CASE PRESENTATION CEIII-II PWH IP

Yu Wing Lam Zoe

PROFILE

M, 56y C admitted on 6/11/2012 x lap cholecystectomy Diagnosis: Gall Stone Open cholecystectomy on 7/11 Chest physio + triflow Ix: USG abd: gallbladder packed with stones

PMH: BPH with TURP (Transurethral resection of prostate) done 2010 Appendicectomy Hx of epilepsy Social Hx: NDNS, unaided outdoor walker lives with family, retired

GALLSTONE
Crystalline concretion formed within gallbladder May distally pass into other parts of the biliary tract May causes acute cholecystitis Gallstones in other parts of the biliary tract can cause obstruction of the bile ducts e.g. ascending cholangitis Or pancreatitis

GALL STONES
different size and shape Cholesterol stones: light yellow to dark green or brown and are oval, at least 80% cholesterol

Pigment stones: small and dark, comprise bilirubin and calcium salts, <20%

Mixed stones: 20-80% cholesterol Other common constituents E.g. caco3

SIGNS & SYMPTOMS

May be asymptomatic silent stones dont require treatment Symptoms commonly begin, size >8mm Gallstone attack: intense pain UR abd, nausea + vomit, increase for ~30mins to several hrs May feel referred pain between the shoulder blades or below the right shoulder often occur after a practically fatty meal / happen at night

PATHOPHYSIOLOGY

Cholesterol GS develop when bile too much cholesterol & not enough bile salts 1. How often & how well gallbladder contracts 2. Incomplete & infrequent emptying of gallbladder Causes bile over-concentrated

Can be caused by high R to the flow of bile out of gallbladder due to complicated internal geometry of the cystic duct

Eg Increased levels of estrogen Hormonal contraception increase cholesterol and decreases gallbladder movt

TREATMENT Medical sometimes GS dissolved by oral ursodeoxycholic acid, up to 2 yrs, may recur once drug stopped Endoscopic retrograde sphincterotomy follow by ERCP Broken up by lithotripsy Suitable only by a small no of GS

TREATMENT Surgical Cholecystectomy 99% chance of eliminate recurrence Only indicated in symptomatic pt No ve consequences in many ppl 10-15% postcholecystectomy syndrome causes GI distress & persistent pain in UR abd, 10% chronic diarrhea

OPEN CHOLECYSTECTOMY
traditional a major abdominal surgery Abdominal incision below lower right ribs Removes the gallbladder through a 5 to 7-inch incision Remain in hospital at least 2-6 days 4-6 weeks at home

AFTER OPEN CHOLECYSTECTOMY

http://www.drugs.com/cg/open-cholecystectomyinpatient-care.html Walk around same day or the day after surgery Deep breathing and coughing (wound supported) Drink liquids->soft->solid foods +/-Antibiotics, anti-nausea, pain killer PCA +/-Stool softeners

LAPAROSCOPIC
Laparoscopic: first choice, unless contraindications e.g. technical reason/ safety Open more prone to infection small (1/4 - ) incisions Laparoscope introduced into abd + short Post-OT recovery +rapid return to full f(x)

1ST SESSION

D2

9/11/12

C/O: Wound P+++ O/E: Very large GS specimen Off O2 On PCA, Foley Chest: AE fair, coarse crackles bil LZ, moist cough, cough effort fair, decrease basal AE Limbs range full, power 4+ allow to walk around the bed and sit-out

1ST SESSION

D2

9/11/12

Treatment Triflow 2balls up 1-2s 5times per half hr Wound supported coughing ex +/-huffing Bed side standing and stepping

10/11 off IV, PCA AXR: prominent SB loops generalized occ wheeze 11/11mild crepitus CXR: LLZ hazziness, mild blunt L CP angle inadequate inspiratory effort AXR: prominent bowel loops

2ND SESSION

12/11/12

Complaint of mild (chest?)abdominal discomfort ECG: SR 104/min, no ST/T wave changes Abdominal distension Decrease basal AE, mild crep, moist cough, fair cough effort (wound supported) Treatment FET->whitish sputum coughed out Deep breathing ex Triflow Walking ex around ward

3RD SESSION

13/11/12

AXR: dilate small bowel, multiple fluid level Contact precaution: diarrhea NG tube inserted: remove gastric secretions and swallowed air in patients with gastrointestinal obstructions, drain fluids and stomach acid self ambulate in ward Decrease wound pain Treatment FET->whitish sputum coughed out Deep breathing ex Triflow Walking ex around ward Static bike ex

4TH SESSION

15/11/12

AXR: dilated SB with multiple air-fluid levels, LB gas seen Off NG tube, keep IV drip Decrease abdominal discomfort Improve AE

16/11 AXR still dilated SB, LB gas seen, air/fluid level seen Try fluid diet Decrease distension Repeat AXR: dilated SB loops, improving 17/11 abd mod distended, off drip, start soft diet 18/11 soft diet tolerated, abd decrease distension

5TH SESSION

19/11/12 D12

All stitches removed AE sat, no added sound, moist cough, strong cough effort, whitish spt coughed out Decrease abd distension Triflow Self ambulate Static bike D/C?

THE END
Thank you!