MSN 5600 Diagnosis, Symptom and Illness Management
Gallbladder and Common Duct Stones Case Study
The patient, a 44-year-old mother of seven children, was an obese woman. Two weeks before she was admitted to the hospital, she began to complain of right upper quadrant abdominal pain associated with nausea and vomiting. Two days before admission she noticed that her urine was very dark and her stools were lighter in color. The results of her physical examination revealed she was mildly icteric. Her abdominal examination results indicated mild upper abdominal tenderness and muscle guarding. No other abnormalities were noted during her physical examination.
| Studies | Results |
| Complete blood cell count (CBC), electrolyte, glucose, and blood urea nitrogen (BUN) determinations | Normal |
| Total serum bilirubin determination | 3.8 mg/dL (normal: 0.1-1.0 mg/dL) |
| Indirect fraction | 1.0 mg/dL (normal: 0.2-0.8 mg/dL) |
| Direct fraction | 2.8 mg/dL (normal: 0.1-0.3 mg/dL) |
| Urine bilirubin test | +3 (normal: negative) |
| Liver enzymes test | |
| Serum aspartate aminotransferase (AST) | 46 International units/L (normal: 5-40 International units/L) |
| Serum alanine aminotransferase (ALT) | 40 International units/L (normal: 5-35 International units/L) |
| Lactic dehydrogenase (LDH) | 228 units/L (normal: 90-200 units/L) |
| Alkaline phosphatase (ALP) | 885 units/L (normal: 30-85 units/L) |
| 5′-Nucleotidase | 2.4 units (normal: 0-1.6 units) |
| Leucine aminopeptidase (LAP) | 250 units/mL (normal: 75-185 units/mL) |
| Serum gamma-glutamyl transpeptidase (GGTP) | 250 units/L (normal: 5-27 units/L) |
| Total serum protein test | 7.2 g/dL (normal: 6-8 g/dL) |
| Serum albumin test | 4.2 g/dL (normal: 3.2-4.5 g/dL) |
| Prothrombin time (PT) test | 14.2 seconds (patient); 12.0 seconds (control) |
| Ultrasound examination of the liver and gallbladder | Dilated intrahepatic and extrahepatic bile ducts; presence of stones within the gallbladder |
| Endoscopic retrograde cholangiopancreatography (ERCP) | Dilated common bile duct containing a gallstone |
Diagnostic Analysis
Obstructive jaundice was suspected as the cause of this patient’s complaints because of the increased levels of direct bilirubin, alkaline phosphatase, 5′-nucleotidase, GGTP, and LAP, along with the minimally elevated levels of AST and LDH. The urine bilirubin level corroborated the clinical finding of a direct type of hyperbilirubinemia. The prolonged PT resulted from impaired intestinal absorption of vitamin K and impaired hepatic synthesis of prothrombin and factors VII, IX, and X.
Ultrasound examination of the gallbladder revealed the presence of gallstones; however, it had to be verified that gallstones alone were the cause of the common bile duct obstruction because patients with gallstones may also have a tumor obstructing this duct. The ERCP results indicated that only a gallstone was causing the common bile duct obstruction.
The patient underwent a sphincterotomy (papillotomy) of the ampulla of Vater. Common bile duct stones were removed. Laparoscopic cholecystectomy was then performed. The patient’s postoperative course was uneventful. Her serum bilirubin level returned to normal. She returned to her normal physical activity in 5 days.
Critical Thinking Questions
1. Why was the patient’s urine dark-colored?
2. What is the difference between a direct and an indirect type of hyperbilirubinemia?
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