Please, answer all questions with a scholarly response using APA and include 2 scholarly references. Answer both case studies on the same document.

Case Study 3
Gallbladder and Common Duct Stones

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, p. 174 Normal
Total serum bilirubin determination, p. 121 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, p. 1013 +3 (normal: negative)
Liver enzymes test
Serum aspartate aminotransferase (AST), p.
119 46 International units/L (normal: 5-40 International units/L)
Serum alanine aminotransferase (ALT), p.
39 40 International units/L (normal: 5-35 International units/L)
Lactic dehydrogenase (LDH), p. 329 228 units/L (normal: 90-200 units/L)
Alkaline phosphatase (ALP), p. 47 885 units/L (normal: 30-85 units/L)
5′-Nucleotidase, p. 376 2.4 units (normal: 0-1.6 units)
Leucine aminopeptidase (LAP), p. 337 250 units/mL (normal: 75-185 units/mL)
Serum gamma-glutamyl transpeptidase (GGTP), p. 246 250 units/L (normal: 5-27 units/L)
Total serum protein test, p. 424 7.2 g/dL (normal: 6-8 g/dL)
Serum albumin test, p. 424 4.2 g/dL (normal: 3.2-4.5 g/dL)
Prothrombin time (PT) test, p. 434 14.2 seconds (patient); 12.0 seconds (control)
Ultrasound examination of the liver and gallbladder, p. 866 Dilated intrahepatic and extrahepatic bile
ducts; presence of stones within the gallbladder
Endoscopic retrograde cholangiopancreatography (ERCP), p. 605 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?

Case Study 4

A 52-year-old male was admitted to the hospital complaining of severe epigastric pain with radiation to his back. The pain started on the day before admission and was associated with nausea and vomiting. On examination he was found to be dehydrated and to have only mild epigastric midline tenderness and guarding. He denied a recent alcohol debauch. Because of previous symptoms, the patient had undergone an ultrasound of the gallbladder, the results of which were normal.

Studies Results
Routine laboratory studies Within normal limits (WNL) except for the following:
White blood cells (WBCs), p. 526 15,000/mm3 (normal WBC: 5000-10,000/mm3)
Serum amylase test, p. 61 640 International units/L (normal: 56-190 International units/L)
Urine amylase test, p. 909 1240 International units/hour (normal: 3-35 International units/hour)
Serum lipase test, p. 339 240 units/L (normal: 0-110 units/L)
Ultrasound examination of pancreas, p.
887 Edematous and enlarged head of the pancreas
Computed tomography (CT ) scanning of abdomen, p. 1020 Diffusely edematous and enlarged pancreas
Endoscopic retrograde
cholangiopancreatography (ERCP), p. 605 Normal pancreatic duct

Diagnostic Analysis
The diagnosis of pancreatitis was certain in light of the elevation of both the serum and urine amylase levels and also of the serum lipase level. Alcohol and gallstones are the two most common causes of pancreatitis; however, the patient denied drinking alcohol, and previous ultrasound of the gallbladder excluded gallstones. Because cancer of the pancreas also can cause distal pancreatic inflammation, tumor had to be ruled out as a cause of this pancreatic episode. Ultrasonography, which is occasionally inaccurate for pathologic pancreatic conditions, indicated an enlarged head of the pancreas that could be compatible with a tumor. However, CT scanning and ERCP results eliminated the possibility of cancer.
The patient was treated with nasogastric (NG) suction and IV infusions until his gastrointestinal function returned to normal. His pancreatitis was subsequently found to be drug induced (by hydrochlorothiazide). The drug was stopped, and he had no further problems.

Critical Thinking Questions
1. Why was it important to question this patient about binge drinking?
2. What advantage is achieved by obtaining urine amylase levels in addition to serum amylase levels?

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