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gall bladder carcinoma Long case surgery

  1. Presented By : Intern doctor Amit Kumar Shah Intern doctor TythiKundo Department of surgery
  2. Particulars of the patient:  Name: Mrs. Suraton  Age : 80 years  Sex: Female  Adress: bangla Heli, Hakimpur,DinajpurSadar  Marital status: Widow  Religion: Islam  Date of admission: 07-11-2022@7:14 PM  Date of examination: 07-11-2022@7:30 PM
  3. Chief Complaints: 1. Pain in the upper abdomen for 4 months. 2. Loss of appetite for 3 months. 3. Weight loss for 3 months.
  4. History of present illness: She was apparently alright 4 months ago when she start experiencing episodes of sudden onset of pain in right upper abdomen which is colicy in nature radiating to back in the shoulder occurring around 20 to 30 minutes after meals and subsides on its own after an hour or two.
  5. She experiences this episodes daily associated with feeling of fullness in upper abdomen after taking meals but no complaints of heartburn. From the last1 month she start having dull aching pain in the right abdomen which was continuous in nature not radiating to back, more after taking meals and do not subsides completely.
  6. She also gives history of loss of appetite which let her to lose weight of 8-10 k kg in last 3 months but this was not associated with abdominal distension, nausea or vomiting .There is no history of yellow colouration of eyes or skin, high colour rine or itching over the body
  7. There is no history of fever , no history of altered bowel habit, no history of blood in the stool or black colored stool. There is no history of lump in the abdomen or swelling in the neck or other part of body . No history breathlessness, cough, or chest tightness.
  8. History of past illness: Hysterectomy was done for uterine prolapse 2 months back. She is hypertensive and on medication for last 5 years and has no history of DM, asthma, tuberculosis. Immunization History: She is immunized as per EPI schedule. She is immunized against HBV. (For surgeon’s safety)
  9. Personal history: No addiction Bowel and bladder habit normal Sleep and appetite decreases Mixed bengali diet
  10. Family History No history of gallbladder stone disease in any family member No history of malignancies in her any family member No history of liver disease
  11. Menstrual history She attains menopause at the age of 47 years and previous menopausal history is unremarkable . Obstetric history she have 5 childrens and age of last child born is 45 years.
  12. Drug history: She took anti- Hypertensive drug and also took some tablets from local quack but could not mention the names.
  13. General Examination Patient was examined in well lit room after obtaining consent in presence of female attendant  Conscious, co operative and well oriented to time, place and person  Lean, thin,well hydrated, lying confortably in bed with iv canulla in left hand and cathetrized  Temperature: 98.6 (Right axilla)
  14. Pulse : 76min regular rhythm (right radial artery) BP: 130/80mmhg ( right arm supine position ) RR: 14/ min Anemia:mild anemic
  15.  Non icterus, cyanosis, clubbing, koilonychias, leuconychia were absent  Lymphoneds are not enlarged , no bipedal edema
  16. Abdominal Examination: Examined on the supine position with arm kept on sides and exposed from lower chest to pubic tubercle( after taking consent again and in presence of female attendant) INSPECTION: Abdomen was normal in shape with a central and inverted umbilicus and vertically slitted.
  17. Overlying skin was normal with an scar of previous surgery ( lower midline incision),there was no dilated veins, visible pulsation , peristalsis absent All quadrant moves equally with respiration and is thoraco- Abdominal No visible lump in any of the quadrant nor was any swelling at hernial site
  18. Palpation: Temperature was not raised There is no superficial tenderness The abdomen is soft There is a single globular lump palpable in the right hypochondriac region around 4cm X 3 cm extending 1cm lateral and 3 cm medial to right
  19. midclavicular line and extending 3cm below the right costal margin. The surface is irregular, margins are well defined , is hard in consistency and moves well with respiration. It become palpable when patient is asked to raised a head.
  20. There is no evidence of hepatomegaly and spleenomegaly or any other lump. Hernia sites are normal. Percussion: Abdomen is tympanic on percussion. But the lump is dull on percussion and is in continuation with the dullness of liver which ends at the 6th ICS in the mid clavicular line
  21. Auscultation:  Normal bowel sound are audible and no hepatic bruit On D/R/E: Yellow staining of examining figure is noticed and no mass detected
  22.  On cardiovascular examination and respiratory examination revels no abnormalities , nervous system ……
  23. Case summery : Mrs. Suraton, 80 years old hypertensive, non diabetic lady resident of Bangla Heli, Hakimpur, Dinajpur sadar got admitted to TMC & RCH with the complaints of episodes of colicy right upper quadrant pain for last 4 months which change to dull aching continuous pain for last 1 month without any jaundice or bowel habit alter.
  24. She also gives history of loss of appetite which let her to lose weight of 8-10 k kg in last 3 months but this was not associated with abdominal distension, nausea or vomiting
  25. On examination she is lean but pale lady without icterus , single hard lump in the right hypochondrium 4X3 cm with well defined margins and irregular surface moving well with respiration , lump was dull on percussion. There is no clinical evidences of ascitis and this mass is likely to arise from gall bladder.
  26. Provisional Diagnosis: Gall bladder malignancy
  27. Differential Diagnosis: „Mucocele of gallbladder  „Empyema of gallbladder „„ Periampullary carcinoma „ Cholangiocarcinoma involving the distal bile duct „
  28. Investigation: „Ultrasonography of whole abdomen :  Suggestive of gall bladder mass.  Hydronephosis( bilateral)  And H/O hysterectomy with inflammed stump. And patient is adiviced to do CT abdomen but patient refuse.
  29.  Patient refuse to pay test for CT scan of abdomen, so we advice the patient CEA and CA 19-9 , it is increased in other GI malinancy but if we suscpect Ca gall bladder CEA and CA 19-9 will be absolutly raised .  CEA:153 ng / mL ( <5ng/mL)  CA 19-9 : >1000.00 U/mL ( normal < 35)
  30. CBC:  Hb: 9.60%  ESR: 72 mm at 1st hour  TC: 14.60 k/uL  DC: N- 79% ; L- % ; M-1% ; E- 05% ; B- 00%  Microcytic hypochromic anemia with neutrophilic leucocytosis.
  31. Random Plasma Glucose : 5.80mmol/ Serum Creatinine:1.36 mg/dL Blood Grouping and Rh factor: “o” positive
  32.  Urine R/E showing 8-10/ HPF pus cell,
  33. Confirm Diagnosis: Gall bladder carcinoma
  34. Treatment: 1. Pre-operative preparation. 2. Surgery: If the disease is localized and there is no distant spread then I will plan for curative surgery. I will do an exploratory laparotomy and assess the operability and if it is operable I will do radical cholecystectomy
  35. 3. with advanced gallbladder cancer These patients need palliative treatment only: „Palliation of jaundice: ERCP and stenting with a self expanding metallic stent provides relief of jaundice with less need for repeated change of stent. „
  36. Palliation of gastric outlet obstruction: Gastric outlet obstruction may also be relieved by endoscopic duodenal stenting or by open operation of gastrojejunostomy. „ Palliation of pain: NSAID → Opioids → percutaneous neurolysis of celiac plexus by injecting alcohol.
  37. Chemotherapy is not very effective in carcinoma gallbladder. Most frequently 5-fluorouracil and mitomycin have been used. Cisplatin has shown better results Radiation therapy has been used after resectional surgery as an adjuvant.
  38. No survival advantage has been reported. Radiation sensitizer 5- fluorouracil along with radiation provides some benefit. Advanced unresectable disease radiotherapy is not useful. Prognosis: 5-year survival rate < 5%
  39. Thank you