CHOLELITHIASIS

Gallstones can cause severe abdominal pain or, you may have no symptoms at all.
Having gallstones, also called cholelithiasis, is a very common problem. It's most common
among women, people older than age 40, and Native Americans.
The gallbladder is a sac that stores a substance called bile, which is produced by the liver.
After meals, the gallbladder contracts and releases bile into the intestines to aid in digestion.
Gallstones occur when one of the substances that make up the bile (usually a waste product
called bilirubin, or cholesterol) becomes too concentrated and forms a hard stone.
Often gallstones just sit in the gallbladder and don't cause problems. But sometimes they block
the exit from the gallbladder, called the cystic duct.
When this occurs, the gallbladder goes into spasms and becomes inflamed, a condition called
cholecystitis.
An episode of cholecystitis may resolve on its own, or it may progress to a more serious
condition involving bacterial infection of the inflamed gallbladder.

Causes of Gallstones
Many different factors can cause gallstones. Some possible causes include:
Excess bilirubin in the bile
Excess cholesterol in the bile
A non-stone-related blockage in the gallbladder that prevents proper emptying
Low bile concentration of a substance called bile salts

Risk Factors
The risk factors for gallstones include:
A family history of gallstones
Taking medications to lower cholesterol levels
Having diabetes
A rapid, large loss of weight
Taking birth control pills or hormone replacement therapy
Being pregnant
Being overweight
Eating a diet rich in fat and cholesterol and without enough fiber

Gallstone Symptoms
It's not uncommon for gallstones to cause no symptoms at all, and to be diagnosed during
screening and testing for some other health problem.
But, in many people, gallstones can cause the symptoms of cholecystitis, including:

Abdominal pain in the right upper part of the abdomen

Back pain, particularly located between your shoulder blades
Pain beneath the right shoulder blade
Pain in those areas which comes on quickly, worsens, and persists for at least 30
minutes, and may even last for a few hours
Fever with chills
Vomiting and nausea
Jaundice (yellowing of the skin and whites of the eyes)
Stools the color of clay
Pain that strikes after eating a fatty meal
Indigestion, bloating, and gas

If you have any of these symptoms, it's possible that gallstones may be to blame, so it's
important to head to your doctor for an exam and to get started on treatment.

Gallstones may also rarely be an indication of gallbladder cancer, so it's best to get the problem
correctly diagnosed right away.

Diagnostic Studies

Biliary ultrasound: Reveals calculi, with gallbladder and/or bile duct distension
(frequently the initial diagnostic procedure).

Oral cholecystography (OCG): Preferred method of visualizing general appearance and

function of gallbladder, including presence of filling defects, structural defects, and/or stone in
ducts/biliary tree. Can be done IV (IVC) when nausea/vomiting prevent oral intake, when the
gallbladder cannot be visualized during OCG, or when symptoms persist following
cholecystectomy. IVC may also be done perioperatively to assess structure and function of
ducts, detect remaining stones after lithotripsy or cholecystectomy, and/or to detect surgical
complications. Dye can also be injected via T-tube drain postoperatively.

Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by

cannulation of the common bile duct through the duodenum.
 Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes
between gallbladder disease and cancer of the pancreas (when jaundice is present); supports
the diagnosis of obstructive jaundice and reveals calculi in ducts.

Cholecystograms (for chronic cholecystitis): Reveals stones in the biliary system.

Note:Contraindicated in acute cholecystitis because patient is too ill to take the dye by mouth.

Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile ducts, and distinguish
between obstructive/nonobstructive jaundice.

Hepatobiliary (HIDA, PIPIDA) scan: May be done to confirm diagnosis of cholecystitis,

especially when barium studies are contraindicated. Scan may be combined with
cholecystokinin injection to demonstrate abnormal gallbladder ejection.

Abdominal x-ray films (multipositional): Radiopaque (calcified) gallstones present in

10%15% of cases; calcification of the wall or enlargement of the gallbladder.

Chest x-ray: Rule out respiratory causes of referred pain.

CBC: Moderate leukocytosis (acute).

Serum bilirubin and amylase: Elevated.

Serum liver enzymesAST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase and 5-
nucleotidase are markedly elevated in biliary obstruction.

Prothrombin levels: Reduced when obstruction to the flow of bile into the intestine
decreases absorption of vitamin K.

Surgery: Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is

performed most frequently through laparoscopic incisions using laser. However, traditional
open cholecystectomy is the treatment of choice for many patients with multiple/large
gallstones (cholelithiasis) either because of acute symptomatology or to prevent recurrence of
stones.
A cholecystectomy consists of excising the gallbladder from the posterior liver wall and ligating
the cystic duct, vein, and artery. The surgeon usually approaches the gallbladder through a right
upper paramedian or upper midline incision if necessary, the common duct may be explored
through this incision. When stones are suspected in the common duct, operative
cholangiography may be performed (if it has not been ordered preoperatively). The surgeon
may dilate the common duct if it is already dilated as a result of a pathologic process. Dilation
facilitates stone removal. The surgeon passes a thin instrument into the duct to collect the
stones, either whole or after crushing them.

After exploring the common duct, the surgeon usually inserts a T-tube to ensure adequate bile
drainage during duct healing (choledochostomy). The T-tube also provides a route for
postoperative cholangiography or stone dissolution, when appropriate.

A conventional open cholecystectomy is indicated when a laparoscopic cholecystectomy does

not allow for retrieval of a stone in the common bile duct and when the clients physique does
not allow access to the gallbladder. Occasionally, when a client is very obese, the gallbladder is
not retrievable via laparoscopic instruments. Further, a surgeon may have difficulty accessing
the gallbladder in an adult with a small frame and may need to perform the conventional open
cholecystectomy.
NURSING CARE PLAN

Nursing Priorities

1. Promote respiratory function.

2. Prevent complications.
3. Provide information about disease, procedure(s), prognosis, and treatment needs

Discharges Goals

1. Ventilation/oxygenation adequate for individual needs.

2. Complications prevented/minimized.
3. Disease process, surgical procedure, prognosis, and therapeutic regimen understood.
4. Plan in place to meet needs after discharge.
 NURSING CARE PLAN

DIAGNOSIS NURSING

Fluid Volume, risk for deficient related to Excessive losses through gastric suction;
vomiting, distension, and gastric hypermotility. Altered coagulation, e.g., reduced
prothrombin, prolonged coagulation time.

DESIRED OUTCOME

Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous
membranes, good skin turgor, capillary refill, individually appropriate urinary output,
absence of vomiting.

NURSING INTERVENTION

Maintain accurate record of I&O, noting output less than intake, increased urine specific
gravity. Assess skin and mucous membranes, peripheral pulses, and capillary refill.
Monitor for signs and symptoms of increased or continued nausea or vomiting,
abdominal cramps, weakness, irregular heart rate, hypoactive or absent bowel sounds,
depressed respirations.
Eliminate noxious sights or smells from environment.
Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.
Use small-gauge needles for injections and apply firm pressure for longer than usual
after venipuncture
Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums,
ecchymosis, petechia, hematemesis or melena.
Keep patient NPO as necessary.
Insert NG tube, connect to suction, and maintain patency as indicated and ordered.
Give adequate fluids as ordered and electrolytes. Vitamin K injection as prescribed.
EVALUATION
After rendering care the patient displays normal vital signs. She had elastic skin turgor and
moist mucous membranes. No signs of internal and external bleeding. Can tolerate taking fluids
orally without vomiting. Intake and output remained balance. Laboratory works became normal
until discharge.
NURSING DIAGNOSIS
Acute pain related to,
Biological injuring agents: obstruction/ductal spasm, inflammatory process, tissue
ischemia/necrosis

As evidence by reports of pain, biliary colic (waves of pain) Facial mask of pain; guarding
behavior.Autonomic responses (changes in BP, pulse).Self-focusing; narrowed focus

DESIRED OUTCOMES

Report pain is relieved/controlled.

Demonstrate use of relaxation skills and diversional activities as indicated for individual
situation.

NURSING INTERVENTION

Observe and document location, severity (010 scale), and character of pain (steady,
intermittent, colicky).
Note response to medication, and report to physician if pain is not being relieved.
Promote bedrest, allowing patient to assume position of comfort.
Control environmental temperature.
Encourage use of relaxation techniques. Provide diversional activities.
Make time to listen to and maintain frequent contact with patient.
Maintain NPO status, insert and/or maintain NG suction as indicated.
Administer medication as prescribed.
EVALUATION
After a nursing intervention rendered, patient verbalized relief or the pain is controlled. Able to
rest and sleep and provide positive outcome. Performing relaxation skills whenever possible
and divert activities.
NURSING DIAGNOSIS

Nutrition: Less Than Body Requirements, Risk for Imbalanced

Risk factors may include

Self-imposed or prescribed dietary restrictions, nausea/vomiting, dyspepsia, pain

Loss of nutrients; impaired fat digestion due to obstruction of bile flow

DESIRED OUTCOME

Report relief of nausea/vomiting.

Demonstrate progression toward desired weight gain or maintain weight as individually
appropriate.

NURSING INTERVENTION

Calculate caloric intake. Keep comments about appetite to a minimum.

Weigh as indicated.
Consult with patient about likes and dislikes, foods that cause distress, and preferred
meal schedule.
Provide a pleasant atmosphere at mealtime; remove noxious stimuli.
Assess for abdominal distension, frequent belching, guarding, reluctance to move.
Ambulate and increase activity as tolerated.
Consult with dietitian or nutritional support team as indicated.
Advance diet as tolerated, usually low-fat, high-fiber. Restrict gas-producing foods
(onions, cabbage, popcorn) and foods or fluids high in fats (butter, fried foods, nuts).
EVALUATION

After giving health teachings and intervention rendered patient shows no signs of
malnutrition, takes adequate amount of calories or nutrients. Patient maintains weight or
displays weight gain on the way to preferred goal, with normalization of laboratory values.
Patient presents understanding of significance of nutrition to healing process and general
health.