CASE

CHOLELITHIASIS
Pembingbing: dr. Sjaifuyl Bachri, Sp.B(K)BD
Disusun oleh: Sheany Lestatila (406152017)

IDENTITAS
Nama
: Ny. L
Jenis kelamin
: Perempuan
Usia
: 39 tahun
Pendidikan
: SMA
Pekerjaan
: Ibu rumah tangga
Alamat
: Citapen

ANAMNESIS
Anamnesis secara Autoanamnesis
pada tanggal 17 january 2017
Keluhan utama :
Nyeri perut di sebelah kanan atas
Keluhan tambahan :
Demam

RIWAYAT PENYAKIT SEKARANG

Os datang dengan keluhan nyeri perut kanan atas sejak 3
hari smrs. Nyeri timbul secara tiba-tiba, tidak sehabis
makan makanan yang berlemak. Nyeri tersebut dirasakan
terus-menerus, tidak membaik dengan istirahat.
Awalnya nyeri dirasakan di ulu hati yang menjalar ke kanan
atas serta pinggang yang disertai mual dan muntah.
Os juga mengeluhkan demam yang timbul sebelum adanya
nyeri pada perut kanan atas tsb. Demam terus menerus,
sudah minum antipiretik namun demam tidak membaik.

RIWAYAT PENYAKIT DAHULU

Riwayat penyakit kuning (-)
Riwayat sakit maag (-)

RIWAYAT PENYAKIT KELUARGA

Keluarga yang memiliki keluhan serupa (-)

STATUS GENERALIS
Kesadaran
: Compos Mentis
Keadaan umum : Tampak sakit sedang
Tekanan darah
: 130/80 mmHg
Nadi
: 88 x/menit
Pernafasan
: 20 x/menit
Suhu
: 36,5 C

STATUS LOKALIS ABDOMEN

Inspeksi :
Dinding abdomen simetris
Auskultasi :
Bising Usus (+) normal
Palpasi :
Nyeri tekan (+) di epigastrik dan RUQ, Murphy sign (+)
Perkusi :
Timpani di seluruh lapangan abdomen
Nyeri ketok CVA (-)

RESUME
Telah diperiksa seorang perempuan berusia 39 tahun datang
dengan keluhan nyeri pada RUQ sejak 3 hari smrs.
Nyeri timbul mendadak, dirasakan terus menerus, tidak
memberat setelah makan makanan yang berlemak, tidak
membaik dengan istirahat.
Keluhan nyeri perut kanan atas sebelumnya didahului oleh
demam yang terus menerus dan tidak membaik dengan obat
paracetamol.
Pada pemeriksaan fisik di dapatkan nyeri tekan pada RUQ
dan Murphy sign (+)

DIAGNOSIS BANDING
Cholelithiasis
Cholecystitis

PEMERIKSAAN PENUNJANG
Pemeriksaan darah
USG abdomen

LABORATORIUM
PEMERIKSAAN

HASIL

NILAI NORMAL

Hb

14,2

13-16 g/dl

Ht

41

40-54%

Leukosit

16.900

4000 10000/ul

Trombosit

246.000

150000 450000/ul

USG
Gallbladder:
Dinding tampak menebal, batu (+) 3 buah dengan
ukuran -/+ 1,6cm, sludge (-).
Kesan :
Cholecystitis dengan Cholelithiasis

DIAGNOSIS KERJA
Kolelitiasis

PENATALAKSANAAN
Kolesistektomi dengan laparaskopi

PROGNOSIS
Ad vitam
: Bonam
Ad funtionam
: Bonam
Ad sanactionam : Bonam

INTRODUCTION
Cholelithiasis Gallstones form in the biliary tract, usually in the
gallbladder.
develop insidiously, asymptomatic for decades.
Migration of a gallstone into the cystic duct block the outflow of
bile during gallbladder contraction increase in gallbladder wall
tension Pain (billiary colic)
Cystic duct obstruction more than a few hours acute
cholecystitis progressive fibrosis and loss of function of the
gallbladder chronic cholecystitis : predisposes to gallbladder
cancer.
Ultrasonography is the initial diagnostic procedure of choice in
most cases of suspected gallbladder or biliary tract disease

ANATOMY

pear-shaped
L: 7 10 cm
D: 3 5 cm
C: 30 60 ml empedu

 During fasting, with the

sphincter of Oddi
contracted and the
gallbladder filling.

In response to a meal, the

sphincter of Oddi relaxed
and the gallbladder
emptying

PATOPHYSIOLOGY
Gallstone formation: certain substances in bile present
concentrations approach the limits of their solubility.

in

Bile become supersaturated with these substances precipitate

from the solution as microscopic crystals that trapped in
gallbladder mucus gallbladder sludge.
crystals grow, aggregate, and fuse to form macroscopic stones.
Occlusion of the ducts by sludge and/or stones produces the
complications of gallstone disease.
2 main substances: cholesterol and calcium bilirubinate

Cholesterol gallstones. (>>80%)

The main factors:
the amount of cholesterol secreted by liver cells, relative to lecithin
and bile salts.
the degree of concentration and extent of stasis of bile in the
gallbladder.
Calcium, bilirubin, and pigment gallstones.
Billirubin is actively secreted into bile by liver cells, >> billirubin
conjugated but small proportion consists of unconjugated bilirubin
UB form insoluble precipitates with calcium, Calcium enters bile
with other electrolytes.
high heme turnover (chronic hemolysis or cirrhosis): unconjugated
bilirubin present in bile at higher than normal concentrations
Calcium bilirubinate crystallize form black pigment stones. (10%
20%)

 Situation high heme turnover (chronic hemolysis or cirrhosis):

unconjugated bilirubin

present in bile at higher than normal

concentrations Calcium bilirubinate crystallize form black

pigment stones. (10% 20%)
unusual circumstances (biliary stricture) bile colonized with
bacteria: hydrolyze conjugated bilirubin increase unconjugated
bilirubin precipitation of calcium bilirubinate crystals.
Bacteria also hydrolyze lecithin to release fatty acids bind calcium
and precipitate from the solution resulting claylike consistency
brown pigment stones.

ETIOLOGY
Cholesterol gallstones, black pigment gallstones, and brown pigment
gallstones have different pathogeneses and different risk factors.
Cholesterol Gallstones

Obesity
Pregnancy
Gallbladder stasis
Drugs
Heredity

Black and brown pigment gallstones

Individuals with high heme turnover
Disorders of hemolysis

CLINICAL PRESENTATION
Gallstone disease may be thought of as having the following 4 stages:
The lithogenic state, in which conditions favor gallstone formation
Asymptomatic gallstones
Symptomatic gallstones, characterized by episodes of biliary colic
Complicated cholelithiasis

Billiary Colic:
Episodes are sporadic and unpredictable. The patient localizes the pain
to the epigastrium or right upper quadrant and may describe radiation
to the right scapular tip (Collins sign)
Other symptomps:
indigestion, dyspepsia, belching, bloating, and fat intolerance non
specific.

PHYSICAL EXAM
Patients with the lithogenic state or asymptomatic gallstones have no
abnormal findings on physical examination.
Distinguishing uncomplicated biliary colic from acute cholecystitis or
other complications is important.

COMPLICATIONS

Acute chronic Cholecystitis

Gallbaldder Empyema
Gallbladder Adenocarcinoma

PATIENT EDUCATION
Patients with asymptomatic gallstones should be educated to
recognize and report the symptoms of biliary colic and acute
pancreatitis.
Alarm symptoms:
Persistent

epigastric

pain

lasting

>20

accompanied by nausea, vomiting, or fever.

minutes,

especially

if

DD
Cholecystitis
Cholangitis
Pancreatitis
Hepatitis

WORKUP
Patients with uncomplicated cholelithiasis or simple biliary colic
typically have normal laboratory test results. Laboratory testing is
generally not necessary unless cholecystitis is a concern.
Abdominal Radiography
Upright and supine helpful in establishing a diagnosis of gallstone
disease.
Black pigment or mixed gallstones contain sufficient calcium
radiopaque.
Calcification in the gallbladder wall severe chronic cholecystitis.

USG
The sonographic features of
acute cholecystitis include:
gallbladder wall thickening (>5
mm)
pericholecystic fluid
gallbladder distention (>5 cm)
sonographic Murphy sign
It is highly sensitive and specific
for gallstones greater than 2
mm

ERCP
(ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY)

TREATMENT (ASYMP GALLSTONES)

cholecystectomy for asymptomatic gallstones may be indicated in the
following patients:
Patients with large gallstones, greater than 2 cm in diameter
Patients with nonfunctional or calcified (porcelain) gallbladder
observed on imaging studies
Patients with spinal cord injuries or sensory neuropathies affecting
the abdomen
Patients with sickle cell anemia in whom the distinction between
painful crisis and cholecystitis may be difficult

Patients with risk factors for complications of gallstones may be

offered elective cholecystectomy, even if they have asymptomatic
gallstones. These groups include persons with the following conditions
and demographics:
Cirrhosis
Portal hypertension
Children
Transplant candidates
Diabetes with minor symptoms

Medication
cholesterol gallstones: ursodeoxycholic acid (8-10 mg/kg/d PO)
divided bid/tid requires 6-18 months.
The recurrence rate is 50% within 5 years. Moreover, after
discontinuation of treatment, most patients form new gallstones over
the subsequent 5-10 years.

TREATMENT (SYMP GALLSTONES)

Cholecystectomy (open vs laparoscopic)
Cholecystostomy
Endoscopic spinchtertomy

PREVENTION
Administration of ursodeoxycholic acid at a dose of 600 mg daily for 16
weeks reduces the incidence of gallstones by 80% in this setting.
Recommending dietary changes of decreased fat intake may
decrease the incidence of biliary colic attacks. However, it has not
been shown to cause dissolution of stones.

CHOLELITHIASIS