DC is a 46-year-old female who presents with a 24-hour history of RUQ pain. She states the pain started about 1 hour after a large dinner she had with her family. She has had nausea and on instance of vomiting before presentation.
PMH: Vitals: HTN Temp: 98.8oF Type II DM Wt: 202 lbs Gout Ht: 5 8 DVT Caused by oral BCPs BP: 136/82 HR: 82 bpm
Current Medications: Notable Labs: Lisinopril 10 mg daily WBC: 13,000/mm3 HCTZ 25 mg daily
Total bilirubin: 0.8 mg/dL Allopurinol 100 mg daily Direct bilirubin: 0.6 mg/dL Multivitamin daily Alk Phos: 100 U/L AST: 45 U/L ALT: 30 U/L
Allergies: Latex Codeine Amoxicillin
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PE: Eyes: EOMI
GI:Nondistended, minimal tenderness
Skin:Warm and dry
Neuro: Alert and Oriented Psych:Appropriate mood
Pharmacotherapy for Gastrointestinal and Hepatobiliary Disorders
The most probable diagnosis from the case study is cholelithiasis. It is a chronic recurrent hepatobiliary disorder which presents with defective cholesterol metabolism, bilirubin and bile acids that leading to the formation of gallstones in the common bile duct or hepatic bile duct. The rate of the disease has increased due to factors such as; changes in dietary intake, decline of motor activity, and a decrease in physical load. Risk factors associated with the development of the disease include; gender; it is more common in women, age, genetic predisposition, and race (Littlefield & Lenahan, 2019). Other factors are; losing weight rapidly, DM, obesity, pregnancy, drugs, and hypertriglyceridemia.
There are four stages of gallstone disease; the lithogenic stage in which conditions promote formation of gallstones, asymptomatic state, symptomatic gallstones which are expressed by incidents of biliary colic and lastly, and complicated cholelithiasis (Heuman, 2021). The symptoms and complications are as a result of the effects that occur in the gallbladder or from the stones that leave the gallbladder to embed in the common bile duct. The clinical presentation is a biliary colic that takes place when gallstones accidentally lodge in the cystic duct during gallbladder contraction thus increasing the gallbladder wall tension. On most occasions, the pain resolves between 30 to 90 minutes after relaxation of the gallbladder and the obstruction is relieved. The pain is located in the epigastrium or RUQ which at times radiates to the right scapular tip, it is intermittent and has unpredictable episodes, it begins post-prandial after intake of a fatty meal, is described as dull and intense, and is not alleviated by antacids, emesis, defecation or positional changes(Tanaja J; Lopez RA; Meer JM, 2022). It is also accompanied by bloating, belching, nausea, vomiting, and bloating.
On physical examination, the pain is poorly localized and visceral in origin and is not associated with guarding or rebound tenderness. Fever is not also present. From the case study, some of the factors associated with gallstones formation include;
- Obesity: the patient’s BMI is 30.7kg/m2 which classifies her as being obese. According to (Lee & Jang, (2020), obesity is an essential risk factor for gallstone disease, especially in women. It increases biliary secretion of cholesterol secondary to an increase in HMG-CoA reductase activity.
- Age: gallstone formation and detection rates increase with age according to Lindenmeyer, (2021). Beyond 20 years, the probability of gallstone formation increases with every decade. This is because the cholesterol amount in bile increases with age.
- Gender: according to Lee & Jang, (2020), the female population during their fertile years is two times as likely as men to experience gallstone disease. High levels of estrogen hormone levels as a result of pregnancy or hormonal therapy may elevate the cholesterol levels in bile and decrease gallbladder movement causing gallstone formation.
- Drugs: estrogen containing oral contraceptives increase the occurrence of gallbladder disease in young women, especially because of their use of oral contraceptives during their earlier years.
The primary treatment of gallstones is their removal from the bile ducts or gallbladder. The precipitating factors of the disease including; obesity, hemolytic anemia, and diabetes mellitus should be treated. Pain management with NSAIDs is administered. Medical treatment of cholelithiasis includes litholytic therapy which involves stone dissolution (Gutt et al., 2020) About 30% of patients undergo litholytic therapy which uses drugs containing ursodeoxycholic or chenodeoxycholic acid, a gallstone solubilizing agent. They eliminate bile acid and inhibit cholesterol synthesis in the liver and its release into the bile as well as uptake in the intestines, ultimately leading to decreased bile cholesterol levels and stone dissolution (Gutt et al., 2020). In order to achieve for successful therapy, the following criteria should be met; the size of the stone should not be >1.5cm, the stone should be cholesterol or mixed, the gallbladder’s function should be fully preserved; the common bile duct and cystic duct should be patent and the enterohepatic bile acid circulation has to be functional.
The dosage of the drug is dependent on the body weight; the daily dose of bile acids should be more in obese patients. The duration of treatment is between 6 months to 2 years or more with ultrasound guidance and blood tests done every three months during therapy. Intake of a low cholesterol diet should be encouraged in the course of treatment. However, it is important to note that gallstones may reoccur after successful dissolution. For prevention of recurrence small dose of UDCA is endorsed as it results in a significant decrease in the bile lithogenicity index and hinders recurrence of the gallstones.
I would however recommend surgical intervention for the patient since the gallstones are symptomatic. According to Bloom, (2022), cholecystectomy is the definitive management plan once the once gallstones are symptomatic.
Bloom, A. A. (2022, June 16). Cholecystitis: Practice Essentials, Background, Pathophysiology. Medscape.com; Medscape. https://emedicine.medscape.com/article/171886-overview
Gutt, C., Schläfer, S., & Lammert, F. (2020). The Treatment of Gallstone Disease. Deutsches Ärzteblatt International. https://doi.org/10.3238/arztebl.2020.0148
Heuman, D. M. (2021, October 17). Gallstones (Cholelithiasis): Practice Essentials, Background, Pathophysiology. Medscape.com; Medscape. https://emedicine.medscape.com/article/175667-overview
Jones. (2022, April 13). Gallstones (Cholelithiasis). https://pubmed.ncbi.nlm.nih.gov/29083691/
Lee, D. K., & Jang, S. I. (2020). Pathogenesis and Treatment of Gallbladder Stone. Diseases of the Gallbladder, 85–100. https://doi.org/10.1007/978-981-15-6010-1_8
Lindenmeyer, C. C. (2021, September 21). Cholelithiasis. MSD Manual Professional Edition; MSD Manuals. https://www.msdmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/cholelithiasis
Littlefield, A., & Lenahan, C. (2019). Cholelithiasis: Presentation and Management. Journal of Midwifery & Women’s Health, 64(3), 289–297. https://doi.org/10.1111/jmwh.12959
Tanaja J; Lopez RA; Meer JM. (2022, May). Cholelithiasis. https://pubmed.ncbi.nlm.nih.gov/29262107/