(Disclaimer: This article is for scientific use only. To protect patient privacy, the relevant information in the following content has been processed)
Abstract: The patient, Uncle Li, 45 years old, had no obvious cause of right upper abdominal pain for 4 days 1 month ago, with paroxysmal vague pain, accompanied by acid reflux and belching symptoms, and the above symptoms still appeared after treatment, aggravated after eating, with back support and distension, combined with CT and MRCP examination, can be diagnosed as common bile duct stones, after surgery and drug treatment, the condition is basically stable, the right upper abdominal pain symptoms disappeared.
Basic information】Male, 45 years old
Disease Type】Choledocholithiasis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of consultation】November 2020
Treatment plan】Surgical treatment (endoscopic retrograde cholangiopancreatography for stone extraction) + oral medication (ursodeoxycholic acid capsule) + intravenous infusion (cefoperazone sodium sulbactam sodium for injection)
Treatment period】5 days of hospitalization and review 1 week after discharge
Treatment effect】The condition was basically stable, and the right upper abdominal pain disappeared.
I. Initial consultation
When we first saw the patient, he presented an acute face and was mentally available. He was discharged from the hospital after anti-infection treatment (details unknown). 1 week ago, he developed the above symptoms again, which were aggravated after eating, with a feeling of back support and distension, and were not accompanied by fever or nausea. Physical examination of the patient showed right upper abdominal pressure pain without rebound pain and positive Murphy’s sign, accompanied by percussion pain in the liver area. A CT scan of the hepatobiliary, pancreatic and spleen showed a round-like high-density foci with a diameter of 0.9 cm in the common bile duct travel area.
II. Treatment history
According to the patient’s physical condition, after discussing with the patient and his family, we decided to treat him with endoscopic retrograde cholangiopancreatography to retrieve the stone. On the first day of admission, i.e. before the operation, coagulation and antibiotic allergy tests were given, and the preoperative examination criteria were met. On the second day of admission, the patient was treated with retrograde cholangiopancreatography under general anesthesia, and all the common bile duct stones were successfully removed during the operation, and after the operation, the patient was given intravenous cefoperazone sodium sulbactam for anti-infection treatment, while the nasobiliary drainage tube was placed outside the body and fasting treatment was given. On the first day after surgery, that is, the third day of admission, the drainage tube was open, the drainage fluid was 500mL, and there were no obvious signs of infection, and liquid food was given. On postoperative day 4, that is, day 5 of admission, the drainage fluid was <50mL, and the drainage tube was removed. The patient's right upper abdominal pain disappeared and his condition was more stable, so he was discharged from the hospital. If there is any discomfort, consult the doctor at any time.
III. Treatment effect
When the patient was treated by endoscopic retrograde cholangiopancreatography, the anesthesia effect was good and no uncomfortable symptoms appeared, and the procedure was relatively smooth. On the fifth day of admission, the patient’s vital signs were stable, the right upper abdominal pain did not recur, the drainage fluid was clear, and the patient was discharged from the hospital.
IV. Precautions
After systematic treatment, the patient’s right upper abdominal pain disappeared and all the stones were removed, I felt very relieved, but the following precautions still existed.
1. the patient was discharged from the hospital on an easily digestible soft diet, such as noodles, rice porridge, etc., and could gradually resume a normal diet after 1 week.
2, diet patients should choose low-fat, high-fiber food foods, such as lean meat, celery, leeks, etc., which will not increase the digestive burden of the gastrointestinal tract, but also promote intestinal peristalsis.
3. Patients need to go to the hospital to recheck blood amylase within 1 week after discharge, and go to the hospital promptly if there are uncomfortable symptoms.
V. Personal insight
Choledocholithiasis is a common disease of the biliary tract. For the patient in this case, the transendoscopic retrograde cholangiopancreatography for stone extraction is a minimally invasive treatment modality, and the patient recovered relatively well after the operation without leaving more serious sequelae, which is the preferred surgical modality for patients with choledocholithiasis. After discharge, patients should seek medical attention promptly to inhibit further development of the disease if abdominal pain, chills, high fever, jaundice and other uncomfortable symptoms occur again.