Clinical Case Study: 43-Year-Old Female with Gallstones

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After studying Module 5: Lecture Materials & Resources and Chapter 23 discuss the following:

Ms. Burton, 48, presents at the clinic complaining of abdominal pain. She is a middle-aged woman, overweight, pale and sweating, with jaundice (yellowish skin and sclerae). Her heart rate is 102 beats/min and BP is 145/98 mm Hg. She describes the pain as “severe” and “steady” over the past night, accompanied by nausea and vomiting. She sits leaning forward and indicates that the pain is in the epigastric region radiating up to the tip of the right shoulder. Ms. Burton’s medical history shows that she has had several episodes of biliary colic (pain caused by gallstones going through the bile duct). She says her current pain is “sort of like that, but it’s lasted longer.” She says her last meal was a seven-cheese pizza the previous night, and that the pain began 3–4 hours after eating. She denies drinking or smoking.

Do any of Ms. Burton’s signs and symptoms suggest that her current problem is related to the biliary system? Why or why not?
Why would pain related to gallstones begin after a high-fat meal?
If Ms. Burton’s current problem is related to obstruction of the biliary ducts, which other signs or symptoms would you expect her to develop?

Sample Solution

Biliary System Involvement

Yes, Ms. Burton’s signs and symptoms strongly suggest involvement of the biliary system. Her history of biliary colic, the timing of the pain after a fatty meal, the location and character of the pain, and the presence of jaundice are all highly suggestive of biliary tract disease.

Why Pain After a High-Fat Meal?

Fat stimulates the gallbladder to contract and release bile into the duodenum. If a gallstone is present, it can obstruct the bile duct, leading to increased pressure and severe pain. This is why fatty meals often trigger biliary colic attacks.

Potential Signs and Symptoms of Biliary Duct Obstruction

If Ms. Burton’s current problem is related to obstruction of the biliary ducts, she may develop additional signs and symptoms, including:

  • Jaundice: This occurs due to the accumulation of bilirubin in the blood, causing yellowing of the skin and eyes.
  • Dark urine: Bilirubin can be excreted in the urine, causing it to darken.
  • Clay-colored stools: Bile is necessary for the digestion and absorption of fats. Obstruction of the biliary tract can lead to decreased bile flow into the intestine, resulting in pale or clay-colored stools.
  • Fever and chills: If the obstruction leads to infection (cholangitis), fever and chills may develop.

Diagnostic Tests

To confirm the diagnosis and determine the best course of treatment, the following tests may be ordered:

  • Liver function tests (LFTs): To assess liver function and identify any abnormalities.
  • Bilirubin level: To measure the level of bilirubin in the blood.
  • Amylase and lipase: To rule out pancreatitis.
  • Ultrasound of the abdomen: To visualize the gallbladder, bile ducts, and liver.
  • Endoscopic retrograde cholangiopancreatography (ERCP): A diagnostic and therapeutic procedure to visualize the bile ducts and potentially remove gallstones.

Management

The management of Ms. Burton’s condition will depend on the specific diagnosis. However, initial management may include:

  • Pain management: Administering pain relievers, such as opioids or NSAIDs.
  • Hydration: Ensuring adequate fluid intake, either orally or intravenously.
  • Anti-emetics: To control nausea and vomiting.
  • If gallstones are confirmed:
    • Medical management: For small stones, medications can be used to dissolve them.
    • Surgical intervention: For larger stones or recurrent attacks, gallbladder removal (cholecystectomy) may be recommended.

It is important to note that this is a general approach, and the specific management plan should be tailored to the individual patient’s clinical presentation and test results

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