12-10-2017 DEPT OF PAEDIATRIC SURGERY • Dr. E VAMSHI KRISHNA CASE PRESENTATION • PG- General surgery BILIARY TRACT • Dr. GANGADHAR ANATOMY • PG- Dept of anatomy • Dr. M SRAVAN KUMAR CASE DISCUSSUION • PG- General surgery
CASE REPORT (PAEDIATRIC SURGERY) DR E VAMSHI KRISHNA 2 ND YR POST GRADUATE GENERAL SURGERY
2yrs old female baby brought to the paediatric surgery OPD by her Mother With c/o abdominal pain since 1 month
• Pt was apparently assymptomatic 1 month back then she developed mild pain in upper abdomen since 1 month - intermittent - colicky type - not associated with vomitings - episodes of lite yellowish colored stools since 10 days • No fever, constipation / diarrhoea / malena
• No h/o cough/ hemoptysis • No respiratory symptoms • No urinary symptoms - urine colour normal
Past history • h/o 3 similar attacks of abdominal pain which was subsided with medication - No h/o jaundice in the past • Not a k/c/o DM/ HTN/ TB/ Asthma/ Epilepsy • No previous surgical history
Birth history • Product of Non consanguineous marriage • Mother Age 26 yrs, G2 P1 L1 • Order of birth : 2 nd baby • Full term , LSCS ( Indication – previous LSCS) • Birth weight = 3.1 kgs • No h/o birth asphyxia Neonatal period • No prolonged period of physiological jaundice
Developmental history • Attained milestones as per age • No regression Vaccination : • Vaccinated regularly as per schedule
Personal history • Diet – mixed • Appetite – normal • Bowel , bladder - regular Family history • No h/o similar complaints in other family members Socio economic status • Lower middle class
GENERAL EXAMINATION • Baby is active, cooperative • Mild - icterus present • No- pallor ,no- clubbing, no- cyanosis, no- lymphadenopathy, no- edema Vitals: • Temp = 98.6 F • PR-96 bpm, regular, rhythmic normal volume. • BP-100/60 mmHg measured on Rt arm in supine position.
Anthropometry • Weight : 10 kgs (50 th percentile) • Height : 84cm ( 50 th percentile) • Head circumference : 47cm ( 50 th percentile) • Abdominal girth : 46cm • Mid arm circumference : 15cm
Examination of abdomen Inspection • Abdomen is flat, no localised fullness • Umbilicus central in position, inverted. • All quadrants are equally moving with respiration, abdomino-thoracic type • No scars, no discharging sinuses, engorged veins, visible pulses, visible peristalisis • No visible mass
Palpation • Mild tenderness present in right hypo chondrium • Vague irregular mass approximately 4 x3 cm palpated in right hypo chondrium, borders are ill defined, • Moving with respiration cranio caudally • Firm in consistency • No hepato spleno megaly • Renal angles not full
Percussion • Liver dull note- 5 th ICS in MCL continued with the mass inferiorly No free fluid in abdomen Auscultation: • Normal bowel sounds heard • Hernial sites- normal Per rectal examination • Normal • Stool colour - normal
• Cardiovascular system : NAD • Respiratory system : NAD • No neurological deficit
PROVISIONAL DIAGNOSIS With history and clinical examination findings • Distended gall bladder • Choledochal cyst • Liver abscess • Retroperineal swelling
INVESTIGATIONS Blood group- A +ve Hb- 11.2 gm% TLC- 6,000 /cu.mm Platelet count: 2.5 lakhs/cumm CUE = WNL BT-2mins 30 sec CT-4mins PT = 14 seconds, APTT = 29 second INR = 1.11
RFT Blood urea- 28mg/dl Creatinine- 0.4mg/dl Uric acid 1.6 mg/dl Calcium 8.5mg/dl Sodium 144meq/litre Potassium 3.5meq/litre Chloride 99meq/litre RBS = 115mg/dl
LFT TSB 2.32 mg/dl DB 1.30 m/dl SGOT 444 IU/L SGPT 56 IU ALP 403 IU Total protiens 4.6 gm/dl Albumin 2.6 gm/dl A/g ratio 1.03 • Sr amylase = • Sr lipase =
HIV-Non reactive HbsAg-Negative HCV-Negative
USG ABDOMEN • 36mm hypoechoeic lesion anterior to portal vein • Dilated IHBDR • S/O Choledochal cyst
CECT ABDOMEN
HEPATO BILIARY SCINTIGRAPHY • Large choledochal cyst involving entire CBD with obstructive pattern of drainage with preserved hepatic function
ECG
FINAL DIAGNOSIS • Choledochal cyst type 1-A
• Planned for surgery: Cyst excision and Roux-en-Y – Hepaticojejunostomy Preoperative preperation: • IV antibiotics : 3 days inj CEFOTAXIM 500mg/IV/BD inj METROGYL 15ml /IV/TID • Inj Vitamin K 2mg/ im given 3 doses • IVF 5% DEXTROSE- 500ml
• Surgery planned : cyst excision and Roux-en-Y – Hepaticojejunostomy • Position: supine • Under general anesthesia • NG tube, foley’s catheter inserted • Incision: right subcostal
INCISION
DISTENDED GALL BLADDER
Tube introduced for inta op cholangiogram
Intra operative cholangiogram
Mobilization of gall bladder from its bed
Cystic duct leading to choledochal cyst
Choledochal cyst opened
Lily’s procedure
Gall bladder is attached to upper ½ of cyst
Distal end of CBD is cannulated
POD - 0 • NBM • IVF – ISOLATE P 1000ml • Inj.CEFOTAXIM 500mg/iv /BD • Inj.AMIKACIN 100mg / iv/ BD • Inj.METROGYL 15ml/iv/TID • Inj.PARACETAMOL 150mg/iv/TID • O2 inhallation- 3lit/min • Ryles tube aspiration
POD - 1 • No fever/ vomittings • PR: 106/min • BP: 100/60 mmHg • NG tube – minimal • Drain site – minimal soakage, bile stained • P/A- soft, no distension no guarding/ rigidity bowel sounds- not present • Input/ output – 1100/ 800ml • Same treatment continued • Chest physiotherapy
POD - 2 • No fever/ vomittings • PR: 108/min • BP: 100/60 mmHg • NG tube – minimal • Drain site – minimal soakage, bile stained • P/A- soft, no distension no guarding/ rigidity bowel sounds- sluggish • Same treatment continued • Chest physiotherapy • ASD – done, wound healthy healing
POD - 3 • No fever/ vomittings • NG tube – scanty • Drain site – minimal soakage • P/A- soft, no distension no guarding/ rigidity bowel sounds- present • Passed flatus • IVFluids- isolate-p 500ml, DNS- 500ml, with Inj.MVI 1amp • Same treatment continued • Chest physiotherapy • ASD – done, wound healthy healing
POD - 4 • No fever/ vomittings • NG tube – nil • Drain site – minimal soakage • P/A- soft, no distension no guarding/ rigidity bowel sounds- present • Passed stools • NG tube, foley’s catheter removed • Sips of oral fluids • Inj. PCM 15mg/IV /SOS • Same treatment continued • Chest physiotherapy • ASD – done, wound healthy healing
POD - 5 • Tolerating sips of oral fluids • No fever/ vomittings • Drain site – minimal soakage • P/A- soft, no distension bowel sounds- present • Passed stools • Liquid diet • Same treatment continued • Chest physiotherapy • ASD – done, wound healthy healing
POD - 6 • Tolerating liquid diet • No fever/ vomittings • Drain site – minimal soakage • P/A- soft, no distension bowel sounds- present • Passed stools • soft diet • Same treatment continued • Chest physiotherapy • CRD shortened • ASD – done, wound healthy healing
POD - 7 • Tolerating liquid diet • No fever/ vomittings • Drain site – minimal soakage • P/A- soft, no distension bowel sounds- present • Passed stools • soft diet • Same treatment continued • Chest physiotherapy • CRD shortened • ASD – done, wound healthy healing
• POD 8 – CRD removed • POD 9 – Alternate sutures removed • POD 10 – All sutures removed wound healthy healing, no gaping, no discharge
Post operative CT ABDOMEN with Oral contrast
• Discharged on POD- 11 • Advised syrup SEPTRAN- 2.5ml /BD (TRIMETHAPRIME 40mg + SUXAMETHAZONE 200mg in 5ml) • Reviewed after 1 week • Next follow up after 3 months
THANK YOU
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