NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

Figure 7-4: A T-tube cholangiogram, following a common duct exploration, showing free flow of dye into the duodenum.

Case 7.5 Right Upper Quadrant Pain in Pregnancy

A woman who is 6 months pregnant is admitted with symptomatic cholelithiasis.

Q: What is the appropriate management plan? A: Gallstones are present up to 10% of pregnant women and in most cases are asymp- tomatic. Symptomatic cholelithiasis as well as gallstone pancreatitis can be managed nonoperatively in the majority of pregnant patients with hydration and pain management. If the patient has recurrent episodes of pain or an episode of biliary colic, acute cholecystitis, obstructive jaundice, or peritonitis, surgery or ERCP is justifiable. When needed, cholecystectomy is safest during the second trimester. In selected cases, ERCP and sphincterotomy are usually safe. After delivery, the gallblad- der is removed.

Digging Deep

The health of the mother is the most import- ant factor in a fetus’s care. If the mother is sick, the fetus is at risk and can be signifi- cantly affected.

Case 7.6 Right Upper Quadrant Pain with Cholelithiasis and Elevated Amylase A 35-year-old is admitted with symptomatic cholelithiasis and gallstones visible on ultrasound. Blood studies show that there is an elevated amylase. Q: How does this laboratory finding influence management? A: Most patients with an elevated amylase have mild pancreatitis The pancreatitis may result from either edema and inflammation of the distal bile duct and pancreas due to the gall- bladder inflammation or a common duct stone. Usually, the amylase returns to normal quickly, and the patient improves by the next day. Cholecystectomy and operative cholan- giography may then be performed (Fig. 7-5) . SAMPLE