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

ORDER  HERE A PLAGIARISM-FREE PAPER HERE

He has been told he has “…no willpower, or is weak, and that he needs to change his lifestyle, eat less, and exercise more.” Jordan says “I go for a couple days without eating, but then I get so hungry that I could eat the couch!”
Jordan has recently been diagnosed with gallbladder disease and has symptoms that typically occur after eating that include mild pain in the midepigastric region, radiating to the right upper quadrant of the abdomen and right subscapular area of the body.
You are the nurse assigned to Jordan.
1. What would you include in your initial assessment data based on the scenario provided?
2. What would you teach Jordan based on the Recommended Daily Allowance from choosemyplate.gov (Links to an external site.) discussed in Week 1 and the information provided about gallbladder disease provided in Week 6?
3. Based on your assessment data and the information from the scenario, what might be two high-priority nursing diagnoses to guide Jordan’s plan of care?Gallbladder Disease Case Study

Complications: Complications from gallstone disease include complications involving the gallbladder (acute and chronic cholecystitis) and complications involving the passage of stones from the gallbladder (including pancreatitis, choledocholithiasis, cholangitis, and gallstone ileus).

ANALYSIS

Objectives

1. Know the etiology of gallstone disease and learn the differences among biliary colic, acute cholecystitis, and chronic cholecystitis.

2. Know the basic diagnostic and therapeutic plans for patients with gallstone disease.

3. Learn the complications that can develop from gallstone disease.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 dysfunction. Only a small fraction (15%-20%) of patients with gallstones develop symptoms. Although it is unknown why some patients with gallstones develop symptoms whereas others do not, it is clear that those who develop symptoms are at risk for the subsequent development of complications, including acute and chronic cholecystitis, choledocholithiasis, pancreatitis, and cholangitis.Gallbladder Disease Case Study

Patient Evaluation and Treatment

The evaluation in every patient should consist of a history, a physical examination, a complete blood count, liver function studies, a serum amylase determination, and RUQ ultrasonography (Table 8–1). It is important to differentiate biliary colic from complicated gallstone disease, such as acute or chronic cholecystitis, choledo-cholithiasis, cholangitis, and biliary pancreatitis, because the management varies for these conditions. For example, a patient with choledocholithiasis (CBD stone) may present with symptoms identical to those of biliary colic, but the condition may be differentiated on the basis of an elevation in serum liver enzyme levels and dilation of the CBD by ultrasound. In contrast to patients with biliary colic, who are treated by elective cholecystectomy, patients with choledocholithiasis require in-hospital observation for the development of cholangitis and early endoscopic clearance of CBD stones, in addition to cholecystectomy. A major goal in patient evaluation is to make an accurate diagnosis without using unnecessary imaging and invasive diagnostic studies. Choledocholithiasis should be suspected if the RUQ ultrasound findings include a CBD diameter greater than 5 mm in the presence of elevated liver enzyme levels. Gallstone pancreatitis should be considered in the presence of significantly elevated amylase and lipase values.Gallbladder Disease Case Study

Definitive preoperative diagnosis is difficult as it is often
confused for acute cholecystitis. Gallbladder volvulus can lead
to obstruction of biliary drainage and arterial flow leading to
ischemia, necrosis, perforation and biliary peritonitis. However,
with timely diagnosis and surgical intervention of these
complications can be prevented. Currently the disease mortality
is quite low at roughly 5%
Case Presentation
A 76 year old white female presented with severe right upper
quadrant pain, nausea and emesis. The pain was described
as achy and radiated to the right mid back. The patient’s past
medical history included hypertension, hyperlipidemia, gerd
and irritable bowel syndrome. Her surgical history included a
hysterectomy with bilateral salpingo ophrectomy and repair of
an enterocele. On examination, the patient was tender in the
right upper quadrant without guarding or rebound. Laboratory
values and vital signs showed the following:Gallbladder Disease Case Study
Received: May 13, 2017; Accepted: May 23, 2017; Published: May 30, 2017
Gallbladder Volvulus: A Case Study
and Review of Literature
Abstract
Gallbladder volvulus or gall bladder torsion (GBT) is a relatively rare condition
affecting roughly 1 in 365,520 patients. Only about 300 such cases have been
reported in the literature but the age range is 2 to 100 years old. The first case was
described by Wendel in 1898 in which he described it as a “floating gallbladder.”
It is defined as a rotation where there is a mechanical organo-axial torsion that
occurs along the gallbladders longitudinal axis involving the cystic duct and artery.
But the etiology is still not well known. The condition is overwhelming found in
the geriatric population with 85% of patients being over the age of 60. There is a
predilection for white females as well.
Keywords: Gallbladder volvulus; Gallbladder torsion; Acute cholecystitis; Floating
gallbladder; Chronic cholecystitis; Biliary peritonitis; Laparoscopic cholecystectomy
A significant WBC of 18.8 was noted however the patient was
afebrile. An Ultrasound was performed which showed no
evidence of cholelithiasis (Figure 1) [1]. Biliary “sludge” was
noted without cholecystic fluid or gallbladder wall thickening.
Ultrasound impression was no acute process. A CT of the
abdomen and pelvis was obtained. This showed a moderately
distended gallbladder with pericholecystic fluid consistent with
inflammation (Figures 2 and 3).Gallbladder Disease Case Study
The patient was consented for a laparoscopic cholecystectomy
with intraoperative cholangiogram; possible open
cholecystectomy. Intraoperatively, a floppy/floating gallbladder
was noted without attachment to the liver with the exception
of the cystic artery and cystic duct. The gallbladder was rotated
about its longitudinal axis in a counter clockwise fashion. The
gallbladder appeared necrotic (Figures 4 and 5). Gallbladder Disease Case Study