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DIGESTIVE,

HEPATOBILIER
AND
PANCREATIC
SYSTEM
by 3
squad
rd

by 3rd
squad
Rahmania Ulfah
6130014027
6130014023
Dana Madya Puspita
Aisyah Imas Setiawati
6130014030
6130014025
Athyatul Ulya
Niken Ayu Kusumawardani
6130014028
6130014026
Nurma Islamiyah
Anydhia Fitriana Afiuddin
6130014029
6130014022
Rosyidah Husnaa Hanifah
Anang Maulana Yusuf

Nur Amiroh Aulia Sari


6130014024

6130014021

CASE
You are a general parctician who was
on duty at the emergency departments,
obtaining a patient, Mrs. S, 45 years old
came with complaints of pain in the
right upper abdomen.
Present of Disease:
Patients complain of pain in the right
upper abdomen accompanied by body
heat since two days ago. Pain

CASE
Recent History of Disease:
Pain in the upper right abdomen
felt since one year ago. Pain is felt
penetrating to the rear and is
preceded by nausea, especially a
few hours after eating fatty foods,
but the pain at that time can be
reduced with anti-pain medication.

Physical
examination:
General
appearance
:
Weak
GCS 456
Tension : 100/60
mmHg
RR : 28 times /
min
Temperature
:
38,4C
Head / Neck :
Jaundice +
Abdomen
:

Laboratory
examination :
Hb 13.0 g%
WBC 16.500 /
mm3
Total
bilirubin
5.8 mg / dl
Direct bilirubin
3.8 mg / dl
AST 24 IU / L
ALT 56 IU / L
Alkaline
Phosphatase
642 IU / L
Amilase
1245
IU/L
Lipase 500 IU/L

Radiological
examination :
Abdominal
ultrasound:
dilated gallbladder with
thickening
of
the
gallbladder
wall
and
multiple stones. Looks
stones
in
the
distal
common bile duct, with
dilatation of the bile duct.

Difficult
Word
Distal
common bile
duct

Keywor
Ad
woman, 45 years old, complaints of
pain in the right upper abdomen.
Heat agency since two days ago,
nausea and vomiting, dark yellow
urine, which like tea and defecated
white as putty, jaundice since

Mind Map

Learning
Objective
1. Describe the epidemiology and
etiology of the disease on the
case.
2. Describe the pathogenesis of
the disease in case.
3. Describe the pathophysiology
of the disease in case.
4. Explain the flow diagnosis in
the case.

Diagnose And
DD Based On
Medical Record
Gallstones or cholelithiasis is a pile of
crystals in the gallbladder or in the bile
ducts, or both. Gallstones are a hard
material are round, oval, or triangularterms contained in the bile duct and
contains
no
cholesterol,
calcium
carbonate, calcium bilirubin, or a mixture
of
these
elements
(Debas,
2004).
Location gallstones can vary - the kind in
the gallbladder, cystic duct, choledochal
duct, ampulla of Vater, in the heart.
Sometimes patients (contained in the

Diagnose And
DD Based On
Medical Record

Diagnose And
DD Based On
Based on the Tokyo Guidelines
Medical Record
(2007), the diagnostic criteria for
cholecystitis are:

Cholecystitis or acute

Symptoms and local signs

inflammation

o Signs Murphy

gall
when

bladder
the

of

the

occurs
bile

to

accumulate

in

the

gallbladder

because

of gallstones that clog


the

discharge

channel. Symptoms of

o Pain or tenderness in the right


upper quadrant of the abdomen
o The mass in the right upper
quadrant of the abdomen
Symptoms and systemic signs
o Fever
o leukocytosis
o Increased levels of CRP
Imaging studies
o The findings, according to the

Differential
Diagnose
NO
1

Differential
Diagnose
Abcess Hepar

Similarity with
Diagnose
Upper right
abdominal pain

Eliminator
On ultrasound /
CT Scan will be

Febris

easily found

Jaundice

abscess

Leukocytosist
Liver Physiology :
disrupted
2

Ca Hepar
(Nurman A.,
1990)

Upper right
abdominal pain

On ultrasound /
CT Scan there

Jaundice

are tumor in the

Febris

liver

No
3

Differential
Diagnose
Acute Pancreatitis
(Dongoes,2000)

Similarity with
Diagnose
Experiencing the bile
duct disease
Serum amylase
increased
Increased serum
lipase
Serum bilirubin
increased
Alkaline phosphatase
increase
Nausea vomiting

Eliminator

Location severe
pain in the
abdomen middle to
left.

Ultrasound: Seen
inflammation of the
pancreas
Endoscopic
examination: Seen
pancreatic ductal
anomalies

Rapid breathing
4

Hepatic Amebiasis
(Pridady,2006)

Upper right
abdominal pain

Found Entamoeba
histolytica in stools

a.
Anamnesis, History
of present illness,
past medical history

Physic Examination

b.
c.
d.
e.
f.
g.

Support Examination

Diagnostic :
CHOLECYSTITIS,CHOLE
YTIASIS

h.

Diagnostic
Pathway

In the scenario :
Upper right
abdominal pain,
intensified when
eating fatty foods
Fever
Eyes and yellow
body
Piss like old tea
Defecate like putty,
Woman, age 42,
obesity
Abdomen:
tenderness upper
right (+), murphy's
sign
Leukocytes:
16,500 / mm3;
bil.Total 5.6mg%;
Direk: 3.8 mg%;
Alkaline fosfatase
642 IU/L; -GT 150
IU/L; amilase: 1245
IU/L, lipase: 500

Epidemiolog
y of
Cholelithiasi
Cholelithiasis has become an important healthsproblem in
Western countries, but in Indonesia only gets attention of
clinical and research publications are still limited
(Lesmana, 2006).
Cholelithiasis often found on over 40 years of age,
especially in women due to risk factors, including obesity,
advanced age, high-fat diet, and genetics. The incidence
of cholelithiasis in Western countries is 20% and more in
adults and the elderly (Jong Sjamsuhidajat W. & R., 2005).
Cholelithiasis small migrate more easily thus increasing
the risk of complications of acute cholelithiasis, acute
biliary pancreatitis, comon bile duct obstruction in duct
(CBD) and cholangitis. While large gallstone potentially
cause gallbladder cancer (Cahyono, 2014).

Etiology of
Cholelithiasi
s
The etiology of gallstones is not
known with certainty, while the most
important predisposing factors are :
1. Changes Composition of Bile
2. Static Gall
3. Gall Bladder Infections (Hadi
S.,2002)

Risk Factors
of
Cholelithiasi
s the risk
with or without

Cholelithiasis may occur


factors. However, the more risk factors, the greater the
possibility of the occurrence of cholelithiasis. The risk
factors include:
1. Age
2. Gender
3. Weight
4. Food
5. Physical activity
6. Long-Term Intravenous
Nutrition (Lesmana L.,2000)

Pathogenesi
s

Pathogenesi
s
Unphysiological
biliary
supersaturation
from
hypersecretion
of
cholestrol,
gallbladder hypomotilty and the
accumulation
of
mucin
gel
contribute to the formation of
cholesterol gallstone. In excess
cholesterol
or
deficiency
of
phospholipids and/or bile acids (a

Pathophysiol
ogy
Upper right abdominal pain great
In bile duct stones will usually occur effort
of the smooth muscle of the bile vesica wall
to remove the stone. It will sensitize nerve
fibers that innervate the smooth muscle of
the bile vesica wall that coeliacus and nerve
plexus splanchnicus major, and would feel
referred pain in the right upper quadrant or
epigastric or regions (Price, 2005).
The relationship of age and gender with the
complaints of Gallstone
Risk factors known by the acronym 4F, the
Forty, Female, Fat, Family.

Pathophysiol
ogy
Increasing pain when eating fatty
foods
Bile serves to emulsify fat. Fatty foods
will stimulate spending bile from the
gallbladder and increased peristaltic
duct. The presence of stones in the
bile duct causing biliary obstruction.
This will aggravate the pain in
patients (Price, 2005).
Nausea
Bilirubin can not be secreted into the

Pathophysiol
ogy
Mild intermittent fever
Mild fever is intermittent because the
inflammatory process is still lightweight
and yet sepsis (Sudoyo, 2007).
Eyes and yellow body
Obstruction of ductus choledokus
conjugated bilirubin into the duodenum
can not accumulate in the liver is released
into the blood plasma conjugated bilirubin
eyes and yellow body (Sudoyo, 2007).
Urinating like old tea

Pathophysiol
ogy
Defecation like putty
Putty-colored feces showed no stercobilin.
Communist cause biliary obstruction
conjugated bilirubin can not be
channeled into the duodenum so that no
faecal staining by stercobilin (Sudoyo,
2007).
Alkaline phosphatase
Increases in serum when no obstacle in
the bile duct (cholestasis)
Amylase

Complication
1.Choledokolitiasis
Stones in the common bile duct (CBD) occurs 1015% of patients with gallstones who experience
symptoms.
2.Acute Cholesistitis
Inflammatory diseases of the gall bladder which
are caused by gall bladder stones (the most
common cause), ischemia, motility disorders,
trauma direct chemical, infections, collagen
disease, or allergic reactions.

Complication

Complication
3. Acute Biliary Pancreatitis
Gallstones that migrate and clog the pancreatic ducts cause
bile reflux and increase the pressure in the pancreatic duct,
causing autodigestion.
4. Cholangitis
Acute cholangitis is an infectious disease characterized by
systemic inflammation and acute infection in the bile ducts
caused by a combination of the blockage and the growth of
bacteria in the biliary system.
5. Mirizzi Syndrome
Stone stuck in the gallbladder infundibulum or Hartmann's

Complication
6.Gallstone Ileus
Gallstone ileus occurs when one or more of gallstone stuck
in the small intestine
7.Hidrops
Chronic obstruction of the gallbladder that common in
cystic duct until the gallbladder can not be filled by bile.
8.Empiema
Gallbladder
pus-filled.
Complications
in
patients
undergoing empiema requires immediate treatment
because it can be life-threatening.

Managements

Promotive :
1. Urge people to live healthy.
2. Maintain a diet.
3. And behavior or a healthy lifestyle.
.Preventive : to minimize the risk factors associated with
cholelithiasis, such as reducing fatty foods and cholesterol,
improve eating fruits and vegetables, exercise regularly and
drink enough water.
.Curative :
Surgical : cholecystectomy (laparoscopic)
Non surgical : non-surgical treatment is by dissolving
gallstones using MTBE, ERCP, and ESWL.

Managements

Antibiotics :
Antibiotic treatment in the early phase is very important
to prevent complications of peritonitis, cholangitis and
septicemia.
Patients may be given antibiotics third or fourth
generation cephalosporin or flurokuinolon, coupled with
metronidazole.
Non-steroidal anti-inflammatory drugs (NSAIDs) may be
given for pain. One that can be selected NSAID is
diclofenac or indomethacin.

Conclusion
Disease suffered by the patient is accompanied cholecystitis
cholelithiasis. Cholelithiasis is the term for the occurrence of
crystals or stones in the gall bladder, while cholecystitis is a
term for inflammation of the gallbladder. Cholelithiasis
diagnosis can be clearly established through radiological
examination results which indicate the presence of
gallstones in the distal and thickening and dilation of the
gallbladder wall, for cholelithiasis or gallstones are
asymptomatic or cause no symptoms as the patient's
complaints. Complaints of the patient and the clinical
manifestations it leads to a lot of cholecystitis is a
complication of kolelitiasis.Data patient also supports the
diagnosis of disease, that patients were women aged 45
years and BMI obesity, according to a risk factor for
cholelithiasis is female, fourty, fat, family.