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    MCS Case 8 2020

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    abdisamed
    A 32-year-old man presents with worsening right upper quadrant pain, fever, chills, and jaundice 10 days after a laparoscopic cholecystectomy. On examination, he has tenderness and peritonitis in the right upper quadrant and jaundice. The most likely diagnosis is an obstructing biloma caused by a post-operative bile leak. Tests such as bloodwork, imaging, and MRCP are needed to identify the site of obstruction and evaluate for possible bile duct injury from the prior surgery.

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    MCS Case 8 2020

    Uploaded by

    abdisamed
    83 views2 pages
    A 32-year-old man presents with worsening right upper quadrant pain, fever, chills, and jaundice 10 days after a laparoscopic cholecystectomy. On examination, he has tenderness and peritonitis in the right upper quadrant and jaundice. The most likely diagnosis is an obstructing biloma caused by a post-operative bile leak. Tests such as bloodwork, imaging, and MRCP are needed to identify the site of obstruction and evaluate for possible bile duct injury from the prior surgery.

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    A 32-year-old man presents with worsening right upper quadrant pain, fever, chills, and jaundice 10 days after a laparoscopic cholecystectomy. On examination, he has tenderness and peritonitis in the right upper quadrant and jaundice. The most likely diagnosis is an obstructing biloma caused by a post-operative bile leak. Tests such as bloodwork, imaging, and MRCP are needed to identify the site of obstruction and evaluate for possible bile duct injury from the prior surgery.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    83 views2 pages

    MCS Case 8 2020

    Uploaded by

    abdisamed
    A 32-year-old man presents with worsening right upper quadrant pain, fever, chills, and jaundice 10 days after a laparoscopic cholecystectomy. On examination, he has tenderness and peritonitis in the right upper quadrant and jaundice. The most likely diagnosis is an obstructing biloma caused by a post-operative bile leak. Tests such as bloodwork, imaging, and MRCP are needed to identify the site of obstruction and evaluate for possible bile duct injury from the prior surgery.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    MCS Case 8 2020

    Clinical Presentation:
    A 32-year-old man presents to your facility 10 days after undergoing a laparoscopic
    cholecystectomy for acute cholecystitis at another hospital. He is complaining of severe pain in
    the right upper quadrant along with fever, chills, and scleral icterus, all of which began about five
    days ago and have progressively worsened. The heart rate is 120 bpm, blood pressure is 100/70
    mmHg ((13.3/8.3 kPa), and respiratory rate is 30. Examination is remarkable for tenderness and
    peritonitis in the right upper quadrant and icterus of the sclerae. There are two surgical wounds in
    the right upper quadrant, one in the epigastrium, and one just above the umbilicus, all are clean
    and healing well. The surgeon who performed the operation is not available for consultation. The
    operative report states that the laparoscopic cholecystectomy was uneventful and the surgeon
    was able to achieve the critical view of safety before dividing the cystic duct.

    Questions:

    1. What is the differential diagnosis? What is the most likely diagnosis?

    answer

    a. post laparascopic cholycystectomy Biloma obstructing extrahepatic ducts


    b. post cholecystectomy bile leak
    c. stone failed from cyctic duct to CBD
    d. Righ Hepatic Duct or CBD injury

    2. What are the priorities in caring for this patient?

    Answer

    a. start giving antibiotics


    b. iv fluids
    c. pain control
    d. do CBC , LFT including bilirubin level and type
    e. do imagine for the abdomen : US/CT or MRI
    3. What tests can you use to make the diagnosis? What tests can you use to evaluate the
    anatomic basis of the diagnosis?

    Answer

    a. do CBC , LFT including bilirubin level and type


    b. do imagine for the abdomen : US/CT or MRI
    c. MRCP or cholangiogram to evaluate the site of obstruction
    4. What is the “critical view of safety” in laparoscopic cholecystectomy?
    Answer

    The critical view of safety in laparoscopic cholecystectomy is making sure that


    there is two tubal structures which are entering to the gallbladder (Cystic duct and
    cystic are artery)

    5. Once the patient is stable, how would you care for this injury?

    Answer

    a. insert ultrasound guided percutaneous drain tube


    b. do ERCP
    6. If the injury were more severe, how would you care for it?

    Answer

    Where there is severe injury to the extrahepatic ducts post laparoscopic cholecystectomy

    I will do open laparotomy and CBD exploration

    7. What would you do in a resource-poor setting if advanced endoscopic modalities were


    not available? Discuss various options.

    answer

    a. US guided percutaneous drain insertion


    b. open laparotomy and insertion of T-tube
    c. open laparotomy for CBD exploration with intraoperative cholangiogram

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