![The patient was then admitted to the General Surgery ward and necessary
haematological and radiological investigations were carried out. An outside
CE CT W/A [12/7/24] showed asymmetric thick GB wall ( thickness ~2.6 cm. )
with Loss of fat plane with adjacent liver, Periportal lymphadenopathy.`
USG W/A done in this hospital [16/7/24]showed partially contracted GB with ill-
defined outline. Lumen filled with sludge and two calculi: one 1.5 cm calculus in
lumen and another 1.6 cm calculus in neck. Diffusely thickened edematous wall
measuring 2.7 cm; features suggesting of GB empyema.
His tumor marker reports were: CEA 18.51ng/ml. LDH 359 U/l. CA 19-9 value is
10.32 for which an oncologists opinion was taken who advised MRCP.
MRCP done on 20.7.24 revealed markedly thickened and oedematous GB wall
with partially contracted lumen. Two calculus noted: one in fundus and one at the
neck. The wall of the hepatic aspect appears sloughed off. Pericholecystic fat
stranding and fluid collection seen.](https://image.slidesharecdn.com/adenocagb-241110082943-b012cfa5/85/AdenoCA-Gg-by-dr-souparno-mandal-pgt-2nd-year-jimsh-5-320.jpg)
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AdenoCA Gg by dr souparno mandal pgt 2nd year jimsh
- 1. GENERAL SURGERY Unit 1 A case presentation on Adeno Carcinoma Of Gall Bladder
- 2. PATIENT PARTICULARS Name : Mr. Jakir Husen Age: 36 years Sex: Male Religion: Islam Occupation: Tailor Address: Uttar Dinajpur Date of admission: 29/07/2024 Date of Examination: 15/09/24 Marital Status: Married Bed Number : Male Surgery Ward 1: Bed 9
- 3. Pain right upper abdomen for 1 month Fever 20 days Vomiting 20 days CHIEF COMPLAINTS
- 4. The patient was apparently well 1 month back when he started having pain right upper abdomen which was insidious in onset, gradually progressive, colicky in nature, aggravated with food and relieved on medication. There is no history of radiation of pain. History of fever 20 days back. It was on and off over the period of last two weeks. The fever was not associated with cough and sore throat. The fever was intermittent in nature. There was history of vomiting 3- 4 episodes. The vomitus was non foul smelling, non-projectile and contained food particles. No history of weight loss, No history of yellowish discoloration of skin and eyes, clay/ black colour stool ,constipation,burning micturition or altered bowel habits. He has no known comorbidities. No surgical history. HISTORY OF PRESENT ILLNESS
- 5. The patient was then admitted to the General Surgery ward and necessary haematological and radiological investigations were carried out. An outside CE CT W/A [12/7/24] showed asymmetric thick GB wall ( thickness ~2.6 cm. ) with Loss of fat plane with adjacent liver, Periportal lymphadenopathy.` USG W/A done in this hospital [16/7/24]showed partially contracted GB with ill- defined outline. Lumen filled with sludge and two calculi: one 1.5 cm calculus in lumen and another 1.6 cm calculus in neck. Diffusely thickened edematous wall measuring 2.7 cm; features suggesting of GB empyema. His tumor marker reports were: CEA 18.51ng/ml. LDH 359 U/l. CA 19-9 value is 10.32 for which an oncologists opinion was taken who advised MRCP. MRCP done on 20.7.24 revealed markedly thickened and oedematous GB wall with partially contracted lumen. Two calculus noted: one in fundus and one at the neck. The wall of the hepatic aspect appears sloughed off. Pericholecystic fat stranding and fluid collection seen.
- 6. After PAC ,Open cholecystectomy was done on 31/07/2024 under GA . Intra op GB was found to be adhered densely with omentum. Also a part of transverse colon was adhered to the anterior part of GB. GB appeared to be adhered, edematous, indurated and grossly adhered to liver bed. Pus discharge from GB when tried to manipulate. Suction done for pus and stones identified and removed by fundus first approach with help of Desjardins forceps. Since the GB was friable it had to be removed in fragments. Since Calots triangle was frozen cystic duct and CBD could not be differentiated. So choledochoduodenostomy had to be done for drainage of bile. Post op the patient was shifted to SICU. On POD-1, one unit PRBC was transfused (Hb 8.0). Drain output was 950 ml (bilious) and from next day severe bile soakage at drain site and drain output was minimal(10-15ml) till POD 3. On the 4th post operative day 4 units of FFP was transfused due to low albumin(2.7). The patient was then kept NPO and required KCl for hypokalemia.
- 7. Eventually, the patient was started on TPN and NG tube drainage was initiated. From POD 5-7 since the abdomen was tense and there was minimal drain output and severe soakage (bilious) around drain site USG W/A done on 08/08/24 which showed multiple septated collection in gallbladder fossa region, likely residual gallbladder wall. From POD 6 potassium and Hyperglycemia correction was initiated. The HPE report following the surgery showed Adenosquamous carcinoma of gall bladder. The patient was taken up for Exploratory laparotomy with peritoneal washing and feeding jejunostomy with omental patch repair was done on 14/08/2024. The patient had a paracolic drain on the right side and a pelvic drain. The patient started having hyponatremia eventually which was corrected. FJ feeding was started on 20.8.24. Pelvic drain was omitted on 22.8.24. The patient was shifted to ward on 3/9/24. He was discharged on 17.9.24 with paracolic drain in situ.
- 8. PAST ILLNESS Patient was admitted with similar complains on 15/7/24 and discharged on 26/7/24. During his stay here he was investigated, oncology opinion was taken and MRCP was done. No history of Diabetes Mellitus, Thyroid disorders, hypertension, epilepsy.
- 9. PERSONAL HISTORY Bladder: No burning micturition or increased frequency. Bowel: No irregularities. Sleep: Adequate. Appetite: Reduced. Vices: None. Allergies: Not allergic to any known food or drug allergen. Diet: Non vegetarian diet.
- 10. FAMILY HISTORY Father is alive and has T2DM. Mother is alive and has HTN. Maternal lineage does not have significant carcinoma history.
- 11. OTHER SYSTEM EXAMINATION CVS: S1 and S2 heard. No added sound. RESPIRATORY SYSTEM: VBS heard bilaterally, no additional sounds heard CNS - no abnormality detected.
- 12. GENERAL SURVEY Performance state: ECOG Scale - 4 Mental status : Patient is Alert, conscious, cooperative, oriented to time, place and person Built : Thin Nutrition : poorly nourished. Facies: Hepatic facies Decubitus : of patients choice Hydration: Tongue moist Pallor: Present. Icterus, Cyanosis and Clubbing are absent. Lymph nodes: Not palpable. Oedema or dehydration absent Cervical lymph node: not palpable Neck veins- not engorged Vital signs are within normal limits.
- 13. INSPECTION LOCAL EXAMINATION : PER ABDOMEN Shape of abdomen: Scaphoid Position of umbilicus: Central Movements of abdomen: Respiratory Skin over the abdomen: Scar- 1)midline scar extending from xiphysternum to. 2)Kochers incision right subcostal No obvious swelling. Hernial sites: No expansile impulse on cough. External genitalia: No abnormalities noted.
- 14. PALPATION Superficial palpation Temperature: Not raised Tenderness: Non tender Any muscle guard: Absent Any swelling: Absent Deep palpation: No mass Liver: Not palpable Spleen: Not palpable Kidneys: Non ballotable Fluid thrill: Absent
- 15. PERCUSSION & Auscultation C. Percussion: General note over abdomen: Tympanic Shifting dullness: Absent Upper border of liver dullness: 5th intercostal space Upper border of splenic dullness: 9th intercostal space D. Auscultation: Bowel sounds: Present over all four quadrants Any added sound: none
- 16. This is a case of a 36 y/o male who presented to the OPD with complaints of pain abdomen associated with fever and vomitingfor the last 30 days on 15/7/24. Outside report of CT, MRI and tumor markers suggestive of suspected case of Carcinoma GB, suspected case of EMPYEMA of gallbladder, GB wall was taken approx 2.6 cm, tumour marker were not raised. Oncology opinion was taken and MRCP was advised. MRCP report showed empyema of GB The patient after discharge, came back 3 days later on 29/7/24 and was taken up for Open cholecystectomy with choledochoduodenostomy was done. An exploratory laparotomy was planned and carried out along with omental patch repair and feeding jejunostomy. The biopsy from the previous surgery came out to be adenosquamous carcinoma of Gallbladder. SUMMARY
- 17. THANK YOU