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“A 22 years old male presented with obstructive jaundice.”
1. CLINICAL SEMINAR
ON
“A 22 years old male presented with
obstructive jaundice.”
ORGANIZED BY-
DEPARTMENT OF SURGERY,
UNIT-I, MMCH
2. CHAIRPERSON:
PROF. M. A. GAFUR MIAH
PROFESSOR & HEAD
DEPARTMENT OF SURGERY, MMCH.
SPEAKER:
Dr.S.M.SUFI SHAFI-UL-BASHAR
Assistant Registrar, Surgery Unit – I, MMCH.
3. Particulars of the patient :
Name: Mr. Jewel Miah
Age: 22 yrs
Sex: Male
Religion: Islam
Occupation: Farmer
Marital status: Married
Address: Kalmakanda, Netrokona.
Ward no. - 06, Bed No.-06
Reg. no.- 105686/165
Date of admission: 12/11/13
Date of examination: 12/11/13
4. Chief complaints:
Yellow colouration of skin, eye and
urine for 6 months.
Pain in abdomen for same duration.
Fever for same duration.
5. History of present illness:
According to the statement of the patient
he had a history of open cholecystectomy in
a pvt. hospital about 6 months back. After
then he gradually developed yellow
colouration of skin, eye and urine for 6
months which was flactuating in nature
associated with generelized itching,
bodyache, dark coloured urine and pale
coloured stool which floated on water.
6. History of present illness(contd.):
The patient had pain in right side of
the upper abdomen for same
duration. Pain was recurrent,
spasmodic in nature, moderate
intensity, non radiating associated
with nausea occasionally vomiting,
not associated with heart burn or
regurgitation, aggravated by taking
fatty food and relieved by taking
medication.
7. History of present illness(contd.):
He had also fever which was usually
high grade, intermittent, associated
with chills and rigors, not associated
with night sweating, cough,
chestpain, generelized pigmentation,
relieved by taking medication. He has
no recent travelling history.
8. History of present illness(contd.):
He also gave history of loss of
appetite,weight loss, generalized
weakness, fatigue during the
last 6 months.
9. History of present illness (cotd.):
He had no history of hematemesis,
melena,haematuria,generalized
oedema, dysuria, dyspnoea, cough,
chestpain,haemoptysis. His bowel
and bladder habbit is normal.He is
normotensive and diabetic for 3
months.
He was admitted in MMCH with the
same problem 3 weeks back. But
operation was not done due to
uncrolled DM.
10. History Of Past illness:
He has history of open
cholecystectomy due to chronic
calculus cholecystitis in a
private hospital (Norshingdi)
about 6 months back. He has no
history of TB or any significant
illness.
11. Drug History:
History of taking
Paracetamol
PPI
Oral hypoglycaemic drug
Inj. Actrapid (100IU) following
admisson to hospital.
Patient is not known to be allergic
to any drug or food.
12. Personal history:
He is non smoker, non-alcoholic,
no history of drug abuse. He
used to take normal diet.
13. Family history:
None of his family members
sufferred from such kind of illness.
No family history of DM,HTN,
TB and IHD.
15. Socio-economic history:
He came from a low socio-
economic family and lives in
“kacha” house.He maintains
poor sanitation & hygiene.
16. General Examination:
Appearance : Ill-looking
Intelligence : Intelligent
Body built &
nutritional status : Average
Co-operation : Co-operative
Decubitus : On choice
Anemia : Mildly anaemic
Jaundice : Present
Cyanosis : Absent
Dehydration : Mild
17. General Examination(contd):
Koilonychia : Absent
Leukonychia : Absent
Clubbing : Absent
Pulse : 65beats/min,
regular
BP : 110/70 mmHg
Respiration : 18 breaths/min
Temperature : 100°F at the
time of examination
Neck vein : Not engorged
18. General Examination(contd):
Thyroid gland : Not enlarged.
Lymph node : Not palpably
enlarged.
Skin condition : Yellow colouration
with multiple scratch
marks are present.
19. Systemic Examination:
Examination of Alimentary System:
Mouth, tongue and Pharynx:
Normal
Per abdominal examination
Inspection
Abdomen is normal in size ,shape.
Complexion is yellowish.Umbilicus was in normal
position, inverted. Flanks are not full.
20. inspection contd.
There was an incisional scar mark in right
subcostal region and multiple scratch
marks on the skin.
There were no visible peristalsis,engorged
veins, visible pulsation and pigmentation.
Hernial orifices are intact.
External genitalia – Normal.
21. Palpation:
The local temperature was raised.
Tenderness present in right
Hypochondrium.
There was no palpable lump,liver
and spleen were also not palpable.
No other organomegaly present.
Fluid thrill absent.
22. Percussion: Tympanic all over
the abdomen.
shifting dullness absent.
Auscultation: Normal bowel
sound present.
23. Digital rectal examination:
There was no anal fissure, fistula,
swelling,hemorrhoid, excoriation
of perianal skin.
Perianal sensation & anal tone intact.
Rectum empty, rectal mucosa
free.There was no secondary deposit
in the recto-vesical pouch. The finger
is not stained with pus, mucous or
blood.
24. Other Systemic Examinations:
Respiratory System:
There was no chest deformity,
Trachea centrally placed, breath
sound vesicular with no added
sounds.
Genito-urinary System:
External genitalia normal, Urinary
bladder was not palpable &
Kidneys are not ballotable.
25. Cardiovascular system:
All pulses were present.
Precordium normal, heart sound
audible in all areas, no murmur.
Nervous system:
Higher psychic function is normal,
All cranial nerves are intact. Muscle
bulk, tone & power are normal. All
jerks are normal.sensory intact.
26. Salient features:
Mr. Jewel Miah, 22 years old,male,
muslim, married, farmer, hailing
from Kalmakanda, Netrokona, admitted
in this hospital with the complaints of
flactuating jaundice for 6 months,
recurrent pain in the rt.hypochondrium
and intermittent fever with chills and
rigors for same duration.
27. Salient Feature(contd.)
He gave history of open
cholecystectomy about 6months
back. He had history of
generalized itching, anorexia ,
nausea , occasional vomiting and
weight loss. He had no history of
haematemesis and melena.
The patient is normotensive but
diabetic for three months.
28. Salient Feature(contd.)
On G/E- patient was ill looking,
mildly anaemic, icteric, mildly
dehydrated.Oedema was absent.
There were multiple scratch
marks present all over the
body.His pulse was 65 b/min,
BP- 110/70 mmHg, R/R- 18
breaths/min, Temp-100ºF.
There was no lymphadenopathy.
29. Salient Feature(contd.)
P/A/E- size& shape of the abdomen
was normal, umbilicus was in normal
position & inverted, flanks were not
full. An incisional scar mark present in
the right subcostal area, local temp. is
raised, tenderness present at the rt.
hypochondrium.
30. Salient Feature(contd.)
No ascites , no organomegaly
present. Percussion note was
tympanic all over the abdomen.
Normal bowel sound was present.
Others Systemic examination
revealed no abnormalities.
32. Differential diagnosis:
1. Post operative Obstructive jaundice
due to stricture of common bile
duct with DM.
2. Post operative Obstructive jaundice
with worm in common bile duct
with DM.
3. Post operative Obstructive
jaundice due to periampullary
carcinoma with DM.
33. Investigations:
Investigations for Diagnosis :
USG OF Whole Abdomen(previous
admission):
From Nuclear Med.& Ultrasound( 28.10.2013):
Liver is mildly enlarge in size and
shows shiny tissue echotexture.
Intrahepatic biliary tree is mildly dilated.
GB is not outlined(operated).
Sludge material is seen in CBD.
34. Investigations(contd.):
USG OF Whole Abdomen:
Pancreas appear normal in size and
tissue echotexture.
Spleen shows normal in size and
homogeneous tissue echotexture.
Comment:
Sludge in CBD with dilated intrahepatic
Biliary tree. Mild hepatomegaly with fatty
change in liver.
35. Investigations:
Investigations for Diagnosis :
USG OF Whole Abdomen:
From Nuclear Med.& Ultrasound( 16.11.2013):
Liver appears normal in size and
shows normal tissue echotexture.
GB is not outlined(operated).
CBD is dilated(1.3 cm) & there is a
1.4cm stone in the terminal part of
the common bile duct.
36. Investigations(contd.):
USG OF Whole Abdomen:
Pancreas appear normal in size and
tissue echotexture.
Spleen shows normal in size and
homogeneous tissue echotexture.
Comment: Choledocholithiasis.
40. Other Investigations to assess the patient:
*Blood for TC-14610/cumm ,
DC (N-64.3%,L-20.9%M-5.5%,
E-9.2%)
HB% -10.0 gm/dl.
ESR -68 mm in 1st
hour.
MCV- 85.6 fL.
PLT-420 + (10^3/uL).
PCV-28.0%.
41. Other Investigations to assess the patient
(contd.):
*CXR P/A View-Normal
*HBsAg –Negative.
*FBS- 4.4 mmol/L ( pt is on
insulin)
*2HABF-6.8 mmol/L (pt is on
insulin
42. Other Investigations to assess the patient
(contd.):
*S. Creatinine- 0.9 mg/dL
*Urine R/M/E- albumin- trace,
sugar- nil
pus cell- 4-5/HPF
*Blood Group- A +ve.
*ECG- Normal.
*ICT for Kala-azar- Negative
*ICT for Malaria- Negative
44. Some important points in preoperative
preparation
Inj. Konakion 10mg-1ampule i/v
daily for 5 days
Nothing per oral for 3 days prior to
surgery
3L of fluid daily started with 1L of
5%DA with 10 unit of inj.actrapid
with 2 amp. Inj.KT in it is given for 3
days prior to surgery with monitoring
of RBS.
10%DA with 20 unit of inj.actrapid in
it is given in preoperative night.
46. Operation note(continued):
Findings: After laparotomy there
was morbid adhesion in operating
area. After some dissection duodenum
was found to adhere with undersurface
of liver near porta hepatis.Then
duodenum was seperated from the liver.
47. Operation note(continued):
During that time a small opening
was found in 1st
part of the
duodenum. Some ligature was
found adjacent to porta hepatis,
after every possible effort proximal
common bile duct was not found
distal to ligature but distal part was
identified by another ligature.
48. Operation note(continued):
Then searching of under surface of liver
done and a opening was found near
porta hepatis. After introduction of
dilator bile was coming out through this
opening. It was identified as common
hepatic duct.
