM General inspection of the cardiovascular system: Patient appears calm with no signs of breathlessness, anxiety or discomfort. Examination of the neck region: No carotid shudder is felt. Neck veins are not visible. Arterial blood pressure: 140/80 mmHg Pulse Rate : 78 beat per minute Palpation of the apex beat: Apex beat in this patient was not palpable. Palpation of the pulse: Carotid artery: - Pulse not visible, but felt - Regular pulse with regular resistance and strength Axillary artery: - Pulse not visible, but felt - Regular pulse with regular resistance and strength Inguinal artery: - Pulse not visible, but felt - Regular pulse with regular resistance and strength Popliteal artery: - Pulse not visible, but felt - Regular pulse with regular resistance and strength Tibialis posterior: - Pulse not visible, but felt - Regular pulse with regular resistance and strength Dorsalis pedis: - Pulse not visible, but felt - Regular pulse with regular resistance and strength

Palpations of apex beat: palpated 2cm medial to the left midclavicular line. Auscultation: Points 1st point 2nd point 3rd point 4th point Botkin-erbs point S1 Normal Normal Normal Normal Normal S2 Normal Normal Normal Normal Normal S3 _ _ _ _ _ S4 _ _ _ _ _

Auscultatory findings: No pathologies were found Percussion of the heart: Relative heart dullness: Relative borders of the heart Right border Left border Upper border Absolute heart dullness: Absolute borders of the heart Right border Left border Upper border Dullness levels Left edge of the sternum 1 cm from the relative heart dullness 4th intercostals space Dullness levels 3 cm laterally to the right edge of the sternum 1 cm medially from the midclavicular line 3rd intercostals space

Configuration of the vascular bundle: The configuration of the vascular bundle is without any peculiarities. Configuration and assessment (shape) of the heart dullness: The heart dullness is relatively normal with no mitral or aortic (so-called sitting duck or boot shaped) configuration of the heart dullness.

URINARY SYSTEM Inquiry: Patient had no complains. She has no pain or any discomfort in her lumbar region. The patients micturation is normal with no pain of discomfort during this process. Physical examination: Inspection: There are no physical signs of fetor uremicus. There is no abnormal swelling or protrusion in the patients loin region. Palpation: The kidneys were impalpable. No tenderness over renal ENDOCRINE SYSTEM Physical examination: Inspection: Patients general outlook does not indicate any endocrinal abnormalities. Patients mental and emotional state was normal. Her sleeping patterns have not changed. CENTRAL NERVOUS SYSTEM Inquiry: Consciousness : conscious and alert Headache : absent Dizziness : absent Sleeping disorders : absent Memory status : Normal STATUS LOCALIS (Digestive system) Physical examination of the gastrointestinal tract: Inspection: The general appearance of the patient is satisfactory and there is no evidence of poor nutritional state or cachexia. Oral cavity: no foul smell or any other unpleasant odor. State of the teeth : no cavities were present. State of the gums: pink color without hemorrhages, no ulceration and no purulent inflammation. State of the tongue: the tongue is clean and moist with visible papillae. Palpation of the Stomach: soft, without pain Schutkin-Blumberg sign : Negative Peritoneal signs : Negative Ortner sign : Negative Auscultation : normal bowel sounds

LIVER AND THE GALL BLADDER Physical examination: The inspection was carried out during the day in a room with proper light settings. The habitus of the patient was normal. No icteric of the sclera. Normal pinkish colour of all parts of the tongue, palms and soles. Skin:

No abnormal discoloration of the skin. Few scratch marks were revealed during inspection. No hemorrhagic diathesis. No spider angiomatas.

Percussion of the liver: Topographic lines Linea axillaris anterior dextra Linea midclavicularis dextra Linea parasternalis dextra Lines mediana anterior Superior liver borders 7th rib 6th rib Superior edge of the 6th rib _ Inferior liver borders 10th rib Arcus costalis 2 cm below the interior edge of the right costal arch 3 cm below the base of the xiphoid process

The left border of the liver dullness was on the linea parastenalis sinistra. Palpation of the liver and gallbladder: Palpation of the liver: Palpation was not performed due to post-operative drainage at right hypogastric region.

Gall bladder Murphys sign Otners sign Georgivsky- de musses sign Spleen Palpation of the Spleen: The spleen was impalpable. Percussion of the spleen: Axis Transverse axis Long axis Measurements 5.5 cm 7 cm Negative Negative Negative

PRESUMPTIVE DIAGNOSIS Chronic Cholecystitis.

Methods of investigations Common blood count Biochemical blood test Common urine test Prothrombin index HBs Ag, antiHCV, HIV test Ultrasound examination Oesophagogastroduodenoscopy ECG Instrumental and laboratory methods General analysis of the blood Date of the sample: 13.03.2012 Parameters WBC RBC HGB Hematocrit Platelet Mean Corpuscular Volume Mean Corpuscular Hemoglobin MCHC Lymphocyte Monocyte Granulocyte Biochemical Analysis of the Blood Date: 13.03.2012 Parameters Total Protein Albumin Urea Total bilirubin Iron Creatinine Cholesterin Tryglyceride Results 63 g/l 38g/l 6.3 mmol/l 9.9 micromol 6.6 mmol.l 101.1 micromol/l 6.1 mmol/l 1.04 mmol/l Obtained results 11.1 10^9 /l 4.21 10^12 /l 116 g/l 37.4 182 10^9/l 89 fl 27.5 pg 311 g/l 26 % 6% 69 %

AST ALT a-Amylase Alkaline Phosphotase Glucose General analysis of patients urine sample Date of sample: 14.09.2011 Properties Color Transparency Urine pH Reactivity to blood Protein Ketone body Bilirubin Pigments Urobilin Leucocytes Prothrombin index (13.03.2012) : 84% HBs Ag test : Negative antiHCV test : Negative HIV test : Negative

46 E/l 38 E/l 27 E/l 160 E/l 4.1 mmol/l

Results yellow clear 6.0 - acidic negative 0.5 g/l 4 mmol/l 8.5 umol/l 34 umol/l 250 Leu/uL

ULTRASONOGRAPHY INVESTIGATIONS Date 11.03.2012 Concrement in gall bladder. Chronic calculous cholecystitis, bile duct not dilated. Date : 13.03.2012 Separated from subdiaphragmatic peritoneum on the right and left, obstructive, near the spleen in the lateral left and right canals. In pelvic cavity, no peculiarities identified. Intrahepatic bile ducts are not dilated. In region of gallbladder, fluid delineated structures are not identified. Hepaticocholedochus : 5.5 6mm Liver: Parenchyma : Changed Focal changes : None Intrahepatic duct : Poor Gallbladder: Deformed, Size increased, wall is without changes. Contents are non-homogenous. Palpation in region of gallbladder is without pain. Common bile duct is without changes.

Pancreas: Normal value, not dilated, no focal changes Spleen : No significant changes Conclusion : Cholelithiasis. Chronic Calculous Cholecystitis.

ENDOSCOPIC INVESTIGATIONS Esophagogastroduodenoscopy: Date: 12.09.2011 Patients throat was anesthetized with 10 % of lidocaine. There was no obstacle in the passage of the fiberscope. The esophageal lumen was free. The opening at the esophagealgastric junction not deformed. Mucosa is pale-pink. There are no pathogenic changes in the esophagus. Cardiac sphincter does not close completely. Evacuation from oesophagus is normal. Empty stomach with mucous. Folds in normal form, during insufflation of air expanded satisfactorily. Peristalsis symmetrical. Mucosal focal hyperaemia. Angle of stomach, antral part without peculiarities. Evacuation is normal. Duodenum is without peculiarities. Mucosal layers is without defect. Postbulbar part is normal. Conclusion : Chronic Gastroduodenitis

ELECTROCARDIOGRAPHIC INVESTIGATIONS Sinus rhythm with no signs of current attact of coronary heart disease.

CLINICAL DIAGNOSIS Chronic Calculous Cholecystitis

LAPAROSCOPIC CHOLECYSTECTOMY Under endotracheal anaesthasia, impositioned pneumoperitoneum and administrated trocar in typical points. Video revision : No effusion in peritoneal cavity. Gall bladder normal size. Wall is thickened, fused and sealed to duodenum. Bile duct is visually not dilated. Fusion is dissected, removed bladder duct and artery, clipping and separately crossed. Bladder is separated from position with coagulation after. Hemostasis in course of operation. Bladder is extracted from peritoneal cavity through paraumbilical puncture. Peritoneal cavity drained. Removed pneumoperitoneum. Suture on punctures.

MEDICATION 1. Ketorol 1.0 / D 2. Ceftriaxone 1.0 2x/D 3. Analgia 50% 2.0 (if pain arises)

CONCLUSION The patient was diagnosed with chronic calculous cholecystitis. The diagnosis in this patient was confirmed through instrumental investigation by ultrasonography of the right hypochondriac region. Diagnosis was also achieved with relation to patients symptom of feeling heaviness in region under costal arch. During ultrasonography on 11.03.2012, concrement in gall bladder was revealed. Chronic calculous cholecystitis was the presumptive diagnoses. During ultrasonography on 13.03.2012, signs of Intrahepatic bile ducts are not dilated. In region of gallbladder, fluid delineated structures are not identified. Hepaticocholedochus : 5.5 6mm. The was also an increase of urobilin in her urine test. Patients with choledocholithiasis may be completely asymptomatic; symptoms occur when the stones obstruct the CBD. The ultrasonography confirmed the diseases. In the hospital, the patient had undergone laparoscopic cholecystectomy under anesthesia as treatment. DIFFERENTIAL DIAGNOSIS Acute gastritis Amoebic hepatic abcess Appendicitis Biliary colic Cholangitis Cholangiocarcinoma Acute pancreatitis Nephrolithiasis Gastric ulcer Peptic ulcer disease

CHRONIC CALCULOUS CHOLECYSTITIS

Chronic cholecystitis is gallbladder inflammation that has lasted a long time. It almost always results from gallstones. It is characterized by repeated attacks of pain (biliary colic). 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. The gallbladder usually contains sludge (microscopic particles of materials similar to those in gallstones) or gallstones that block its opening into the cystic duct or reside in the cystic duct itself.

PATHOPHYSIOLOGY Gallstones result from supersaturation of cholesterol in the bile, which acts as an irritant, producing inflammation in the gallbladder, and which precipitates out of bile, causing stones. Risk factors include gender (women four times as like to develop cholesterol stones as men), age (older than age 40), multiple parity, obesity, use of estrogen and cholesterol-lowering drugs, bile acid malabsorption with GI disease, genetic predisposition, rapid weight loss. Pigment stones occur when free bilirubin combines with calcium. These stones occur primarily in patients with cirrhosis, hemolysis, and biliary infections. Acute cholecystitis is caused primarily by gallstone obstruction of the cystic duct with edema, inflammation, and bacterial invasion. It may also occur in the absence of stones, as a result of major surgical procedures, severe trauma, or burns. Chronic cholecystitis results from repeated attacks of cholecystitis, presence of stones, or chronic irritation. The gallbladder becomes thickened, rigid, fibrotic, and functions poorly.

CLINICAL PRESENTATION Recurrent episodes of biliary pain in the right upper abdomen, sometimes in epigastrium, often with irradiation to the right scapular region. Biliary pains may be in the right hypochondrium, frequently or occasionally, of different intensity and duration, related to intake of fatty meals. 1. In addition, a biliary pain may occur with one or more of the following symptoms: a. regular or periodical feeling of bitter taste b. nausea, sometimes vomiting c. regular or periodical abdominal bloating and borborygmus d. unstable stool with constipation or diarrhea prevailing 2. Impaired gallbladder emptying. 3. According to ultrasound examination, thickening of the gallbladder wall up to 3-4 mm and presence of gallstones in the gallbladder lumen.

Chronic cholecystitis on ultrasonography

MEDICATION For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, analgesia, and intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy with a single broadspectrum antibiotic is adequate. The current Sanford guide recommendations include piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or meropenem (Merrem, 1 g IV q8h).

In severe life-threatening cases, the Sanford Guide recommends imipenem (500 mg IV q6h) third-generation cephalosporin plus Flagyl (1 g IV loading dose followed by 500 mg IV q6h).

Pathogenetic treatment of patients with chronic calculous cholecystitis Accordingly, treatment of chronic calculous cholecystitis (with biliary pain) aiming for prophylactics of the acute calculous cholecystitis, duodeno-gastral reflux, antral atrophic (bile-acid-dependent) gastritis and chronic biliary pancreatitis includes: 1. 2. Celecoxib - 100 mg, 2 times a day after meal for 5-7 days, after which Ursodeoxycholic acid - 750 mg, once a day (in the evening) for 3 month.

Celecoxib is a selective inhibitor of COX-2. Inhibiting COX-2 activity in the smooth muscle cells of the gallbladder wall and cystic duct it brings relief of the biliary pain within 3-5 days, restoration of the evacuation function of the gallbladder and the gallbladder-dependent output of biliary cholesterol, active and passive passage of the hepatic bile into the gallbladder, and decrease in the gallbladderindependent enterohepatic circulation of bile acids, biliary cholesterol and biliary bilirubin. Celecoxib, a selective inhibitor of COX-2, inhibiting COX-2 activity in the epithelial cells of the gallbladder mucosa causes inhibition of the glycoprotein mucin hypersecretion into the gallbladder lumen,

concentration of glycoprotein biliary mucin in gallbladder bile and viscosity of gallbladder bile, which prevents formation of biliary sludge. Low COX-2 activity in the epithelial cells of the gallbladder mucosa helps restoring the absorption function of the gallbladder (absorption of water and biliary cholesterol from phospholipid vesicles), which results in increase of concentration of total bile acids and decrease of concentration of biliary cholesterol in the gallbladder bile. Also, low COX-2 activity in the epithelial and smooth muscle cells of the gallbladder infundibulum helps lowering the risk of development of acute calculous cholecystitis. Ursodeoxycholic acid, is a hydrophilic hepatoprotective bile acid. It helps in dissolving the cholesterol monohydrate crystals in the gallbladder, decrease of lithogenicity of gallbladder and hepatic bile, disappearance of the chronic bland intrahepatic cholestasis (i.e. results in the restoration of the accumulation and excretion functions of liver) and in some patients helps in dissolving cholesterol gallstones. Celecoxib and Ursodeoxycholic acid, blocking main pathogenetic mechanisms of gallstones formation, help in slowing down the growth of cholesterol gallstones and lower the risk of acute calculous cholecystitis. In some patients the chronic calculous cholecystitis can transfer into the gallstone disease (without biliary pain) or the silent gallstones group. Estimated effectiveness is 95%. Remission period is 18-24 months. Contraindications for Celecoxib: allergic reactions (nettle-rash, bronchial spasm) to acetylsalicylic acid or other NSAIDs (in anamnesis); 3rd trimester of pregnancy; high sensitivity to sulphonamides; high sensitivity to any component of the preparation. Contraindications for Ursodeoxycholic acid: high sensitivity to the preparation; acute inflammatory diseases of the gallbladder and the bile ducts; ulcerative colitis; Crones disease.

MANAGEMENT Patients should be fasted, rehydrated with intravenous fluids, and given oxygen therapy and adequate analgesia. Indometacin (25 mg three times daily for a week) can reverse the inflammation of the gall bladder and the contractile dysfunction seen in the early stages (first 24 hours) of cholecystitis. The prokinetic action of indometacin will also improve postprandial emptying of the gall bladder in patients with gallbladder disease. A single intramuscular dose of diclofenac (75 mg) may substantially decrease the rate of progression to acute cholecystitis in patients with symptomatic gall stones. Because of the risk of superimposed infection, intravenous antibiotics should be started empirically if the patient has systemic signs or if no improvement is seen after 12-24 hours. A second generation or newer cephalosporin should be used (for example, cefuroxime 1.5 g every 6-8 hours) with metronidazole (500

mg every 8 hours). Non-operative managementsolvent dissolution therapy or extracorporeal shockwave lithotripsyhas been used with variable results to treat chronic cholecystitis in patients unfit for surgery, but it has no place in the management of acute cholecystitis.

TREATMENT For patients with symptomatic gallstones and suspected common bile duct stones, either preoperative endoscopic cholangiography or an intraoperative cholangiogram will document the bile duct stones. If an endoscopic cholangiogram reveals stones, sphincterotomy and ductal clearance of the stones is appropriate, followed by a laparoscopic cholecystectomy. An intraoperative cholangiogram at the time of cholecystectomy will also document the presence or absence of bile duct stones . Laparoscopic common bile duct exploration via the cystic duct or with formal choledochotomy allows the stones to be retrieved in the same setting (see Choledochal Exploration). If the expertise and/or the instrumentation for laparoscopic common bile duct exploration are not available, a drain should be left adjacent to the cystic duct and the patient scheduled for endoscopic sphincterotomy the following day. An open common bile duct exploration is an option if the endoscopic method has already been tried or is, for some reason, not feasible. If a choledochotomy is performed, a T tube is left in place. Stones impacted in the ampulla may be difficult for both endoscopic ductal clearance as well as common bile duct exploration (open or laparoscopic). In these cases the common bile duct is usually quite dilated (about 2 cm in diameter). A choledochoduodenostomy or a Roux-en-Y choledochojejunostomy may be the best option under this circumstance.

OPERATIVE APPROACH Surgery is indicated if the patient's condition deteriorates or when generalised peritonitis or emphysematous cholecystitis is present. These features suggest gangrene or perforation of the gall bladder. Cholecystectomy Patients with cholecystitis who undergo early laparoscopic cholecystectomy (before symptoms have lasted 72-96 hours) have lower complication rates and lower conversion rates than open cholecystectomy and shorter hospital stays than those undergoing interval surgery. Surgery for cholecystitis also has a lower conversion rate than delayed surgery (which is performed during the index admission after conservative management and after symptoms have lasted 3-5 days). Early surgery also avoids complications when conservative treatment fails. A long time between onset of symptoms and presentation is associated with advanced disease. Early laparoscopic surgery is safe and feasible in patients with acute or chronic cholecystitis. If early interventionless than 72 hours after symptoms startedcan be achieved, oedema planes present during this period allow the gall bladder to be dissected laparoscopically. Although it is desirable to operate within this time period, it is often difficult to do so in clinical practice. By the time inflammation has been present for more than 72 hours, features of chronic inflammation (such as fibrosis) predominate and make it more difficult to dissect the gall bladder. Contraindications for laparoscopic cholecystectomy include the following:

High risk for general anesthesia Morbid obesity Signs of gallbladder perforation, such as abscess, peritonitis, or fistula Giant gallstones or suspected malignancy End-stage liver disease with portal hypertension and severe coagulopathy

Percutaneous cholecystostomy Percutaneous cholecystostomy is a minimally invasive procedure that can benefit patients with serious comorbidity who are at high risk from major surgery. Percutaneous cholecystostomy can be performed at the bedside under local anaesthetic and is suitable for patients in intensive care units and those with burns. It is the definitive treatment in patients with acalculous cholecystitis or it may be used as a temporising measureto drain infected bile and delay the need for definitive treatment.

Percutaneous cholecystostomy. A pigtail catheter has been placed through the abdominal wall, the right lobe of the liver, and into the gallbladder.

Percutaneous cholecystostomy gives clinical improvement in about three quarters of patients. Mortality after this procedure is related to comorbidity (for example, pneumonia or myocardial infarction) or preexisting sepsis. An incomplete or poor response to cholecystostomy within the first 48 hours may indicate causes of sepsis other than cholecystitis, inadequate antibiotic coverage, possible complications (such as dislodgement of the drainage tube), or necrosis of the wall of the gall bladder. Patients can undergo cholecystectomy after percutaneous cholecystostomy. In patients unfit to be given a general anaesthetic, the drain can be left in place for more than six weeks to allow radiological extraction of calculi at a later date.

Risks The overall risk of laparoscopic gallbladder surgery is very low. The most serious possible complications include:

Infection of an incision. Internal bleeding. Injury to the common bile duct. Injury to the small intestine by one of the instruments used during surgery. Risks of general anesthesia.

Recovery is much faster and less painful after laparoscopic surgery than after open surgery.

The hospital stay after laparoscopic surgery is shorter than after open surgery. People generally go home the same day or the next day, compared with 2 to 4 days or longer for open surgery. Recovery is faster after laparoscopic surgery. You will spend less time away from work and other activities after laparoscopic surgery (about 7 to 10 days compared with 4 to 6 weeks).

POSTCHOLECYSTECTOMY SYNDROME Postcholecystectomy syndrome sometimes occurs when abdominal symptoms develop after surgery to remove the gallbladder(cholecystectomy). Between 5% and 40% of people who have thegallbladder removed may experience this syndrome. Symptoms of postcholecystectomy syndrome may include: Upset stomach, nausea, and vomiting. Gas, bloating, and diarrhea. Persistent pain in the upper right abdomen You can ease diarrhea by taking the medicine cholestyramine. If pain continues, you may have a problem caused by something other than the gallbladder or a gallstone. Other possible causes of abdominal pain include irritable bowel syndrome, stomach (peptic) ulcers, pancreatitis, or abdominal pain from an unknown cause. COMPLICATIONS (1) Gangrenous cholecystitis Gangrenous cholecystitis occurs in 2-30% of cases of acute cholecystitis. Men aged over 50 with a history of cardiovascular disease and leucocytosis (>17 000 leucocytes/ml) have the highest risk of gangrene of the gall bladder.Gangrene occurs most commonly at the fundus because the vascular supply often becomes compromised. Urgent laparoscopic cholecystectomy should be considered in patients at high risk of gangrene, and the surgeon should have a low threshold for conversion to open cholecystectomy during the procedure. (2) Gallbladder perforation The gall bladder is perforated in 10% of cases of acute cholecystitisusually in patients who sought medical attention after a delay or in those who do not respond to conservative management. Perforation most commonly occurs at the fundus. After the gall bladder has perforated, patients may experience transient relief of their symptoms because the gall bladder decompresses, but peritonitis then develops. Free perforation presents with generalised biliary peritonitis and is associated with a mortality of 30%. Localised perforation, with the formation of pericholecystic abscesses, is more common, because the adherent viscera adjacent to the perforation tend to localise spillage of the contents of the gall bladder. A mass may be palpable in patients with localised perforation, and computed tomography is the most useful investigation. (3) Cholecystoenteric fistulas An acutely inflamed gall bladder may create a cholecystoenteric fistula by adhering to and causing a perforation in other parts of the gastrointestinal tract. The most common sites for fistulas are the duodenum and the hepatic flexure of the colon. Decompression of the gall bladder because of a fistula may cause resolution of the acute cholecystitis. Air in the biliary tree (pneumobilia) can be seen on abdominal radiographs, and imaging enhanced with contrast agents may show fistulas. (4) Gallstone ileus Gallstone ileusobstruction of the small intestine caused by a gall stone passing from the biliary tract into the intestinal tract through a fistulashould be considered in elderly patients with no obvious

cause for the intestinal obstruction. Patients may not have a history of cholecystitis. Mortality (15-20%) is attributed to delays before surgery is performed or to coexisting medical illnesses. Classic findings on abdominal radiographs include pneumobilia, intestinal obstructions, and gall stones in unusual sites. PROGNOSIS
For uncomplicated cholecystitis, the prognosis is excellent, with a very low mortality rate. In patients who are critically ill with cholecystitis, the mortality rate approaches 50-60%, especially in

the setting of gangrene or empyema. Once complications such as perforation/gangrene develop, the prognosis becomes less favorable. In patients who are critically ill with acalculous cholecystitis and perforation or gangrene, the mortality rate can be as high as 50-60%. TREATMENT FOR PATIENT Laparoscopic cholecystectomy was done to remove inflamed choledocus. It was successful to stop patients complaints and to prevent complications in the future. POSTOPERATIVE PERIOD Patient spent his post-operative period in the surgical ward. Her general condition was good with disappearance of main complaints. Prognosis is good with no post-operative complication and she will be discharge on 19/03/2012. RECOMMENDATION 1. Patient should be managed and monitored with correction of fluid and electrolyte abnormalities, Antibiotics for complicating infections, performing imaging studies as appropriate (eg, ultrasound, HBS) and lab data for follow-up care. 2. Patient should maintain healthy life style