Case Study 12-1: Cholecystectomy
G.L., a 42-year-old obese Caucasian woman, entered the hospital with nausea and vomiting, flatulence and eructation, a fever of 100.5°F, and continuous right upper quadrant and subscapular pain. Examination on admission showed rebound tenderness in the RUQ with a positive Murphy sign. Her skin, nails, and conjunctivae were yellowish, and she complained of frequent clay-colored stools. Her leukocyte count was 16,000. An ERCP and ultrasound of the abdomen suggested many small stones in her gallbladder and possibly the common bile duct. Her diagnosis was cholecystitis with cholelithiasis.
A laparoscopic cholecystectomy was attempted, with an intraoperative cholangiogram and common bile duct exploration. Because of G.L.'s size and some unexpected bleeding, visualization was difficult and the procedure was converted to an open approach. Small stones and granular sludge were irrigated from her common duct, and the gallbladder was removed. She had a T-tube inserted into the duct for bile drainage; this tube was removed on the second postoperative day. She had an NG tube in place before and during the surgery, which was also removed on day two. She was discharged on the fifth postoperative day with a prescription for prn pain medication and a low-fat diet.
Case Study 12-2: Surgical Pathology Report
Gross Description: The specimen is received in formalin labeled "ruptured duodenal diverticula" and consists of enteric tissue measuring approximately 6.3 X 2.8 X 0.7 cm. The serosal surface is markedly dull in appearance and fibrotic. The mucosal surface is hemorrhagic. Representative sections are taken for microscopic examination.
Microscopic Description: Sectioned slide shows segments of duodenal tissues with areas of gangrenous change in the bowel wall, and acute and chronic inflammatory infiltrates. There are chronic and focal acute inflammatory cell infiltrates with hemorrhage in the mesenteric fatty tissue. There are areas of acute inflammatory exudates noted in the fatty tissue. Histopathologic changes are consistent with ruptured duodenal diverticula.
Case Study 12-3: Colonoscopy With Biopsy
S.M., a 24-year-old man, had a recent history of lower abdominal pain with frequent loose mucoid stools. He described symptoms of occasional dysphagia, dyspepsia, nausea, and aphthous ulcers of his tongue and buccal mucosa. A previous barium enema showed some irregularities in the sigmoid and
Case Studies, continued rectal segments of his large bowel. Stool samples for culture, ova, and parasites were negative. His tentative diagnosis was irritable bowel syndrome.
He followed a lactose-free, low-residue diet and took Imodium to reduce intestinal motility. His gastroenterologist recommended a colonoscopy. After a 2-day regimen of soft to clear liquid diet, laxatives, and an enema the morning of the procedure, he reported to the endoscopy unit. He was transported to the procedure room. ECG electrodes, a pulse oximeter sensor, and a blood pressure cuff were applied for monitoring, and an IV was inserted in S.M.'s right arm. An IV bolus of Demerol and a bolus of Versed were given, and S.M. was positioned on his left side. The colonoscope was gently inserted through the anal sphincter and advanced proximally. S.M. was instructed to take a deep breath when the scope approached the splenic flexure and the hepatic flexure to facilitate comfortable passage.
The physician was able to advance past the ileocecal valve, examining the entire length of the colon. Ulcerated granulomatous lesions were seen throughout the colon, with a concentration in the sigmoid segment. Many biopsy specimens were taken. The mucosa of the distal ileum was normal. Pathology examination of the biopsy samples was expected to establish a diagnosis of IBD.
CASE STUDY QUESTIONS
Multiple choice: Select the best answer and write the letter of your choice to the left of each number.
_ 1. Flatulence and eructation represent:
a. regurgitation of chyme b. distention of the esophagus c. passage of gas or air from the GI tract d. muscular movement of the alimentary tract e. sounds heard only by abdominal auscultation
_ 2. Murphy sign is tested for:
a. under the ribs on the left b. near the spleen c. in the lower right abdomen d. under the ribs on the right e. in the lower left abdomen
_ 3. The NG tube is inserted through the _and terminates in the _:
a. nose/stomach b. nostril/gallbladder c. glottis/nephron d. anus/cecum e. Nissen/glottis
_ 4. Enteric tissue is found in the:
a. gallbladder b. stomach c. esophagus d. liver e. intestine
Case Studies, continued
5. The mucosal surface of a digestive organ is the:
a. outer surface b. medulla c. cortex d. inner surface e. central opening
6. Diverticula are:
a. small pouches in the wall of the colon b. communications between two organs c. ducts in the liver d. intestinal obstructions e. polyps in the intestine
7. Dysphagia and dyspepsia are difficulty or pain with:
a. chewing and intestinal motility b. speaking and motility c. swallowing and digestion d. breathing and absorption e. swallowing and nutrition
8. The buccal mucosa is in the:
a. nostril, medial side b. mouth, inside of the cheek c. greater curvature of the stomach d. lesser curvature near the duodenum e. base of the tongue
9. A gastroenterologist is a physician who specializes in study of:
a. respiration and pathology b. mouth and teeth c. stomach, intestines, and related structures d. musculoskeletal system e. nutritional and weight loss diets
10. The splenic and hepatic flexures are bends in the colon near the:
a. liver and splanchnic vein b. common bile duct and biliary tree c. spleen and appendix d. spleen and liver e. mesenteric vessels and liver
11. Intestinal motility refers to:
a. chewing b. peristalsis c. absorption d. antiemetics e. ascites
Case Studies, continued
a. a radiograph of the small intestine b. an endoscopic study of the esophagus c. an upper endoscopy with biopsy d. a type of barium enema e. an endoscopic examination of the large bowel
_ 13. The ileocecal valve is:
a. part of a colonoscope b. at the distal ileum c. near the appendix d. a and b e. b and c
Write the meaning of each of the following abbreviations:
Give the word or words in the case studies with each of the following meanings:
18. pertaining to the first part of the small intestine _
19. pertaining to the membrane that supports the intestine _
20. localized _
21. fluid that escapes from blood vessels as a result of _
22. presence of hidden or microscopic blood _
23. jaundice _
24. drug that treats nausea and vomiting _
25. stones in the gallbladder _
26. endoscopic surgery of the gallbladder _
27. inflammation of the gallbladder _
28. radiographic study of the gallbladder and _
29. ring of muscle that regulates the distal opening _
of the colon
30. surgical excision of tissue for pathology _
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