I.

Patient Identity: Name Sex Age Address Religion Hospitalized Date : Mrs. M : Female : 47 years old : Pegagan Kidul : Islam : 10 May 2010

II.

Anamnesa (Autoanamnesa at 11 May 2010) Main Complaint:

Pain in the right upper abdomen since 5 days SMRS Present History of Disease: The patient came to Emergency Unit through Poliklinik Arjawinangun surgical hospitals with complaints of pain in the right upper abdomen since 5 days SMRS. Intermittent abdominal pain is felt. Pain usually occurs about 15 minutes after eating. Pain can be felt radiating up to Back. However, abdominal pain disappeared a few hours later. The patient also complained of pain in the pit of the stomach area. If the food filled stomach, the patient felt pain and nausea. This complaint felt since one month ago but largely ignored by the patient.

Past History of Disease

The history of the same disease ignored The history of Diabetes Melitus ignored The history of Hipertension ignored

The History of Family Disease : None

III.

Phsycally examination General state General state Awareness Vital sign : BP P T RR Head : Normocephal Eye : Conjungtiva Anemis -/Sclera icteric -/Pupil : isochor Pupil Reflex -/Neck : Tiroid isnt palpable enlarge Lymphaticus Nodes isnt palpable enlarge : moderate illnes : Compos mentis : 110/70 mmHg : 84 x/minute : 36oC : 20 x/ minute

Thoraks Cor

I : iktus cordis isnt visible P : iktus cordis palpable at ICS V midclavicula line

P : heart border is easily assesed A : BJ I-II regular, murmur(-), gallop(-) Pulmo I : symmetrical piston movement in a static state and dynamic P : vokal fremitus right and left hemitoraks are the same P : sonor for both of hemithoraks A : vesicular, rhonki -/-, wheezing -/Abdomen I A P P Ekstremitas : convex, simetris : Bowel sound (+) normal : Timpani in all part of abdomen : soft , tenderness (-), slippery, Murphy sign (+), Pain in the right upper abdomen

left and right superior : udem (-) , warm akral Left superior dan left inferior are localize state left and right inferior : udem (+) , warm akral

IV.

Laboratory result (Blood Test): Hb Leukosit Eritrosit : 12,1 g/dl : 8,8 x 103/l : 4,07 x 106/l

Trombosit : 417 x 103/ l Hematokrit : 33,6 % KGDS SGOT SGPT : 120 mg/dl : 15 U/I : 6 U/I

HbsAg

: 0,445 COI

V.

Work Diagnosis : Cholelithiasis

VI.

Differential Diagnosis : GERD Miokard Infark

VII.

Suggest Examination : USG Upper Abdomen

VIII.

Treatment : Phamacological treatment : Pre-Operative

Antibiotic : ceftriaxon 2x1gr Analgetic : ketorolac 2x1

Operative Procedure :

Cholesistectomy

IX.

Prognosis: Quo ad vitam : dubia ad bonam

Quo ad fungsionam : dubia ad bonam

CHOLELITHIASIS ANATOMY Gall bladder ovate shaped like a lawyer with 4-6 cm long and containing 30-60 ml of bile . Part fundus generally slightly protruding edge hearts out , under the right rib arch , beside the lateral m.rektus abdominis . Most of the corpus menenpel and buried in the heart tissue . Gall bladder viseralis entirely covered by peritoneum , but no gall bladder infundibulum kepermukaan terfiksasi heart by lining the peritoneum . When the gall bladder distention due to retention experienced by the rock , stands out as the infundibulum bag called Hartmann pouch . Sistikus duct 1-2 cm long with a diameter of 2-3 mm . lumen walls contain spiral shaped valve diaphragm valve called Heister , which facilitates bile flow into the gallbladder , but resist the flow discharge . Extra- hepatic bile duct is located in the upper limits hepatoduodenale ligament porta hepatis , which limits sedangakan distal papilla Vater . Intrahepatic bile duct upstream part stems from the small vessels called kanalikulus who continue flushing secretion of bile through the bile ducts keduktus interlobularis lobaris , and further keduktus dihilus hepatikus.

Hepatikus duct length right and left respectively between 1-4 cm. Duct long communist hepatikus very bervasiasi , depending on the place of the mouth of the duct sistikus . Koledokus duct runs behind the duodenum and pancreas tissue penetrating duodenal

wall forming Vater papilla which is located to the medial wall of the duodenum. Distalnya tip surrounded by sfingter Oddi muscle , which regulates the flow of bile into the duodenum . Pankreatikus duct generally boils down to the same place in the papilla of Vater koleokus ducts , but can also be detached . PHYSIOLOGY One of the functions of the liver is to produce bile , normally between 600-1200 ml / day . Gallbladder can store about 45 ml of bile. Outside the meal, bile is stored temporarily in the gall bladder , and here suffered around 50 % concentration . Primary function of the gall bladder bile is thicken with water and sodium absorption . Gallbladder able to condense a tight solutes contained in hepatic bile and reduce your volume 5-10 times 80-90 %. According to Guyton & Hall , 1997 gall perform two important functions , namely: Bile plays an important role in the digestion and absorption of fat, because bile acids are doing two things , among others : bile acid helps emulsify the fat particles are big into smaller particles with the aid of lipase enzyme secreted in the rubber pancreas, bile acid helps transport and absorption of digested fat end products to and through the intestinal mucous membrane . Bile work as a tool to produce a significant number of waste products from the blood , among others bilirubin , an end product of hemoglobin destruction , and advantages in the form of cholesterol by the liver cells . Gall bladder emptying kolesistokinin influenced by hormones , this occurs when fatty foods enter the duodenum about 30 minutes after eating . Policies that caused evacuation is rhythmic alteration of wall gall bladder contractions , but also the effectiveness of evacuation requires a corresponding relaxation of Oddi sfingter in charge of communist biliaris exit duct into the duodenum. Besides kolesistokinin , gall bladder also strongly stimulated by nerve fibers that menyekresi acetylcholine from the vagus and enteric nervous system . Emptying gallbladder bile storage condensed into the duodenum , especially in response to stimulation kolesistokinin . Currently there is no fat in the diet , gall bladder

emptying held bad , but when there adekuat amount of fat in the diet , normal whole gall bladder empty in about 1 hour. Bile salts, lecithin, and cholesterol is the major component ( 90 %) bile . The rest is bilirubin , fatty acids , and inorganic salts . Bile salts are steroids made by hepatocytes and is derived from cholesterol . Arrangements affected production feedback mechanism can be enhanced up to 20 times the normal production if needed

Epidemiology Country western 20 % kolelitiasis affect adults and elderly . Most asymptomatic cholelithiasis . 80 % of gallstones are cholesterol stones . Gallstones are found in Indonesia began at a young age under 30 years , although the average age is 40-50 years common . At the age of 60 years , the incidence of gallstones increases . Number of patients with more women . Increased incidence of gallstones can be seen in the high risk group called " 4 F " : female (woman), fertile (fertile) - especially during pregnancy, fat (fat), and forty (forty years) . Cholelithiasis can occur with or without the risk factors . However , the more risk factors , the greater the possibility for the occurrence of cholelithiasis. The risk factors , among others : Genetic Age : The average age of most frequent occurrence of gallstones are 4050 years old . Very few people with gallstones are found in adolescence , after that as we grow older the more likely to get gallstones , so that at the age of 90, chances are one in three people. Gender : Gallstones are more common in women than in men by a ratio of 4:1.

Several other factors : Other factors that increase the risk of gallstones include: obesity , diet , family history, physical activity, nutrition and longterm venous.

Pathogenesis Gallstones are almost always formed in the gall bladder and bile ducts are rarely on the other and are classified based on its constituent materials . Gallstone etiology is still unknown perfectly , however , the most important predisposing factor apparently is a metabolic disorder that is caused by changes in the composition of bile , bile stasis and gallbladder infection . Changes in the composition of bile may be the most important in the formation of gallstones , due to deposition of cholesterol in the gallbladder . Stasis of bile in the gallbladder may increase the supersaturation

progressive , changes in chemical composition , and deposition of these elements . Bacterial infection in the bile ducts may act partly in stone formation , through enhanced and cell desquamation and mucus formation . Associated with the secretion of cholesterol gallstone formation . On abnormal conditions , cholesterol may precipitate , causing the formation of gallstones . Various conditions can lead to the deposition of cholesterol are : too much water absorption of bile , too much absorption of bile salts and lecithin from bile , too much cholesterol in the bile secretion , amount of cholesterol in the bile is partly determined by the amount of fat that is eaten because the cells hepatic synthesis of cholesterol as one of the products of fat metabolism in the body . For this reason , those who received the high-fat diet in a few years time , will be susceptible to the development of gallstones . Gallbladder stones can migrate into koledokus duct through the cystic duct . In the journey through the cystic duct , the stones can cause

blockage of bile flow by partial or complete gejalah causing biliary colic . If the stone in the cystic duct stalled because its diameter is too large or restrained by stricture , stone will remain there as the cystic duct stones Stone Type a) Cholesterol stones Cholesterol stones contain at least 75 % of cholesterol crystals . And the rest is kalsiumkarbonat , kalsiumpalmitat , and kalsiumbilirubinat . The shape varies over form pigment stones . The formation is almost always didalma gallbladder , can be solitary or multiple stones . The surface may be slippery or multifaceted , round , spiked , and there's nothing like mulberries . Cholesterol stone formation process through four stages , namely saturation of bile by cholesterol , nidus formation , crystallization and stone growth . The degree of saturation of bile by cholesterol can be calculated through the solubility capacity . This saturation can be caused by the increased secretion of cholesterol or bile acids relative decline or phospholipids . Sekeresi increase biliary cholesterol among other things, the state of obesity , a diet high in calories and cholesterol , and taking medications that contain estrogen or klofibrat . Bile acid secretion will be decreased in patients with impaired absorption in iliem , or impaired emptying of the primary content of bile . Saturation excess cholesterol can not form stones, except when there nidus and there are other processes that lead to crystallization . Nidus can be derived from bile pigments , mukoprotein , lenders and other proteins , bacteria or other foreign objects . After crystallization include nidus , there will be the formation of stones . Stones growth occurs due to deposition of cholesterol crystals on inorganic matrix and the speed is determined by the relative speed of dissolution and precipitation . The structure is a matrix containing mineral deposits of calcium salts . Gallbladder stasis also play a

role in stone formation , in addition to the factors mentioned above b. Pigment stones / stone Bilirubin This stone is often found irregularly shaped , small , can amount to a lot , the color varies between brown , reddish to black , and shaped like clay or fragile soils . This stone is often coalesce to form larger stones . Pigment stones are very large bile duct can be found . Pigment stones are cholesterol gallstones that less than 25 % . Black pigment stones formed in the gall bladder is mainly formed on the balance of metabolic disorders such as hemolytic anemia and cirrhosis of the liver without prior infection .

Such as the formation of cholesterol stones , the stones bilirubin associated with age . Infection , static , dekonjugasi bilirubin and calcium excretion is a causal factor . At bakteribilia are gram-negative bacteria , especially E. coli . Gender, obesity and impaired absorption in the ileum did not increase the risk of bilirubin stones . In patients with bilirubin stones , which are not conjugated bilirubin concentration increased . Either in the gallbladder or in the liver . c ) Stone mixed

A mixture of cholesterol stones containing calcium . This stone is often found to be almost 90 % in patients with cholelithiasis . This stone is plural , dark brown . Most of mixed stones have the same basic metabolism of cholesterol stones

Manifestasi klinis 1. Batu Kandung Empedu (Kolelitiasis) F Asimtomatik. Batu yang terdapat dalam kandung empedu sering tidak memberikan gejala (asimtomatik). Dapat memberikan gejala nyeri akut akibat kolesistitis, nyeri bilier,

nyeri abdomen kronik berulang ataupun dispepsia, mual (Suindra, 2007). Studi perjalanan penyakit sampai 50 % dari semua pasien dengan batu kandung empedu, tanpa mempertimbangkan jenisnya, adalah asimtomatik. Kurang dari 25 % dari pasien yang benar-benar mempunyai batu empedu asimtomatik akan merasakan gejalanya yang membutuhkan intervensi setelah periode waktu 5 tahun. Tidak ada data yang merekomendasikan kolesistektomi rutin dalam semua pasien dengan batu empedu asimtomatik. F Simtomatik Keluhan utamanya berupa nyeri di daerah epigastrium, kuadran kanan atas. Rasa nyeri lainnya adalah kolik bilier yang berlangsung lebih dari 15 menit, dan kadang baru menghilang beberapa jam kemudian. Kolik biliaris, nyeri pascaprandial kuadran kanan atas, biasanya dipresipitasi oleh makanan berlemak, terjadi 30-60 menit setelah makan, berakhir setelah beberapa jam dan kemudian pulih, disebabkan oleh batu empedu, dirujuk sebagai kolik biliaris. Mual dan muntah sering kali berkaitan dengan serangan kolik biliaris. F Komplikasi Kolesistitis akut merupakan komplikasi penyakit batu empedu yang paling umum dan sering meyebabkan kedaruratan abdomen, khususnya diantara wanita usia pertengahan dan manula. Peradangan akut dari kandung empedu, berkaitan dengan obstruksi duktus sistikus atau dalam infundibulum. Gambaran tipikal dari kolesistitis akut adalah nyeri perut kanan atas yang tajam dan konstan, baik berupa serangan akut ataupun didahului sebelumnya oleh rasa tidak nyaman di daerah epigastrium post prandial. Nyeri ini bertambah saat inspirasi atau dengan pergerakan dan dapat menjalar kepunggung atau ke ujung skapula. Keluhan ini

dapat disertai mual, muntah dan penurunan nafsu makan, yang dapat berlangsung berhari-hari. Pada pemeriksaan dapat dijumpai tanda toksemia, nyeri tekan pada kanan atas abdomen dan tanda klasik Murphy sign (pasien berhenti bernafas sewaktu perut kanan atas ditekan). Masa yang dapat dipalpasi ditemukan hanya dalam 20% kasus. Kebanyakan pasien akhirnya akan mengalami kolesistektomi terbuka atau laparoskopi. 2. Batu Saluran Empedu (Koledokolitiasis) Pada batu duktus koledokus, riwayat nyeri atau kolik di epigastrium dan perut kanan atas disertai tanda sepsis, seperti demam dan menggigil bila terjadi kolangitis. Apabila timbul serangan kolangitis yang umumnya disertai obstruksi, akan ditemukan gejala klinis yang sesuai dengan beratnya kolangitis tersebut. Kolangitis akut yang ringan sampai sedang biasanya kolangitis bakterial non piogenik yang ditandai dengan trias Charcot yaitu demam dan menggigil, nyeri didaerah hati, dan ikterus. Apabila terjadi kolangiolitis, biasanya berupa kolangitis piogenik intrahepatik, akan timbul 5 gejala pentade Reynold, berupa tiga gejala trias Charcot, ditambah syok, dan kekacauan mental atau penurunan kesadaran sampai koma Koledokolitiasis sering menimbulkan masalah yang sangat serius karena komplikasi mekanik dan infeksi yang mungkin mengancam nyawa. Batu duktus koledokus disertai dengan bakterobilia dalam 75% persen pasien serta dengan adanya obstruksi saluran empedu, dapat timbul kolangitis akut. Episode parah kolangitis akut dapat menyebabkan abses hati. Migrasi batu empedu kecil melalui ampula Vateri sewaktu ada saluran umum diantara duktus koledokus distal dan duktus pankreatikus dapat menyebabkan pankreatitis batu empedu. Tersangkutnya batu empedu dalam ampula akan menyebabkan ikterus obstruktif.

Pemeriksaan Fisik Batu kandung empedu Jika ditemukan kelainan, biasanya berhubungan dengan komplikasi, seperti kolesistitis akut dengan peritonitis local atau umum, hidrops kandung empedu, empiema kandung empedu, atau pancreatitis. Pada pemeriksaan ditemukan nyeri tekan dengan punktum maksimum didaerah letak anatomi kandung empedu. Tanda Murphy positf apabila nyeri tekan bertambah sewaktu penderita menarik nafas panjang karena kandung empedu yang meradang tersentuh ujung jari tangan pemeriksa dan pasien berhenti menarik nafas. Batu saluran empedu Batu saluran empedu tidak menimbulkan gejala atau tanda dalam fase tenang. Kadang teraba hati agak membesar dan sclera ikterik. Namun bila kadar bilirubin darah kurang dari 3mg/dl, gejala ikterik tidak jelas. Apabila sumbatan saluran empedu bertambah berat, baru akan timbul ikterik klinis. Apabila timbul serangan kolangitis yang umumnya disertai obstruksi, akan ditemukan gejala klinis yang sesuai dengan kolangitis tersebut. Kolangitis akut yang ringan sampai sedang biasanya kolangitis bacterial nonpiogenik yang ditandai dengan trias Charcot, yaitu demam dan menggigil, nyeri didaerah daerah hati, dan ikterus. Apabila terjadi kolangitis piogenik intrahepatik, akan timbul 5 gejala pentade reynold, berupa 3 gejala Charcot, ditambah syok dan kekacauan mental atau penurunan kesadaran dan koma.

Jika ditemukan riwayat kolangitis yang hilang timbul, harus dicurigai kemungkinan hepatolitiasis.

Penatalaksanaan 1. Konservatif Lisis batu dengan obat-obatan. Sebagian besar pasien dengan batu empedu asimtomatik tidak akan mengalami keluhan dan jumlah, besar, dan komposisi batu tidak berhubungan dengan timbulnya keluhan selama pemantauan. sehingga penanganan

Kalaupun nanti timbul keluhan umumnya ringan

dapat elektif. Terapi disolusi dengan asam ursodeoksilat

untuk melarutkan dan

batu empedu kolesterol dibutuhkan waktu pemberian obat 6-12 bulan

diperlukan monitoring hingga dicapai disolusi. Terapi efektif pada ukuran batu kecil dari 1 cm dengan angka kekambuhan 50 % dalam 5 tahun.

Disolusi kontak Meskipun pengalaman masih terbatas, infus pelarut kolesterol yang poten (Metil-Ter-Butil-Eter (MTBE)) ke dalam kandung empedu melalui kateter yang diletakkan per kutan telah terlihat efektif dalam melarutkan batu empedu pada pasien-pasien tertentu. Prosedur ini invasif dan kerugian utamanya adalah angka kekambuhan yang tinggi (50% dalam 5 tahun).

Litotripsi (Extarcorvoral Shock Wave Lithotripsy =ESWL). Litotripsi gelombang elektrosyok meskipun sangat populer beberapa tahun yang lalu, analisis biaya-manfaat pada saat ini hanya terbatas untuk pasien yang benar-

benar telah dipertimbangkan untuk menjalani terapi ini. Efektifitas ESWL memerlukan terapi adjuvant asam ursodeoksilat. Endoscopic Retrograde Cholangiopancreatography (ERCP). Pada ERCP, suatu endoskop dimasukkan melalui mulut, kerongkongan, lambung dan ke dalam usus halus. Zat kontras radioopak masuk ke dalam saluran empedu melalui sebuah selang di dalam sfingter oddi. Pada sfingterotomi, otot sfingter dibuka agak lebar sehingga batu empedu yang menyumbat saluran akan berpindah ke usus halus. ERCP dan sfingterotomi telah berhasil dilakukan pada 90% kasus. Kurang dari 4 dari setiap 1.000 penderita yang meninggal dan 3-7% mengalami komplikasi, sehingga prosedur ini lebih aman dibandingkan pembedahan perut. ERCP saja biasanya efektif dilakukan pada penderita batu saluran empedu yang lebih tua, yang kandung empedunya telah diangkat 2. Operatif Open kolesistektomi Operasi ini merupakan standar untuk penanganan pasien dengan batu empedu simtomatik. Indikasi yang paling umum untuk kolesistektomi adalah kolik biliaris rekuren, diikuti oleh kolesistitis akut. Komplikasi yang berat jarang terjadi, meliputi trauma, perdarahan, dan infeksi. Data baru-baru ini menunjukkan mortalitas pada pasien yang menjalani kolesistektomi terbuka pada tahun 1989, angka kematian secara keseluruhan 0,17 %, pada pasien kurang dari 65 tahun angka kematian 0,03% sedangkan pada penderita diatas 65 tahun angka kematian mencapai 0,5 %.

Kolesistektomi laparoskopik. Kelebihan tindakan ini meliputi nyeri pasca operasi lebih minimal, pemulihan lebih cepat, hasil kosmetik lebih baik, menyingkatkan perawatan di rumah sakit dan biaya yang lebih murah. Indikasi tersering adalah nyeri bilier yang berulang. Kontra indikasi absolut serupa dengan tindakan terbuka yaitu tidak dapat mentoleransi tindakan anestesi umum dan koagulopati yang tidak dapat dikoreksi. Komplikasi yang terjadi berupa perdarahan, pankreatitis, bocor stump duktus sistikus dan trauma duktus biliaris. Resiko trauma duktus biliaris sering dibicarakan, namun umumnya berkisar antara 0,51%. Dengan menggunakan teknik laparoskopi kualitas pemulihan lebih baik, tidak terdapat nyeri, kembali menjalankan aktifitas normal dalam 10 hari, cepat bekerja kembali, dan semua otot abdomen utuh sehingga dapat digunakan untuk aktifitas olahraga.

Kolesistektomi minilaparatomi. Modifikasi dari tindakan kolesistektomi terbuka dengan insisi lebih kecil dengan efek nyeri paska operasi lebih rendah. DAFTAR PUSTAKA

1. Sjamsuhidayat R, de Jong W Buku Ajar Ilmu Bedah, Edisi Revisi, Jakarta : EGC,1997. 2. Schwartz S, Shires G, Spencer F. Prinsip-prinsip Ilmu Bedah (Principles of SurgerY). Edisi 6. Jakarta: Penerbit Buku Kedokteran EGC. 2000.459-64. 3. Guyton AC, Hall JE. Sistem Saluran Empedu dalam: Buku Ajar Fisiologi Kedokteran. Edisi ke-9. Jakarta: EGC, 1997.

4. Dunphy Englebert J, MD, Way W Lawrence, MD, Current Surgical Diagnosis & Treatment.
5. Lesmana L. Batu Empedu dalam Buku Ajar Penyakit Dalam Jilid 1. Edisi 3. Jakarta: Balai Penerbit Fakultas Kedokteran Universitas Indonesia. 2000.