Cholecystectomy - Nursing Case Study
Pathophysiology
• Primary mechanism: Cholecystectomy, the surgical removal of the gallbladder, is typically performed to treat gallstones. Gallstones form when substances in bile (cholesterol, bilirubin) harden into small, pebble-like substances. They can cause blockage in the bile ducts leading to inflammation and infection of the gallbladder (cholecystitis) and bile ducts (cholangitis).
• Secondary mechanism: Once gallstones block the bile ducts, bile can no longer flow into the intestine. This leads to the buildup of bile in the gallbladder causing pressure, pain, and potential rupture of the gallbladder. Without treatment, this can lead to serious infections and life-threatening conditions like sepsis.
• Key complication: Postcholecystectomy syndrome (PCS) is a potential complication following surgery. This includes persistent abdominal pain, indigestion, and diarrhea. This may be due to remaining gallstones in the bile ducts or changes in bile flow.
Patient Profile
Demographics:
47, female, office worker
History:
• Key past medical history: Obesity, type 2 diabetes, hypertension
• Current medications: Metformin, Lisinopril, Simvastatin
• Allergies: Penicillin
Current Presentation:
• Chief complaint: Intense abdominal pain, especially after eating fatty meals
• Key symptoms: Nausea, vomiting, fever, jaundice, clay-colored stools
• Vital signs: Blood pressure 145/95 mmHg, pulse 110 bpm, respiratory rate 22/min, temperature 101.2 F, oxygen saturation 94% on room air
Section 1
Change in Patient Status:
Two days post-cholecystectomy, the patient reports increased abdominal pain and discomfort. She describes the pain as a severe burning sensation radiating to her back. She also complains of persistent nausea and has vomited twice since morning. On examination, her abdomen is distended, and there is noticeable tenderness in the right upper quadrant. Her vital signs are as follows: Blood pressure 155/100 mmHg, pulse 120 bpm, respiratory rate 26/min, temperature 102.5 F, oxygen saturation 92% on room air.
New Complications:
The patient's elevated temperature, increased heart rate, and low oxygen saturation suggest a possible infection. Furthermore, the severe abdominal pain along with nausea and vomiting could indicate a postoperative complication such as bile leak or bile duct injury, both of which are known complications of cholecystectomy. To further investigate, the physician orders a complete blood count (CBC), liver function tests (LFTs), and an abdominal ultrasound. The CBC reveals a high white blood cell count of 14,000/uL, indicating a possible infection. The LFTs show elevated levels of AST (65 U/L) and ALT (70 U/L), and alkaline phosphatase (ALP) of 280 U/L, suggesting a possible bile duct obstruction or injury. The ultrasound reveals fluid collection around the surgical area, raising concerns for a bile leak. These complications require immediate medical intervention to prevent further deterioration of the patient's condition.
Section 2
Change in Patient Status:
Following the initial intervention, the patient’s condition has not improved significantly. Her abdominal pain remains intense, and she continues to experience persistent nausea. Additionally, she has developed pruritus and her skin and sclera are noted to be icteric. Her vital signs are still unstable: Blood pressure 160/105 mmHg, pulse 125 bpm, respiratory rate 30/min, temperature 103 F, and oxygen saturation 90% on room air. Her discomfort is evident and she appears visibly distressed.
Response to Interventions:
Despite the administration of broad-spectrum antibiotics and pain management, the patient's symptoms have not subsided. The persistent fever, elevated heart rate, and worsening jaundice indicate ongoing infection and possible bile duct obstruction. Given the seriousness of her condition, the healthcare team decides to escalate her care. They administer oxygen therapy to improve her oxygen saturation and prepare her for an endoscopic retrograde cholangiopancreatography (ERCP) to locate and potentially repair the suspected bile duct injury. The patient is also given ursodiol to decrease her bile acid levels, in an attempt to alleviate her pruritus. The patient's deteriorating condition demands a heightened level of clinical reasoning, focusing on managing her symptoms while addressing the root cause of her complications.
Section 3
New Diagnostic Results:
Post ERCP, the patient’s condition continues to worsen. Her blood pressure has further elevated to 170/110 mmHg, heart rate has increased to 135 bpm, respiratory rate to 35/min and her oxygen saturation has decreased to 85% despite being on oxygen therapy. The lab results have also returned more concerning values; her total bilirubin is 6 mg/dL (normal range: 0.1-1.2 mg/dL) indicating significant jaundice, and her liver enzymes are elevated (AST: 210 U/L, ALT: 230 U/L) demonstrating liver damage. Additionally, her WBC count is 18,000 cells/mcL (normal range: 4,500-11,000 cells/mcL), indicating a systemic infection.
The ERCP shows a major bile duct obstruction, which has led to cholangitis - a severe infection of the bile duct system. This explains her persistent fever and elevated white blood cell count. The obstruction has also led to backflow of bile into the liver, causing hepatocellular injury - reflected in her elevated liver enzymes and bilirubin levels. The healthcare team must now decide how best to manage these new findings, considering the severity of her infection, the extent of her liver damage, and the obstruction in the bile duct. The complexity of her case requires careful thought and clinical reasoning to determine the next course of action.
Section 4
New Complications:
As the healthcare team deliberates on the best course of action, the patient's condition deteriorates further. She becomes increasingly restless and agitated, her skin hue deepens to a more noticeable jaundice, and she complains of worsening right upper quadrant pain. Her vital signs reflect a deteriorating condition: blood pressure has spiked to 180/120 mmHg, heart rate is now 145 bpm, and oxygen saturation continues to drop, now at 80% despite increased oxygen therapy.
The healthcare team swiftly administers analgesics for her pain and adjusts her oxygen therapy in an attempt to stabilize her vital signs. However, despite these interventions, the patient's condition does not improve significantly. Meanwhile, her latest lab results return with an even higher total bilirubin level of 8 mg/dL and her liver enzymes continue to rise (AST: 230 U/L, ALT: 250 U/L). These worsening symptoms and lab values suggest the progression of the cholangitis and hepatocellular injury. The team must now consider more aggressive interventions to address the bile duct obstruction and mitigate further liver damage. The escalating complexity of the case presents the healthcare team with the challenging task of balancing aggressive intervention with the patient's capacity to tolerate such measures.
Section 5
Change in patient status:
Despite the healthcare team's best efforts, the patient's status continues to decline. Her restlessness and agitation escalate to confusion and disorientation, suggesting a possible onset of hepatic encephalopathy. The jaundice becomes even more pronounced, her skin now a deep yellow, and she begins to experience bouts of severe nausea and vomiting. The right upper quadrant pain remains unrelieved, and she reports a new symptom - severe itching (pruritus).
Her latest vital signs show her blood pressure has dropped to 90/60 mmHg, indicative of possible septic shock due to infection. Her heart rate has risen further to 160 bpm, and despite maximum oxygen therapy, her oxygen saturation hovers around 75%. Lab results reveal alarming increases in her bilirubin levels now at 12 mg/dL and liver enzymes (AST: 300 U/L, ALT: 350 U/L), indicating continued and significant hepatocellular injury. The healthcare team is now faced with a rapidly deteriorating situation, suggesting the need for emergent intervention to prevent further complications and potential liver failure.