DUTY REPORT

EMERGENCY ROOM
29TH MAY 2015
ACUTE ABDOMEN WITH OBSTRUCTIVE
JAUNDICE CAUSED BY SUSPECTED
CHOLEDOCHOLITHIASIS
UNCONTROLLED GRADE II ESSENTIAL
HYPERTENSION

GP on duty: dr. Karen Pandhika & dr. Husnah

Co-ass on duty: Raymond Pranata & Grace Fonda
Supervisor : dr Soroy Lardo SpPD FINASIM
PPDS FKUI
Department Of Internal Medicine
Indonesia Army Central Hospital Gatot Soebroto
 RECAPITULATION
1. Mr. Y  GERD
2. Mrs. S  Abdominal pain in jaundice e.c. cholecystitis
3. Mr. Y  dyspnea e.c. suspect COPD
4. Mr. B  polycythemia vera
5. Mrs. S  dyspepsia + herpes zoster infection
6. Mr. S  dyspnea e.c. acute asthma exacerbation
7. Mr. G  dyspnea e.c. acute asthma exacerbation +
neurodermatitis + Hepatitis C
8. Mrs. M  acute psychosis
9. Ms. G  acute gastroenteritis e.c. viral infection
10. Ms. S  acute gastroenteritis e.c. suspect food intoxication
PATIENT’S IDENTITY
 Name : Mrs. S
 Age : 61 y.o
 Occupation : housewife
 Medical record No : 09-51-xx
 Address :
ANAMNESIS

 Alloanamnesis with patient’s daughter

 Chief complaint:
 Abdominal pain since 1 week before admission

 Additional complaint:
 Jaundice

 Pale color stool

 Dark color urine

1 week before 3 days before Days of
admission admission admission

• Sudden • Abd. pain • Abd. pain

onset abd. persists persists
pain, • Sclera • Blood test
radiating to looked 1d before
epigastrium icteric on admission
, back and both eyes  increase
shoulder • 2d before liver
• Dark urine admission function
color +  whole test and
acholic stool body bilirubin
• Not jaundice
relieved
with
antacid
 HISTORY OF PRESENT ILLNESS

 Abdominal pain since 1 week before admission

 Site: Right upper quadrant

 Onset: sudden at midnight (1 week before admission)

 Characteristic: sharp, stabbing

 Radiation: to epigastrium, back, and shoulder

 Not improve with antacid or food, not relieved by defecation

 Continuous throughout the day and interfere with daily

activities

 Getting worse with activity and deep inspiration

 Weight loss (-)

 Associated symptoms:

Dark urine color

Jaundice (‘tea’ color) Pale color stool

Sclera  3 days Onset: 1 week Onset: 1 week

before admission before admission before admission

Whole body  2 Frequency: no Consistency: no

days before
admission changes changes

Blood (-), mucus (-),

Pruritus (-) No blood, painless
steatorrhea (-)

Tenesmus (-), foul

smell (-)
 History of other systemic illnesses:
 Uncontrolled hypercholesterolemia

 Uncontrolled hypertension with BetaBlock™

 High uric acid  controlled without drug

 Habits:
 Frequent consumption of fried and oily food

 Alcohol bingeing (-)

 Smoking (-)

 NSAID use (-)

 History of past illnesses (including surgery)
 Appendectomy at year 2009

 Cataract surgeries on both eyes

 Patient had once been admitted to hospital because of

abnormally high blood cholesterol and cardiomegaly

 History of family illnesses
 DM (-)

 Hypertension (+) in both parents

 Cardiovascular disease (+) in father at age 50

 Cerebrovascular disease (-)

 Kidney disease (-)

 Hypercholesterolemia (-)

 Allergy (-), Asthma (-)

 PHYSICAL EXAMINATION
General Examination
 General condition: moderately ill
 State of consciousness: compos mentis
 Vital signs:
 Blood Pressure : 150/80 mmHg
 Heart rate : 98 bpm
 Respiratory : 22x/minute
 Temperature : 36,7oC

 Body weight : 82 kg
 Body height : 165 cm
 Body mass index :
 Head : normocephal

 Eye : sclera icteric +/+, pale conjunctiva -/-

 ENT : nasal flare (-), discharge (-), blood (-),

hyperemic pharynx (-)

 Mouth : moist lip, papillary atrophy (-)

 Neck : JVP 5+1cmH2O

 Skin : generalized jaundice

 Thorax
 Pulmonary examination
 Inspection: normochest, symmetrical lung movement, scar (-)
 Palpation: symmetrical chest expansion and vocal fremitus, mass (-),
tenderness (-)
 Percussion: sonor at both lung field
 Auscultation: VBS +/+, no additional breath sound

 Cardiac examination
 Inspection: ictus cordis not visible
 Palpation: ictus cordis not palpable
 Percussion: right cardiac border at ICS IV right parasternal line, left
cardiac border at ICS V left mid-clavicular line, upper border at ICS III
left parasternal line
 Auscultation: normal S1/S2 regular, no murmur, no gallop
 Abdomen

 Inspection: flat, jaundice, no venous engorgement

 Auscultation: bowel sound (+) 8 times per minute

 Percussion: tympanic on four abdominal quadrant, shifting

dullness (-)

 Palpation: supple, tenderness (+) on epigastrium and RUQ,

(+) rebound tenderness in RUQ, Murphy sign (+),
splenomegaly (-), liver palpation was not done due to
tenderness, fluid wave (-)

 Extremities: CRT <2 seconds, warm distal extremities, no

edema, no deformities, jaundice
 LABORATORY EXAMINATION
Result
Examination Reference Range
28/5/2015 29/5/2015
Hemoglobin 12.5 12.7 12 – 16 g/dL
Hematocrit 38.3 37 37 – 47%
Leukocyte 14,500 13,190 4,800 – 10,800/uL
Thrombocyte 312,000 262,000 150,000 – 400,000/uL
Bleeding Time 1 1 – 3 minutes
Clotting time 9 7 – 15 minutes
Random Blood Glucose 96 102 70 – 18 mg/dL
Kidney function
Ureum 17.5 17 <48 mg/dL
Creatinine 0.8 0.5 0.45 – 0.75 mg/dL
 Result
Examination Reference Range
28/5/2015 29/5/2015
Liver Function
Total bilirubin 10.94 10.5 0.1 – 1.0 mg/dL
Direct Bilirubin 8.49 0 – 0.2 mg/dL
Indirect bilirubin 2.46 0.1 – 0.7 mg/dL
Alkaline Phosphatase 337 30 – 120 U/L
AST (SGOT) 148 153 <35 U/L
ALT (SGPT) 195 131 <35 U/L
Gamma GT 774 0 – 30 U/L
Electrolyte
Sodium 141.5 142 135 – 147 mmol/L
Potassium 3.99 4.3 3.5 – 5.0 mmol/L
Chloride 101.5 107 95 – 105 mmol/L
 Abdominal ultrasonography (23/05/2015 at Ananda
Hospital, Bekasi)
 Thickening of gallbladder wall (thickness: 6,5mm)

 Sludge (+)

 Suggestive of cholecystitis
RESUME

Patient, 61 y.o female came with chief complaint of RUQ abdominal

pain radiating to epigastrium, back, and shoulder since 1 week
before admission. No fever. Nausea (+), vomit (-). Dark color urine
(+), acholic stool (+). Jaundice (+) since 3 days before admission.
History of hypercholesterolemia, uncontrolled hypertension, high
uric acid.
 PE: high BP, generalized jaundice (+), (+) tenderness on
abdominal palpation, rebound tenderness on RUQ, Murphy sign
(+), ascites (-)
 Lab: leukocytosis, direct hyperbilirubinemia, increased
ALT/AST/ALP/GGT
 Abd. Ultrasound suggestive of cholecystitis
LIST OF PROBLEMS

 Acute abdomen

 Jaundice with direct hyperbilirubinemia and

elevated liver function test

 Uncontrolled grade II hypertension

 Suspected hypercholesterolemia (?)

 Suspected hyperuricemia (?)

WORKING DIAGNOSIS

1. Acute abdomen with obstructive jaundice caused by

suspected choledocholithiasis

2. Uncontrolled grade II essential hypertension

Differential diagnosis:

1. Acute abdomen with obstructive jaundice caused by

suspected cholecystitis dd/ ascending cholangitis
Findings Cholecystitis Choledocholithiasis

RUQ pain radiates to + +

the back
Fever + +

Nausea and vomiting + +

Jaundice - +

Dark color urine - +

Acholic stool - +

Elevated liver enzyme - to + +

Elevated bilirubin + ++

Elevated lipase - +
RECOMMENDATION
 Further examination:
 ERCP + US of biliary tree  to see the presence of common
bile duct stone
 Serum lipase
 Funduscopy: to exclude hypertensive retinopathy
 Chest x-ray
 ECG LVH (?), arryhthmia (?)
 Urinalysis  bilirubin, protein (nephropathy?)
 Lipid profile  dyslipidemia (?)
 Serum uric acid  hyperuricemia(?)
TREATMENT
 Cholecystitis
 IVFD NaCl 0.9% 20 drips per minute
 Ketorolac 1x30 mg IV
 Ondansetron 1x8 mg IV
 Ceftriaxone 1x2 gram IV
 Urdafalk 3x1 cap PO
 Consult gastroentero-hepatologist, digestive surgeon

 Hypertension
 Captopril 1x25 mg per day PO
 Continue beta-blocker medication
 Monitor daily blood pressure
 Suspected hypercholesterolemia (?)
 Atorvastatin 1x20 mg per day PO

 Suspected hyperuricemia (?)

 Serum uric acid level (?)
Source: Lange Symptoms to Diagnosis, 2nd ed. 2009
Source: Tintinalli Emergency Manual
PITFALLS

1. Dilated CBD or CBD stone is seen in only 25% of

patients via trans-abdominal ultrasound

2. ERCP, MRCP and EUS are highly accurate in

detecting CBD stones (sensitivity 90-100%,
specificity 90-100%)

3. Jaundice and marked elevation of liver enzymes are

seen only if the stone migrates into the CBD and
causes obstruction
Source: Lange Symptoms to diagnosis, 2nd ed. 2009
No clinical finding is sufficiently sensitive to rule out
cholecystitis.
1. Fever: present in 35% of patients
2. Murphy sign
 Sensitivity, 65%; specificity, 87%
 LR+ = 5.0, LR− = 0.4

Laboratory findings:
1. Leukocytosis (> 10,000/mcL) 63% of patients.
2. Cholecystitis does not typically cause significant
increases in lipase  complications of pancreatitis and
choledocholithiasis.
Ultrasound

1. Acute cholecystitis  gallstones with gallbladder wall

thickening, pericholecystic fluid, sonographic Murphy sign, or
gallbladder enlargement >5 cm

2. Sensitivity, 88%; specificity, 80%

3. Cholescintigraphy (HIDA) scans

 Nonvisualization of the gallbladder  cystic duct obstruction and is
highly specific for acute cholecystitis (97% sensitive, 90% specific).

 Nonvisualization can also be seen in prolonged fasting, hepatitis, and

alcohol abuse.

 Useful when the pretest probability is high and the ultrasound is

nondiagnostic

 Visualization of the gallbladder excludes acute cholecystitis.

Source: UpToDate, Treatment of Acute Cholecystitis
 Decompression of the biliary system (preferably via
ERCP):
 Emergently done in patient w/ persistent pain, hypotension,
altered mental status, persistent high fever, WBC
<20,000/uL, bilirubin >10 mg/dL

 Electively in more stable patient

 Source:
Kaplan’s Clinical Hypertension (2010)
 Source:
Kaplan’s Clinical Hypertension (2010)
PROGNOSIS

 Quo ad vitam : dubia ad bonam

 Quo ad sanationam : dubia ad bonam

 Quo ad functionam : dubia ad bonam

THANK YOU