Discussion: Teen Case Study Jordan is a 14-year-old middle school student who weighs 275 pounds and is 5’6” tall. Over the past 2 years, he has gained 60 pounds, has begun to withdraw from social activities, and has avoided other students due to bullying from others his age about his weight/appearance. Lately, Jordan has been missing a great deal of school too, particularly on the days he has gym. Jordan’s parents are both average in height and weight. Jordan’s mother says that he just takes after his grandfather William, who “was a husky man, and died of a sudden heart attack at the age of 44.” She says, “We just have fat genes in the family; you can’t do anything about that!” Gallbladder Disease Case Study

Discussion: Teen Case Study Jordan is a 14-year-old middle school student who weighs 275 pounds and is 5’6” tall. Over the past 2 years, he has gained 60 pounds, has begun to withdraw from social activities, and has avoided other students due to bullying from others his age about his weight/appearance. Lately, Jordan has been missing a great deal of school too, particularly on the days he has gym. Jordan’s parents are both average in height and weight. Jordan’s mother says that he just takes after his grandfather William, who “was a husky man, and died of a sudden heart attack at the age of 44.” She says, “We just have fat genes in the family; you can’t do anything about that!” Gallbladder Disease Case Study

Considerations

This patient provides a good history of recurrent upper abdominal pain episodes following meals, consistent with biliary colic. Although she demonstrates minimal tenderness to palpation in her right upper abdomen on physical examination, the elevated leukocyte count and ultrasound findings of gallbladder wall thickening are consistent with acute or chronic cholecystitis. If this patient had a normal WBC count and an ultrasound examination demonstrating stones in the gallbladder and no other abnormalities, the presentation would be consistent with biliary colic, which can be treated by elective cholecystectomy. Because findings in this patient are consistent with cholecystitis, the treatment consists of hospital admission, administration of intravenous antibiotics, and laparoscopic cholecystectomy prior to discharge from the hospital.Gallbladder Disease Case Study

APPROACH TO: Gallstone Disease

DEFINITIONS

BILIARY COLIC: Characterized by waxing and waning, poorly localized postprandial upper abdominal pain radiating to the back and normal laboratory evaluations of liver functions. It is caused by cholecystokinin (CCK)-stimulated gallbladder contraction, following food ingestion. The condition is generally produced by gallstone obstruction at the gallbladder neck or, less commonly, by gallbladder dysfunction.

ACUTE CHOLECYSTITIS: In 95% of patients, acute cholecystitis results from a stone or stones obstructing the cystic duct. Bacterial infection is thought to occur via the lymphatics, with the most commonly found organisms being Escherichia coli, Klebsiella, Proteus, and Streptococcus faecalis. Patients generally present with persistent RUQ pain, with or without fever, gallbladder tenderness, leukocytosis, and often mild, nonspecific elevated liver enzyme levels, which may or may not indicate CBD stones. Treatment includes hospital admission, administration of intravenous fluids, nothing by mouth, antibiotics directed at the organisms just listed, and cholecystectomy during the hospitalization.Gallbladder Disease Case Study

ACALCULOUS CHOLECYSTITIS: Gallbladder inflammation caused by biliary stasis (in 5% of patients with acute cholecystitis) leading to gallbladder distension, venous congestion, and decreased perfusion; it nearly always occurs in patients hospitalized with a critical illness.

CHRONIC CHOLECYSTITIS: Results from repeated bouts of biliary colic and/or acute cholecystitis leading to gallbladder wall inflammation and fibrosis. The patient may present with persistent or recurrent localized RUQ pain without fever or leukocytosis. Sonography may demonstrate a thickened gallbladder wall or a contracted gallbladder.Gallbladder Disease Case Study

CHOLANGITIS: Infection within the bile ducts, most commonly caused by complete or partial obstruction of the bile ducts by gallstones or strictures. The classic Charcot triad (RUQ pain, jaundice, and fever) is seen in only 70% of patients. This condition may lead to life-threatening sepsis and multiple-organ failure. Treatment consists of antibiotic therapy and supportive care; in cases of severe cholangitis, endoscopic decompression of the bile duct by endoscopic retrograde cholangiopan-creatography (ERCP) or surgery is indicated.Gallbladder Disease Case Study

RIGHT UPPER QUADRANT ULTRASONOGRAPHY: Sensitivity of 98% to 99% in identifying gallstones in the gallbladder. The examination is also useful for measuring the diameter of the CBD, which can indicate the possible presence of stones in the CBD (choledocholithiasis). When present, CBD stones are visualized less than 50% of the time with this imaging modality.

BILIARY SCINTIGRAPHY: The study of gallbladder function and biliary patency using an intravenous radiotracer. Normally the liver is visualized, followed by the gallbladder, followed by emptying of the radiotracer into the duodenum. Nonvisualization of the gallbladder in a patient with RUQ pain indicates gallbladder dysfunction caused by acute or chronic cholecystitis.Gallbladder Disease Case Study

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: Endoscopic CBD cannulation and direct injection of contrast material to visualize the duct. An endoscopic sphincterotomy in the duodenum during the procedure may facilitate bile drainage and the clearance of bile duct stones, which is especially useful in treating cholangitis and choledocholithiasis. The procedure requires sedation and may be associated with complication rates of 8% to 10%.Gallbladder Disease Case Study

CLINICAL APPROACH

Pathophysiology

At least 16 million Americans have gallstones, and 800,000 new cases occur each year. Gallstones are categorized as either cholesterol stones or pigmented stones. Cholesterol stones are most common and form as the result of the combined effects of cholesterol supersaturation in the bile and gallbladder dy