CHOLELITHIASIS

(Case Presentation)

Presented by:

Alanguilan, Paula Coroza, Chinkee

Amante, Meleah Cortez, Niel
Azucena, Paul Gensaya, Gretch
Biscocho, Karl Gesmundo, Pamela
Calixihan, Shelly Ona, Nery
Centeno, Zenia Ona, Wyeth Ryan

BSN 3 Group 11
INTRODUCTION

Disorders of the biliary tract and pancreas are common and that gallbladder
disease with gallstones is the most common. Although not all occurrences of
gallbladder inflammation (cholecystitis) are related to gallstones (cholelithiasis),
more than 90% of patients with acute cholecystitis have gallstones.

RATIONALE OF THE STUDY

We chose this case because we wanted to acquire more knowledge about

Cholelithiasis. We wanted to use the knowledge that professionals have acquired
in promoting awareness, prevention, and care needed for patients having the
condition.

SIGNIFICANCE OF THE STUDY

This study will help nursing students by providing information about the
proper management and care for patient with choleliathiasis.
It will also educate the people and vulnerable individuals to seek care in
order to prevent complications.

SCOPE AND LIMITATION

This study is involved with the assessment and care of the client with
cholelithiasis, however, we only had 1 1/2 days to handle the client.

NURSING HEALTH HISTORY

BIOGRAPHIC DATA

Name: Ms. X
Address: 702 Carmelite Road Concepcion, San Pablo City
Birthday: September. 22, 1979
Age: 30 yr/o
Birthplace: San Pablo city
Status: Single
Religion: Catholic
nationality: Filipino
Sex: Female
Attending physician: Dr. Nestor Santiago
Admission Date: Feb. 22,2010
Time: 6:25pm
Admitting doctor: Dr. Chraro Daryl Corpus
Discharge Date: Feb. 26,2010
Time: 3 pm
Final diagnosis: Calculous cholecystitis/cholecystolithiasis
Operation: Laparoscopic cholecystectomy

CHIEF COMPLAINT

The patient was admitted at Community General Hospital on Feb 22, 2010
due to the complaint of epigastric pain and vomiting.

HISTORY OF PRESENT ILLNESS

Few days PTA, patient experienced epigastric pain and vomiting. Patient
sought consultation but few hours PTA, patient was admitted for confinement and
tests were done that confirmed presence of stones in bladder.

PAST HEALTH HISTORY

( +) Hypertension
( - ) Diabetes mellitus
( - ) Thyroid Disease
( - ) Heart Disease
( - ) Asthma
( - ) PTB
( - ) Allergies

PHYSICAL EXAM

BP: 130/80
CR: 99 bpm
RR: 73 bpm
Temp: 36 C
CBG: 138 mg/dL

GENERAL SURVEY

- Conscious, active, awake, not in respiratory distress

HEENT

- Pink Palpebral conjunctiva

- An icteric sclera
- (-) NAD
- (-) TPC
HEART

- A Dynamic Precordium
- Normal Rate
- Regular Rhythm

LUNGS

- Symmetrical Chest Expansion

- (-) Lagging
- (-) Wheezes
- (-) Retractions
- (-) Crackles

ABDOMEN

- Flabby, Non-active bowel sounds

- (-) Tenderness

EXTREMITIES

- Grossly Normal full and equal Pulses

- (-) Edema

Admitting impression: cholelithiasis

PHYSICAL ASSESSMENT

AREA TO ASSESS FINDINGS

INTEGUMENT:
-Skin -skin is intact
-Hair -ecchymosis on right inner arm
-Nails -warts on the neck
-hair colour black, scanty amount
-capillary refill test: returned in 2seconds
-slightly cold to touch skin

HEAD:
-skull &face -skull is normocephalic
-eyes and vision -pupillary size 3
-ears &hearing -symmetric eyes
-nose &sinuses -dry lips and oral mucosa
-mouth &oropharynx
NECK:
-neck muscles -muscle movements of neck normal
-lymph nodes of the neck - non-palpable lymph nodes
-trachea
-thyroid gland

THORAX &LUNGS:
-chest shapes and size -lung sounds clear bilaterally, normal
-breath sounds

CARDIOVASCULAR
&PERIPHERAL VASCULAR
SYSTEMS:
-heart (sounds) -radial pulse 82 beats per minute
-central vessels (carotid arteries -little sweating
&jugular vein) -slightly cold to touch
-peripheral vascular system
(peripheral pulses, veins, and
perfusion)

BREAST AND AXILLA:

-breast size, symmetry -breasts slightly asymmetrical
&contour/shape - nipples dark pink in color
-nipple size, shape, position,
color, discharges, &lesions
-axillary, subclavicular
&supraclavicular lymph nodes

ABDOMEN:
-abdominal contour &symmetry -active bowel sounds auscultated
-bowel sounds -pain during palpation on upper right quadrant
-vascular sounds -slight tenderness
-negative bowel
-(POST-OP) 4incision sites visible on abdomen

MUSCULOSKELETAL:
-muscles -normal bone &muscle movements
-bones -no muscle wasting
-joints -normal ROM of extremities

NEUROLOGIC:
-mental status -patient is anxious of the procedure
-LOC -1hour pre-OP, conscious, alert and responsive
-cranial nerves -30minutes pre-OP, patient
-reflexes -normal reflexes
-motor functions
-sensory functions

GENITOURINARY: -voided 3 times pre-OP

-foley catheter connected during operation and few
hours post-OP

NUTRITION: -NPO prior to surgery

GORDON’S FUNCTIONAL HEALTH ASSESSMENT

CATEGORY FINDINGS
HEALTH PERCEPTION Patient is very much concerned with her health
AND HEALTH condition and as soon as the pain in her abdomen was
MANAGEMENT starting to get worse, she went to the hospital and had
herself checked. Soon, she was diagnosed with
cholelithiasis and she agreed to undergo surgery
(laparoscopic cholecystectomy) under general
anesthesia. Patient is compliant with her current
therapeutic management and she is concerned on how
her GI can function after the surgery and asks about
what foods she should avoid...
NUTRITION AND During hospitalization, particularly prior to surgery,
METABOLISM patient was on NPO diet.
ELIMINATION Patient voided 3 times pre-OP, and she haven’t
defecated for 2 days.
ACTIVITY AND EXERCISE Patient does the regular household chores daily at
home. Her leisure activities are watching television and
listening to the radio. During her hospitalization, she
wasn’t moving as much as she was at home due to the
pain she felt on her abdomen.
COGNITION AND Patient’s mental status is normal and she was
PERCEPTION conscious, alert, and responsive. Patient can answer
questions without hindrances and when asked to point
where she feels the pain, she pointed her upper right
quadrant signifying that her mental status is normal.
Patient can read and write.
SLEEP AND REST During hospitalization, patient wasn’t able to sleep that
well since nurses are checking in on her from time to
time and due to anxiety regarding the procedure that
she was going to undergo.
SELF PERCEPTION AND Patient is a jolly patient and thinks of herself as a
SELF CONCEPT normally functioning human being. But because of the
surgery she had undergone, she is starting to slightly
 think that she might not be able to function normally as
a human.
ROLES AND Patient was close with her parents and also to her in-
RELATIONSHIPS laws. She speaks tagalong and little English.
SEXUALITY AND Patient has no children.
REPRODUCTION

COPING AND STRESS During hospitalization, particularly pre-OP, patient was

TOLERANCE anxious and her mother was there to support and help
her not to be that scared of the procedure. She also
thought that it was for her own good so she managed
her anxiety with little difficulty.
VALUES AND BELIEFS Patient is a Roman Catholic and knows that Go will be
there for her all throughout the hospitalization and
surgery.

LAB RESULTS

URINALYSIS
Type Normal Patient's Significance Initial Medical diagnosis
value actual of the result impression
count
color Varying yellow To screen
degrees the pt's
of yellow urine for
renal or
urinary tract
disease
Transparen Clear turbid To detect May contain RBC
cy substances or WBC, fat or
bacteria and may
reflect renal
infection
Reaction Usually 6.5
acidic
SG 1.005- 1.030
1.035
Sugar (-) (-)
Albumin trace Not Hyperalbuminemia
(-) normal and severe
diarrhea
Pus cells 0-2/hpf 15- Increase Genitourinary tract
20/hpf infection and renal
disease
RBC 0-2/hpf 0-2/hpf
Amurates (-) (+) Not
normal
EP cells (-) (+) Not
normal
mucus (-) (+) Not Genitourinary
threads normal tract infection
Bacteria (-) (+++) Not Genitourinary
normal tract infection

HEMATOLOGY

Type Normal Patient's Significance Initial Medical diagnosis

value actual of the result impression
count
Hemoglobin Female: 129 To determine
120 – the oxygen in
160 the blood
Hematocrit 0.37 – 0.39 This test for
0.47 measuring
the
percentage of
red blood
cells in the
total blood
volume
Total WBC 4 – 10 12.25 To determine increase leukocytosis,
infection or infection and
inflammation cholecystitis

DIFFERENTIAL
COUNT
Neutrophil .50 - .70 0.71 To help Increase stress, acute
diagnose infection
specific
types of
illness that
affect
immune
Lymphocyte .20 - .40 0.19 system decrease Acquired
To determine immunodeficiency
lymphocyte syndrome, aplastic
blood count anemiaand bone
marrow
suppression
0.
Eosinophil 0.1 - 01 To determine
0.0 abnormal
3 blood
differential
 or suspected
specific
diseases

To determine
Basophil 0 – 0.01 0.01 # of
basophils in
peripheral
blood smear

Monocytes 0-0.14 0.08 To help

diagnose an
illness such
as infection
or
inflammatory
disease
Platelet count 150 - adequate
450

PATHOLOGY

Type Normal Patient's Significance Initial Medical

value actual of the result impression diagnosis
count
Marker of
ALT (ALANINE 9 – 52 u/l 48 u/l hepatic
AMINO injury, more
TRANSFERASE) specific of
liver
damage
than AST
ALKP 38 – 126 64 u/l
u/l

Amylase 30- 110 u/l 48 u/l

PATHOLOGY

Type Normal Patient's Significance Initial Medical

value actual count of the result impression diagnosis
Prothrombin 9.8 – 12.7 11.9 sec A protein
time sec produced by
the liver for
clotting of
blood
 Percent
Activity 95.4 %

INR 0.99 INR

Blood Type ¨O¨
Typing To
ABO Positive determine
grouping the ABO
grouping
RH Type To
determine
the RH
factor status

COMPLETE METABOLIC PANEL

Type Normal Patient's Significance of Initial Medical

value actual the result impression diagnosis
count
To determine increase diabetes,
Glucose 74 – 106 114 mg/dl if your blood nephritis
mg/dl glucose level is
within healthy
ranges; to
screen for,
diagnose, and
monitor
hyperglycemia,
hypoglycemia,
diabetes, and
pre-diabetes
To evaluate decrease kidney
CREATININE .7 – 1.2 .6 mg/dl renal function disease
mg/dl

ULTRA SOUND

• The liver is normal in size contour with mild diffuse parenchymal echo
pattern. No discrets parenchymal lesion is seen. The intrahepatic and extra
hepatic bile ducts appear normal.
• Gallbladder is well visualized showing shadowing echogenecity noted in
the neck region. The wall is not thickened. The common bile duct is not
diluted measuring 0.3cm.
• The head, body and visualized tail of the pancreas are normal in size and
contour.
 • There is no disparity in the renal size. The central echo complex in both
side are intact. No renal masses or calculi are seen.
• No abnormal free or located fluid connections are noted. No lithiasis or
masses are seen. The main pancreatic duct is not dilated. The aorta,
periaortic and paracaval areas are unremarkable

Interpretation:
- Mild fatty infiltration of the liver
- Cholelithiasis
- Normal spleen, pancreas and kidney
- Gaseous abdomen

Chest X-ray

Heart shadow and great vessels are normal in size and configuration.
The remainder of the chest structures is unremarkable.

Impression:
Chest radiograph shows
Suspicious opacities in both inner basal lungs
Suspicious pneumonitis, both inner basal lungs

ANATOMY AND PHYSIOLOGY

Liver
 is a vital organ
 it is necessary for survival
 largest gland and the largest internal organ in the human body

 Location
 It is located in the right upper quadrant of the abdominal cavity,
resting just below the diaphragm.
 The liver lies to the right of the stomach and overlies the gallbladder.
 Located behind the ribs in the upper portion of the abdominal cavity.

 Shape
 Triangular shaped
 Irregular hemisphere

 Color
 Pinkish-reddish brown
 Weight
 1800g in men
 1400g in women

 Terminologies
 Falciform Ligament- is a ligament which attaches the liver
to the anterior body wall. It is a broad and thin antero-posterior peritoneal
fold, falciform (Latin "sickle-shaped") in shape, its base being directed
downward and backward, its apex upward and backward.

 Common Hepatic Duct- joins the cystic duct coming from

the gallbladder to form the common bile duct. The duct is usually 6–8cm
length and 6mm in diameter in adults.

 Cystic Duct- is the short duct that joins the gall bladder to
the common bile duct

 Common Bile Duct- is a tube-like anatomic structure in the

human gastrointestinal tract. It is formed by the union of the common
hepatic duct and the cystic duct (from the gall bladder)

 Sphincter of Oddi is a muscular valve that controls the

flow of digestive juices (bile and pancreatic juice) through the ampulla of
Vater into the second part of the duodenum.
  Ampulla of Vater, also known as the hepatopancreatic
ampulla, is formed by the union of the pancreatic duct and the common
bile duct. The ampulla is specifically located at the major duodenal
papilla.

 Functions
1. Circulation of blood
A. Hepatic Portal Veins – drains nutrients from the GI tract
- is a vein in the abdominal cavity that
drains blood from the gastrointestinal
tract and spleen.
B. Hepatic Artery – Rich in oxygenated blood
is a short blood vessel that supplies
oxygenated blood to the liver,
pylorus (a part of the stomach),
duodenum (a part of the small
intestine) and pancreas.

2. Glucose Metabolism

3. Ammonia Conversion

4. Protein & fat Metabolism

5. Vitamin & Iron Storage

6. Drug Metabolism

7. Detoxifies waste products

A. Hepatic cells - Detoxify ingested substance
B. Kupffer cells - Engulf particulate matter(bacteria)

8. Bilirubin Excretion
A. Bilirubin – orange-yellow pigment of bile principally by the
breakdown of hemoglobin in Red Blood Cells
- It is excreted in stool and urine
- It is responsible for the yellow color of bruises, urine,
and the yellow discoloration in jaundice.

9. Bile Formation
A. Bile- yellow to green watery solution containing bile salts, bile
pigment (bilirubin breakdown of hemoglobin), cholesterol,
phospholipids and electrolyte.
- produced by the liver and stored in the gallbladder.
-it receives its color from the bile pigment (bilirubin).
Gall Bladder
 is a small non-vital organ that aids in the digestive process and stores bile
produced in the liver.

 Shape
 Pear shaped, hollow, sac like organ

 Size
 8 cm in length and 4 cm in diameter (when fully
distended)

 Capacity
 30-50ml of bile

 Location
 Inferior surface of the liver
 RUQ/ Rt. Hypochondriac region

 Function
1. Concentrate & stores bile
2. Release bile into the duodenum

 Enterohepatic Circulation
 Refers to the circulation of Biliary
acids from the liver, where they are produced and secreted in the bile, to
the small intestine, where it aids in digestion of fats and other substances,
back to the liver.

CLINICAL DISCUSSION

DEFINITION OF THE DISEASE

Cholelithiasis
 Calculi or gallstones
 Increase prevalence after
40y/o esp.in women
 are crystalline bodies formed
within the body by accretion or concretion of normal or abnormal bile
components.
  Cholelithiasis is the presence
of stones in the gallbladder or bile ducts: chole- means "bile", lithia means
"stone", and -sis means "process".

 2 types of gallstones
1. Pigment stones- from unconjugated pigments in the bile precipitate to form
stones.
- are small, dark stones made of bilirubin and calcium salts
that are found in bile.
2. Cholesterol stones- cholesterol in normal constituent of bile.
- usually green, but are sometimes white or yellow in
color.

RISK FACTORS

 Age
 Obesity
 Females who are over 40 and muliparous
 Use of oral contraceptives, estrogens, and clofibrate
 Diseases including cirrhosis, hemolysis, infectious of the biliary tract,
disease of the gastrointestinal, ileac resection or bypass and DM

PATHOPHYSIOLOGY

AGE Cirrhosis

WOMEN
Hemolysis
OBESITY

Infections of
Disease of the biliary tract
gastrointestinal,
ileac byapss
and DM

Decreased bile acid

synthesis and increased Unconjugated pigments
cholesterol synthesis in in the bile precipitate
liver
 Bile is
supersaturated with
cholesterol

Cholesterol Stones Pigment Stones

Pressure obstruction

Bile Stasis
Decreased in Fat emulsification
• Fat intolerance
• Anorexia
• N/V
• Flatulence, Bloating
• Steatorrhea
Inflammation of the bladder
• Pain (RUQ)
• Fever, leukocytosis
• Murphy’s sign
Biliary obstruction
• Decreased bile to colon
• Acholic stool
• Decreased Vit.K absorption
Increased serum bilirubin
• Jaundice
• Tea-colored urine
Infection
• Cholecystitis
SIGNS AND SYMPTOMS

 Asymptomatic
 Early symptoms are epigastric fullness after eating a fatty meal
 Biliary colic (if stone is blocking cystic of common bile duct), there’s a
steady pain in epigastric or RUQ of abdomen radiating to the back or
right shoulder with N/V, and is noticeable several hours after a heavy
meal
 Jaundice and clay colored stools may occur if there is obstruction of
common bile duct

DIAGNOSTIC TESTS

1. Serum bilirubin: conjugated bilirubin is elevated with bile duct obstruction

2. Increased WBC as with infection and inflammation
3. Increased serum amylase and lipase if obstruction of the common bile duct
has caused pancreatitis
4. Ultrasound of gallbladder: identifies presence of gallstones
5. Other tests may include X-ray of the abdomen
6. Ultrasonography - use of ultrasound is based on reflected sound waves that
can detect calculi of dilated common bile duct
7. Radionuclide imaging or Cholescintigraphy – a radioactive agent is used
intravenously then biliary tract is scanned, and images are obtained
8. Cholecystography – An iodide-containing contrast agent is administered to
the patient and gallbladder fills with the radiopaque substance, which will
appear as shadows on the x-ray film
9. Endoscopic Retrograde Cholangiopancreatography (ERCP) – permits direct
visualization of structures that could once be seen only during laparotomy
10. Percutaneous Transhepatic Cholangiography (PTC) – involves the injection
of dye directly into the biliary tract.

MEDICAL MANAGEMENT
 Major objectives of medical therapy are to reduce the incidence of acute
episodes of gallbladder pain and cholecystitis by supportive and dietray
management and , if possible , to remove the cause by pharmacotherapy,
endoscopic procedures, or surgical intervention.

1. Infusion of a solvent into the gallbladder to dissolve gallstones

2. Stone removal using an instrument with a basket or by ERCP endoscope
3. Extracorporeal shock-wave lithotripsy (repeated shock waves directed at
the gallbladder or common bile duct to fragment the stones),
4. Intracorporeal shock-wave lithotripsy (fragmentation by ultrasound, pulsed
laser, or hydraulic lithotripsy applied through an endoscope directly to the
stones)

SUPPORTIVE AND DIETARY MANAGEMENT

1. Achieve remission with rest, IV, nasogastric suction, analgesia, and

antibiotics
2. Diet immediately after and episode is usually low-fat liquids with high
protein and carbohydrates followed by solid soft foods as tolerated,
avoiding eggs, fatty rich foods, gas-forming vegetables, and alcohol.

PHARMACOLOGIC THERAPY

1. Analgesic agents such as meperidine may be required; avoid morphine

because it increases spasm of the sphincter of Oddi.
2. Ursodeoxycholic acid and chenodeoxycholic acid (chenodiol, or CDCA)
are effective in dissolving primarily cholesterol stones.
3. Long-term follow up and monitoring of liver enzymes

SURGICAL MANAGEMENT

Goal of surgery is to relieve persistent symptoms, remove the cause of

colic, and treat acute cholecystitis.

1. Laparoscopic cholecystectomy – performed through a small incision or

puncture made through the abdominal wall in the umbilicus
2. Cholecystectomy – gallbladder removed after ligation of the cystic duct and
artery
3. Mini – cholecystectomy – gallbladder removed through a 3-4 cm incision
4. Choledochostomy – incision into the common duct for stone removal
5. Cholecystostomy – (surgical or percutaneous) – gallbladder is opened and
the stone, bile, or purulent drainage is removed.