Gallstone (Obstructive jaundice)

Patient is a 31 years old Malay lady, P1, LNMP 2/52 with no known underlying medical illness presented with abdominal pain over 1 week prior to admission with history of similar pain 3 weeks ago.

For the first episode which has occurred last 3 weeks, the pain was in epigastric region, radiated to right and left hypochondriac.  There was no other associated symptoms. She the presented to a hospital in her district for treatment. She was diagnosed with gastritis and was prescribed with gastritis medication. She claimed the pain was relieved.


One week prior to admission, she had recurrent episode of pain similar in character as last 3 weeks. She described the pain as throbbing in nature, persistent and increased in intensity. Pain was aggravated by movement with no specific relieving factor with pain score of 6-7/10. However it was associated with tea vomiting, about 2 to 3 times a day. Vomitus contained food particles with fluid, with no bile or blood.

On further questioning, she also started to notice yellow discoloration of her sclera and skin for 3 days prior to admission. She also complained of having tea-colored urine and pale colored stool for one weeks and itchiness on her arm and abdomen.

Cholestasis means "the slowing or stopping of bile flow" which can be caused by any number of diseases of the liver (which produces the bile), the gallbladder (which stores the bile), or biliary tract (also known as the biliary tree, the conduit that allows the bile to leave the liver and gallbladder and enter the small intestine). When this occurs, conjugated bilirubin and the waste products that usually would be cleared in bile reflux back into the bloodstream. This causes a primarily conjugated hyperbilirubinemia and jaundice; the liver conjugates the bile to make it water-soluble and because the bile has already been processed by the liver, when it gets backed up because of a blockage and is refluxed into the blood, the blood will have high levels of conjugated bilirubin. This is in contrast to primarily unconjugated hyperbilirubinemia which is the water-insoluble form that is bound to serum albumin; the liver has not had a chance to conjugate the bilirubin yet and can be caused either because too much unconjugated bilirubin is made (such as in massive hemolysis or ineffective erythropoiesis) or because too little is conjugated (Gilbert's disease or Crigler-Najjar syndrome). Unconjugated hyperbilirubinemia does not typically cause pruritus.
It is thought that bile acids that deposit into the skin is responsible for the pruritus (itching) but the levels of bilirubin in the bloodstream and the severity of the pruritus does not appear to be highly correlated

Claimed to have history of flatulence dyspepsia but was unsure since when. There was no history of fever with chills and rigor, no chest pain, shortness of breath, palpitation and no acid reflux symptoms. 

Patient presented to nearby hospital in her district, there she was infused with intravenous fluids, analgesics and her blood was taken taken for investigations. She then was referred to here for further investigation and management.

There was no other significant surgical history except for emergency lower caeserian section 6 months ago due to failure of induction of labour. Surgery went well, and she denied postoperative complication. She denied taking oral contraceptive pills.

Her mother was diagnosed with diabetes mellitus on insulin and hypertension which is well-controlled. Her father died 10 yers ago due to infection. There was no history of malinancy or similar problem in family.


She is a factory worker married to a FELDA settler. Their total income is around per month, claimed to be adequate for basic necessaries. Her husband is a smoker. Both partners denied alcohol consumption.

Upon clerking, she was alert and concious. She looked lethargy and in pain. She was jaundiced with poor hydrational status. A branulla was attached on her forearm, and she was infused with flagyl solution. She was on urine bladder catheterization, containing 400 ml dark tea-colored urine. Otherwise , no pallor, spider naevi, koilonichia, clubbing, palmar erythema and ankle edema.

She was on CBD. If someone is presented with sign and symptoms suggestive of obstructive jaundice, they will be put on CBD, not to merely look at the changes, but the most crucial part is to monitor if patient developed sepsis. In cases of obstructed biliary tree like choledocholethiasis, we afraid if patient complicated with ascending cholangitis (possible to develop). Ascending cholangitis is a medical emergency which can develop into sepsis.

Abdomen was not distended and inverted, there is scratch mark seen at the epigastric region. There was a well-healed suprapubic scar measured about 18 cm. No dilated veins seen and hernial orifices were intact. On light palpation, the abdomen was soft and revealed tenderness on the apigastric, right and left hypochondriac regions. Murphy's sign was negative. (In chronic cholecystitis for example, there might be tenderness at RUQ but merely tenderness with no cacthing of breath and painful expression by patient are not Murphy's sign. Murphy's sign should be specfic and sensitive for acute cholecystitis. Liver span was 12 cm. There was no hepatosplenomegaly and no palpable mass. Auscultation and percussion showed no significant finding.

Per rectal examination reveled empty rectum with normal smooth mucosa.

There is almost always tenderness and guarding in the right hypochondrium. Palpate the abdomen just below the tip of the ninth costal cartilage and ask the patient to take a deep breath.When the liver and the attached gallbladder descend and strike the palpating hand, the patient will experience a sharp pain which prevents further inspiration.This is called Murphy’s sign. " -Browse’s Introduction to the Symptoms and Signs of Surgical Disease-

Provisional diagnosis
Choledocholithiasis

Ddxes
-acute pancreatitis
-biliary tumor
-ascending cholangitis

Investigation and management 

Laboratory investigation was ordered for 

• Arterial blood gases
• monitor any respiratory distress
• Full blood count
• white blood cell count
• Renal profile 
• Liver function test
• coagulation profile
• to assess any coagulation defect  
•  If biliary tract is obstructed
• Bile, which is an emulsifying agent, tolong pancreatic lipase to hydrolyse the lipids from foods, cannot reach duodenum
• Lipids not digested..not absorbed
• Leading to passage of loose, pale, foul-smelling fatty stools (steatorrhea) 
• Logically, the fat soluble vitamins also are not absorbed (ADEK)
• Lack of vitamin K leads to inadequate prothrombin synthesis
• Hence defective clotting
• Random blood sugar 
• UFEME

She was then infused with intravenous isotonic solution. *read more on the regimes later*.
She was given 

• cefobid *read more on cephalosporin drugs*
• 
  
• flagyl
• tramadol and paracetamol (PCM)
• analgesic
• please refer local procedure

• PS 0-3	4-6	7-10
  mild	moderate	Severe
  PCM	PCM and tramadol	Morphine +/- (PCM/tramadol)

• omeprazole : peptic ulcer inhibitor
• antidiabetic (WHYYY??? ASK DOCTOR LATER, FOLLOW UP THIS PATIENT)
• metformin
• glibenclamide

Ultrasound of heptobiliary system and abdomen was done revealed impression of chronic cholecystitis and gallstone. But remember the patient already presents with sign and symptoms of obstructive jaundice.

• stone in gall bladder with sludge seen
• gall bladder contracted with thickened gall bladder wall

Completed IMRIE score was done revealing mild pancreatitis.

The patient was planned to undergo ERCP on the third day of admission.

Spectrum of diseases in gall stone

Spectrum of diseases in JAUNDICE

1) malignancy- any malignancy along the hepatobiliary tract, metastases tumor, tumor that metastases to lymph node at porta hepatis, lymphoma etc
2) infections-divide into bacterial, viral, parasite (worm can migrate and block the pathwa)
3) trauma
4) congenital - congenital haemolytic anaemia such as thallasemia, g6pd def, hereditory spirocytosis, wilson disease etc
5) drug induce
6) stone (not fit in any cause)

Spectrum of diseases specific in Obstructive jaundice

1)congenital : choldedocal cyst, biliary atresia

2)infection : ascending cholangitis

3)malignancy

4)iatrogenic

5)miscellaneous : stone

WHAT IS COURVOISIER’S LAW 

There a lots of pictures available in the google or books which illustrate nicely, summarizing the formulation behind this law. My reference was from Burkitt Essential Surgery, my favourite surgery bible so far. Recommended.

References 

Burkitt, H.G, et. al, Essential Surgey: Problems, Diagnosis & Management(2007), Fourth Edition., 

N.L, et. al, Browse’s Introduction to the Symptoms and Signs of Surgical Disease(2005), Fourth Edition, Hodder Arnold, UK.