Question

A 58-year-old Native American woman who comes to the emergency room with severe abdominal pain, nausea, and vomiting. She states the pain began several hours ago after a family barbeque. Tests reveal the presence of gallstones blocking her cystic duct. Pt has had similar episodes of pain in the past, usually after a heavy meal. She is 5 feet 5 inches tall and weighs 220 pounds. She says she has lost 12 pounds over the past month by restricting her intake to 750 calories a day.

Identify Problem, Etiology, and science (PES) statement

Answer 1

The patient's chief complaints include - Severe abdominal pain, nausea, vomiting, and pain started after having food.

* Tests shows gallstones blocking her cystic duct.

Problem, Etiology and science statement -

The condition or problem of the patient may be known as BILIARY COLIC (symptomatic cholelithiasis).

It is also known as gallbladder attack or gallstone attack.

Biliary colic or gallstone attack may be defined as when sudden pain occurs due to a gallstone temporarily blocking the cystic duct. The pain occurs in right upper abdomen usually lasts from 15 mins to few hours. It occurs following a heavy meal.

RISK FACTORS -

• Female sex

• Age more than 40 years

• Obesity

• Pregnancy

• Rapid weight loss

• Cirrhosis

•Prolonged fasting, etc.

AETIOLOGY -

The gall stones can be caused as follows -

1) Metabolic causes - Cholesterol is produced from the liver which gives rise to bile acids. When the ratio of cholesterol and bile acids drops down, it may lead to gall stones.

2) Infection - It is most common cause of gall stones formation. The organisms reach the gall bladder and form a focus around cholesterol and bile salts and later which gets precipitated and leads to stone formation.

3) Bile stasis - As a result of bile stasis, gall stones are formed.

4) Haemolytic anaemia

5) Parasitic infestation can cause stone in biliary tree.

6) Abnormal mucus - Gall stones formed due to impairment of bile flow.

SYMPTOMS -

1) Pain in upper right abdomen and which radiates to right shoulder.

2) Nausea and vomiting.

3) Indigestion.

4) Restlessness and sweating, etc.

INVESTIGATION AND DIAGNOSIS -

1) Complete blood profile

2) X -Ray

3) Ultrasonography

4) Ultrasound ( Gold standard)

5) ERCP, i.e Endoscopic retrograde cholangiopancreaticography

MANAGEMENT AND TREATMENT -

* Initial management includes the relief of symptoms and correcting electrolyte and fluid imbalance that may occur with vomiting, so antiemetics like Domeperidone or dimenhydrinate.

* Pain can be treated with NSAIDs like mefenamic acid or paracetamol.

* In biliary colic, the risk of infection is minimal and therefore antibiotics are not required.

* Gallstone removal surgery required. Laproscopic Cholecystectomy is performed. Cholecystectomy is the removal of gallbladder.