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CASE PRESENTATION

7SITI NUR BAITI BINTI SHAIK KHAMARUDIN012013100196

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PATIENT’S IDENTIFICATION

Name : Norziza Age : 31 Gender : Female Race : Malay Religion : Islam Address : Bandar Parkland, Bukit Tinggi, Klang Occupation : Housewife Marrital status : Married with 2 children Date of admission: 31/10/2015 Date of clerking : 1/11/2015 Informant : Patient

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CHIEF COMPLAINT

Right upper quadrant abdominal pain for 3 days prior to admission.

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HISTORY OF PRESENTING ILLNESS Patient started to have pain at hypochondriac region 2 days before she was admitted to HTAR.

The pain was continuous and sometimes it got worsen.

Pain is non-radiating. Pain is colicky in nature. It was aggravated when the patient moved and

after she ate. The pain is relieved if she lied down or leaned

forward. The pain score was 8/10.

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Patient claimed that she has 2 episodes of vomiting 1 day prior to admission and the vomitus contained food particles.

She also experienced a low-grade fever and loss of appetite.

Nothing abnormal detected in her stool and urine. She denied having symptoms such as headache,

diarrhoea, constipation, urine disturbance and breathing problem.

No loss of weight.

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Menstrual History First menarche: 13 years old. Pattern of menstruation: Irregular No complaint of dysmenorrhea.

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SYSTEMIC REVIEW

Cardiovascular system She has no chest pain and no palpitation.

Respiratory systemShe has no shortness of breath, no cough, no dyspnoea.

Genitourinary system

She has no frequency, no dysuria, no hesitancy, no incontinence or nocturia.

Neurological systemHe has no headache, no visual disturbance or speech disturbances.

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PAST MEDICAL HISTORY

Never undergo any surgery. Never been warded. Not under any prescription medication. No drug allergies.

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SOCIAL HISTORY She has 2 children whom she gave birth under

normal delivery. Financially supported by her husband. Patient claimed she has been taking oral

contraceptive pills (OCP) ever since she gave birth to her first child.

Does not smoke and never smoke. No history of drug abuse and alcohol intake.

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FAMILY HISTORY Family has no history of malignancy and other

medical illness like DM and MI. Both her parents and her siblings are alive

and healthy.

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PHYSICAL EXAMINATION

General Examination - Alert, conscious, pink and hydrated.- Lying comfortably in supine position.- Patient was on Normal Saline intravenous drip

attached to dorsum of her left hand. - ID tag on left arm.- Not in respiratory distress.

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Vital Signs Pulse rate : 84 beats/min Breathing rate : 20 breaths/min Body temperature: 38.1oC Blood pressure : 125/76 mmHg

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Hand Examination The hands were warm and moist. No flapping tremor. Capillary filling time is normal (<2 seconds) No clubbing. No peripheral cyanosis. No koilinychia. No tobacco stain. No palmar erythema.

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Head and Neck Examination Eye: No conjunctival pallor.

Presence of mild sclerotic jaundice. Mouth: Oral hygiene is satisfactory

No central cyanosis No angular stomatitis

Neck: No lymphadenopathy

Lower Limb Examination No indentation. No pitting oedema.

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ABDOMINAL EXAMINATIONInspection The abdomen is scaphoid, symmetry and

moves with respiration. The umbilicus is centrally located and

inverted. No surgical scars. No prominent dilated veins. No supraclavicular lymph node enlargement.

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Palpation There is tenderness at right hypochondriac

region upon superficial and deep palpation. No guarding and rebound tenderness. No palpable mass. The liver is not palpable. No splenomegaly. Murphy’s sign is positive.

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Percussion No shifting dullness and fluid thrill.

Auscultation Bowel sounds was present with normal

intensity. No renal bruits heard.

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SUMMARYA 31 year-old housewife came to HTAR with a chief

complaint of abdominal right upper quadrant pain for 3 days associated with vomiting, low-grade fever and loss of weight.

The pain was continuous and colicky in nature but non-radiating.

On physical examination, she was pyretic. There was a mild sclerotic jaundice and tenderness at hypochondrium with no other abnormal findings upon abdominal examination.

ZAWIN NAJAH BT RAHIM012013100234

PROVISIONAL DIAGNOSIS Ascending Cholangitis• Jaundice• Fever• Right Upper Quadrant pain• Intake of oral contraceptive pill that is later

replace with contraceptive injection• Dilatation of bile duct• Leukocytosis

DIFFERENTIAL DIAGNOSISDISEASES SUPPORTING

POINTS POINTS AGAINST

ACUTE PANCREATITIS

Present of fever, right upper

quadrant pain

No jaundice, increase serum

amylase

ACUTE CHOLECYSTITIS

Present of fever, right upper

quadrant pain

Positive Murphy’s sign

DISEASES SUPPORTING POINTS

POINTS AGAINST

HEPATITIS Right upper quadrant pain,

jaundice

No fever

LIVER ABSCESS Right upper quadrant

pain,jaundice, fever

No gallstone, no bile duct dilatation

INVESTIGATION Full Blood Count Serum Amylase Level Liver Function Test Renal Profile Transabdominal ultrasound

Full Blood CountTest Result Unit RangeHaemoglobin 14.7 g/dL 8.0-17.0RBC 4.93 10^6/µL 2.5-5.5WBC 16.53 10^3/µL 3.0—15.0Haematocrit 41.3 % 26.0-50.0MCV 83.8 fL 86.0-110.0MCH 29.8 pg 26.0-38.0MCHC 35.6 g/dL 31.0-37.0RDW 47.2 % 11.0-16.0Platelet 529 10^3/µL 50-400MPV 10.5 fL 9.0-13.0Neutrophil % 13.4 % 40-80Lymphocytes % 2.03 % 20-40Monocytes % 1.00 % 2-10Eosinophils % 0.06 % 1-6Basophils % 0.04 % < 1-2

Renal ProfileTest Result Unit Range

Urea 3.6 mmol/L 2.8-7.2

Sodium 141 mmol/L 136-145

Potassium 4.3 mmol/L 3.5-5.1

Chloride 100 mmol/L 98-107

Creatinine 72 mmol/L 59-104

Liver Function TestTest Result Unit Range

Albumin 51 g/L 35-52

Globulin 32 g/L 25-39

A/G ratio 83 0.9-1.8

ALP 221 IU/L 30-120

ALT 423 IU/L 0-50

Total bilirubin 132.0 mmol/L 5-21

Transabdominal ultrasound• LIVER– Normal parenchymal echogenicity with normal focal

lesion.– Smooth liver margin– Liver is normal in size (15.2 cm)

• GALLBLADDER– Well distended with thickened wall (0.8 cm)– No gallbladder calculus– No pericholecystic fluid– No tenderness elicited

• DUCTS– Right and left intrahepatic duct and common bile

duct are mildly dilated.– Mild dilatation of common bile duct– No obvious calculus at the distal common bile

duct• No mass seen at the porta hepatis/pancreatic head

region• Portal vein is within normal caliber• Pancreas is normal and homogenous in echogenicity• Spleen is not enlarged• No free fluid

Serum Amylase 89 U/L n: 40- 140 U/L

HOSPITAL MANAGEMENT• NBM with IVD • IV Flagyl 50 mg TDS • IV Cefobid 2g BD• IV Pantoprazole 40mg BD• IV Tramal 50 mg TDS

DISCUSSION

ANATOMY: HEPATOBILIARY SYSTEM

• Gall bladder – Pear shaped structure– 7.5-12 cm long– 25-30 ml– Fundus, body and neck

• Cystic duct– 3cm ( may be variable)– 1-3mm diameter– Calot’s triangle : cystic duct ( inferior), common

hepatic artery (medial), cystic artery ( superior)

• Bile duct– Right + Left hepatic duct common hepatic duct– Cystic duct + Common hepatic duct Common

bile duct– Common bile duct emerge with pancreatic duct

just before entering the duodenum– Bile duct sphincter – smooth muscle surrounding

the distal end of the duct

ASCENDING CHOLANGITIS• Ascending bacterial infection of biliary tract in

association with partial or complete obstruction of bile duct.

• EPIDEMIOLOGY• Equal in both gender• Mostly in adults with median age at onset 50-60

years

• ETIOLOGY• Gallstone ( most common cause)• Biliary tract intervention/ and stents, stricture,

tumors, choledochal/biliary cyst

CLINICAL FEATURES

• CHARCOT TRIAD– Fever– Right upper quadrant pain– Jaundice

• REYNOLDS PENTAD (progression of illness)– Septicemia– Mental status change

INVESTIGATION

1. Full blood count2. Liver function test3. Blood culture4. Transabdominal ultrasound

MANAGEMENT

• Broad spectrum intravenous antibiotic• Fluid resuscitation and correction of

electrolyte imbalance• Treat cholangitis first before operative therapy• The obstructed bile duct must be drained as

soon as the patient has been stabilized• Emergency biliary decompression – if not

respond to antibiotics and fluid resuscitation

COMPLICATION

• Pyogenic liver abscess• Acute renal failure