Obstructed jaundice with Cholangitis due to Choledocholithiasis

1. Case Presentation
Dr. Md. Zohir Uddin
Intern doctor ,CIMCH

2. Particulars of the Patient
 Name : Mr. Shahjan Mia
 Age : 61
 Sex: Male
 Marital status : Married
 Occupation : Service holder
 Address: West Shahidpur Aminullah master bari, ward #9,Lokkhipur thana,
Lokkhipur
 Date admission : 24/4/19 at 5:40 pm

3. Presenting Complaints
 Pain in the right upper abdomen for 10 days
 Fever for 10 days
 Itching for 5 days

4. History of Presenting illness
 According to patient statement ,he was apparently well 10 days back.
Then he developed severe right upper abdominal pain which is colicky in
nature, intermittent, non radiating, aggravated by taking fatty food and
subsided by taking medication which was given by local doctor. He also
complains of fever with chills and rigor for the same duration which was
intermittent in nature. These problem associated with yellow coloration of
sclera and skin of whole body, passes of high colored urine and pale stool
for the same duration . He also complains of generalized itching for last 5
days. He had no history of weight loss and hemoptysis.

5. History of Past illness
 He had a history of cholecystectomy with choledocholithotomy 10 years
back and stroke 2 years back

6. Drug history
 Patient was on some medication for cardiac disease but he couldn't mentioned.
Personal history : Nothing contributory
Family history : Nothing contributory
Blood transfusion history : Nothing contributory
Immunization history : Nill
Allergic history : Nothing contributory

7. PHYSICAL EXAMINATION
 General examination
 Appearance : ill looking
 Body built : average
 Co-operation : co-operative
 Decubitus : supine (patient choice )
 Anemia : absent
 Jaundice : present (++)
 Dehydration : absent
 Edema : absent
 Lymph node : not palpable
 Thyroid gland : not enlarged
 Hernial orifice : intact
 Skin survey : scratch mark present
 Pulse : 110 beats/min
 Blood pressure : 140/80 mmHg
 Temperature : 104 degree F
 Respiratory rate : 16 breaths /min

8. Systemic examination
 Abdominal examination
 Inspection
 Abdomen is scaphoid in shape
 Umbilicus is centrally placed and inverted
 No engorged vein
 No visible peristalsis
 There is a scar mark on the right upper abdomen
 Scratch mark is also present

9.  Palpation :
 There is a tenderness in upper abdomen
 Murphy's sign negative
 Liver , spleen, kidney , urinary bladder : not palpable
 Percussion :
 Percussion note is tympanic
 Shifting dullness and fluid thrill are absent
 Auscultation : Bowel sound present
 Examination of other systems reveal no abnormality

10. What is the
diagnosis???

11. Provisional diagnosis
 Obstructive jaundice with cholangitis due to choledocholithiasis
Differential diagnosis :
 Carcinoma of the head of the pancrease
 Ca in the common bile duct

12. Investigations
 Ultrasonography of the hepatobiliary system with pancreas : gall bladder is not
seen and there is a echogenic structure in the CBD which is 12 mm in diameter .
 Liver function test
 Serum bilirubin : increased
 SGPT : Increased
 Serum ALP : increased
 Prothrombin time : normal
 Serum amylase : normal
 CBC :
 Hb% : 12.8 gm/dl
 ESR : 14 mm in 1st hour
 WBC count : 14,300 /cumm
 Neutrophill count : 92%

13.  ECG :
 Left atrial hypertrophy
 RBBB
 Echo :
 Regional wall motion abnormalities
 EF : 60%
 Troponin I : 0.460 ng/ml (suggestive of anterior MI )

14. CONFIRMATORY DIAGNOSIS
 OBSTRUCTIVE JAUNDICE WITH CHOLANGITIS DUE TO
CHOLEDOCHOLITHIAISIS

15. TREATMENT
 ERCP stenting
 choledocholithotomy with T-tube drainage

16. Pre-operative preparation
 Correction co morbid condition
 Prophylactic antibiotics
 Fluid and nutritional support (no fatty diet )
 Nothing by mouth for 6 hour before operation

17. T-tube management
 Drainage of bile through T-tube upto 7th post operative day
 Progressive clamping of T-tube from the 7th POD
 On 7th POD T-tube is clamp for 4 hours
 On 8th POD T-tube is clamp for 12 hours
 On 9th POD T-tube is clamp for 24 hours
 Post operative T-tube cholangiography is done 11th post operative day
 Removal of T-tube on 12/13th post operative day by slow sustained traction (if
patient condition is satisfactory )

18. Thank you All

19. Special thanks goes to
Dr. Mizanur Rahman
&
Humayun Rashid
(MBBS 3rd batch )