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laparoscopic cholecystectomy

by: Namira Ali

Patient Hx

H&P

39 y/o F - Lumbar Spine XR: 4 cm calcified density over RUQ. One episode of RUQ pain while walking her dog 2W ago, resolved in 2 min. No postprandial pain, steatorrhea, N/V, melena, hematochezia, fevers, or chills.

PMH: sacral spondylosis, cervical cancer s/p conization, HTN, staghorn kidney stones, and fibroids.

SHx: Nephrolithotomy for removal of staghorn calculi, tubal ligation

SH: No EtOH. Smokes 5-9 cigs/day. No illicit drug use.

FH: Nephrolithasis - father.

FX: Abdomen soft, non-tender, non-distended. Negative Murphy's sign. No jaundice. BMI: 43.4

VTLs NL except for systolic BP 159 mm Hg

BMP, CBC, Coag studies, Fe studies, & Urine Microalbumin/Cr NL

RUQ US: Cholelithiasis. No evidence of acute cholecystitis.

OBLIQUE VIEW

imaging

transabdominal view

longitudinal view

indications for cholecystectomy

INDICATIONS FOR CHOLECYSTECTOMY

Symptomatic Cholelithiasis

Assymptomatic Cholelithiasis with any of the following:

- increased risk of GB cancer (gallbladder polyps, porcelain GB, GB stone > 3 cm)

- increased risk of developing complications (immunocompromised pts, multiple gallstones)

- increased risk of becoming symptomatic (hemolytic anemia, pts undergoing bariatric surgery)

Plan: elective cholecystectomy recommended due to size of stone & to reduce risk of cholangiocarcinoma

procedure

procedure - anatomy

Procedure - access & positioning

retract gallbladder

dissect calot's triangle

Fluorescent cholangiography

resect & remove gallbladder

post-op

Post-op

Question 1

Q1

What is the next step in diagnosis?

42 y/o F presents to ED for sharp RUQ for past 10H. She has vomited 3x.

- vitals normal, BMI 32

- exam: scleral icterus, RUQ tenderness. Nondistended, no rebound, no guarding.

- labs: WBC 9000, Alk Phos 238, AST 60, Bili total 2.8, Bili direct 2.1

A) Abdomen CT

B) Transabdominal US

C) ERCP

question 2

Q2

In addition to a low-fat diet, what is the most appropriate recommendation?

52 y/o F PTC w/4d hx of intermittent R-sided AP. Pain occurs 2H after meals and lasts up to 1H. 1M ago, she underwent PCI for anterior MI. Since then, she has been following a rehab program - she can currently climb 1 flight of stairs without SOB. She has CAD, HLD, & insulin-dependent DM2. BMI is 34. No abdominal tenderness on physical examination. LFTs are NL. ECG shows no acute ischemia or interval changes. Abd US shows 3 intraluminal gallstonoes. Gallbladder wall thickness is NL. No dilation of intrahepatic or extrahepatic ducts.

A) Oral Bile Acid Dissolution

B) Emergency Cholecystectomy

C) Extracorporeal shock wave lithotripsy

question 3

Q3

What is the cause?

43 y/o F comes to ED w/3H hx of upper AP radiating to R shoulder & upper back. She has accompanied nausea and 1 episode of nonbloody vomiting. Pain is described as dull and constant. 1H prior to onset of sx, she was eating a hamburger and fries. PMH includes HLD and HTN. She drinks 2 glasses of wine daily. BMI is 39. Vitals are NL. Abdomen is soft and there is RUQ tenderness to palpation, but no guarding or rebound. WBC 9,000, AST 35, ALT 36, total bili 0.9.

A) Stone impaction in common bile duct

B) Increased intraluminal pressure of the gallbladder

C) Acute gallbladder inflammation

question 4

Q4

Which process is involved in the pathogenesis of this condition?

A previously health 37 y/o F G3P2 at 29 weeks gestation PTC w/colicky postprandial AP. Vitals are NL. Physical exam shows uterus size consistent w/29-week gestation. Abd US shows multiple 5 mm hyperechoic masses in GB lumen.

A) Decreased caliber of bile duct

B) Overproduction of bilirubin

C) Increased secretion of cholesterol

question 5

Q5

What is the cause?

57 y/o M presents to ED for 2d hx of fever & RUQ pain. Physical exam shows jaundice. Abd US shows cholelithasis and marked dilation of biliary duct. ERCP is performed and reveals pus with multiple brown concrements draining from the common bile duct.

A) Decreased UDP-glucoronyl transferase activity

B) Increased cholesterol 7-alpha hydroxylase activity

C) Increased B-glucuronidase activity

Sources

Sources

1. Lack EE. Pathology of the Pancreas, Gallbladder, Extrahepatic Biliary Tract, and Ampullary Region . Oxford University Press; 2003

2. European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones.. J Hepatol .2016; 65(1): p.146-181. doi: 10.1016/j.jhep.2016.03.005.

3. Bouchier IA. The formation of gallstones.. Keio J Med .1992; 41(1): p.1-5. pmid: 1583812.

4.Goljan EF. Rapid Review Pathology. Philadelphia, PA: Elsevier Saunders; 2018

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