CHOLELITHIASIS

CHOLELITHIASI
S
NCM 116 RLE
Cholelithiasis
Cholelithiasis involves the presence of gallstones, which are concretions
that form in the biliary tract, usually in the gallbladder.
Choledocholithiasis refers to the presence of one or more gallstones in

the common bile duct (CBD).
Gallstones are hardened deposits of digestive fluid that can form in your
gallbladder. Your gallbladder is a small, pear-shaped organ on the right side
of your abdomen, just beneath your liver. The gallbladder holds a digestive
fluid called bile that's released into your small intestine.
Cholelithiasis
Gallstones range in size from as small as a grain of sand to as large as a
golf ball. Some people develop just one gallstone, while others develop
many gallstones at the same time.

Types
● Cholesterol gallstones – the most common type, thought to form
in supersaturated bile
● Pigment gallstones – formed mainly of unconjugated pigments in
bile precipitate
● Mixed types – with characteristics of pigment and cholesterol
stones.
Clinical Manifestation
● Pain in your upper belly, often on the right, just under your ribs
● Pain in your right shoulder or back
● An upset stomach
● Nausea and Vomiting
● Other digestive problems, including indigestion, heartburn, and
gas
● Episodic (commonly after a high-fat meal), cramping pain in
the right upper abdominal quadrant or the epigastrium,
possibly radiating to the back near the right scapular tip (i.e.
biliary colic)
● Nausea and vomiting
● Fat intolerance
● Fever and leukocytosis
● Signs and symptoms of jaundice
● Belly pain that lasts several hours
● Fever and chills
● Yellow skin or eyes
● Dark urine and light-colored stool
Signs of serious infection and inflammation
Need to rush in the hospital

Causes
● There’s too much cholesterol in your bile. Your body needs bile for
digestion. It usually dissolves cholesterol. But when it can’t do that, the

extra cholesterol might form stones.
● There’s too much bilirubin in your bile. Conditions like cirrhosis, infections,
and blood disorders can cause your liver to make too much bilirubin.
● Your gallbladder doesn’t empty all the way. This can make your bile very
concentrated.
Risk Factor
● Have a family history of them
● Are a woman
● Are over age 40
● Are obese
● Have a diet high in fat and cholesterol but low in fiber
● Don’t get much exercise
● Use birth control pills or hormone replacement therapy
● Are pregnant
● Have diabetes
● Lose a lot of weight in a short time
● Are fasting
Diagnostic Examination
● Abdominal x-ray. If gallbladder disease is suspected, an abdominal x-ray may be
obtained to exclude other causes of symptoms.
● Ultrasonography. Ultrasonography has replaced cholecystography as the diagnostic
procedure of choice because it is rapid and accurate and can be used in patients with
liver dysfunction and jaundice.
● Endoscopic retrograde cholangiopancreatography (ERCP). ERCP visualizes the biliary
tree after insertion of the endoscope, down the esophagus to the duodenum, cannulation
of the common bile duct and the pancreatic ducts, injection of the contrast medium.
● Hepatic biliary iminodiacetic acid (HIDA) scan. HIDA scan detects obstruction of the
cystic duct.
● Magnetic resonance cholangiopancreatography. This scan can detect gallstones,
choledocholithiasis, masses, biliary stricture, and dilation.
● Abdominal computed tomography (CT) scan. Abdominal CT scan may detect stones in
the gallbladder.
Nursing Diagnoses
● Acute pain related to surgical incision.
● Impaired gas exchange related to high abdominal surgical
incision.
● Impaired skin integrity related to altered biliary drainage
after surgical intervention.
● Imbalanced nutrition, less than body requirements, related
to inadequate bile secretion.
Nursing Intervention
● Lung exercises. Before surgery, teach the patient to cough, deep breathe,
expectorate, and perform leg exercises that are necessary after surgery.
● Patient education. Explain the procedures that will be performed before, during,
and after surgery to help ease the patient’s anxiety and to help ensure his
cooperation.
● Post surgery monitoring. After surgery, monitor the patient’s vital signs for
signs of bleeding, infection, or atelectasis.
● Incision site care. Evaluate the incision site for bleeding; serosanguinous
drainage is common for the first 24 to 48 hours if the patient has a wound drain.
● T-tube care. After a choledochostomy, a T-tube drain is placed in the duct and
attached to a drainage bag, so make sure that the drainage tube has no kinks and
check that the connection tube from the T-tube is well secured to the patient to
prevent dislodgement.
Nursing Intervention
● T-tube drainage monitoring. Measure and record T-tube
drainage daily, which has a normal amount of 200 to 300 ml.
● I&O monitoring. Monitor the patient’s intake and output
● Pain management. Evaluate the location, duration, and character
of the pain, and administer adequate pain medications, especially
before activities that increase pain
Medical Management
● Ursodeoxycholic acid is administered to dissolve gallstones. It
is effective in dissolving about 60% of radiolucent gallstones.
Pigment gallstones cannot be dissolves and must be excised.
● Nonsurgical removal, such as lithotripsy or extracorporeal
shock wave therapy, may be implemented.
Surgical Management
Surgical treatment may be ordered.
Laparoscopic cholecystectomy (usually outpatient surgery) is performed

through a small incision made through the abdominal wall in the
umbilicus.
● Assess incision sites for infection. Instruct the client to notify the
health care provider if loss of appetite, vomiting, pain, abdominal
distention, or fever occur.
● Advise the client that he will need assistance at home for 2 to 3
days.
Surgical Management
Laparoscopic cholecystectomy. This is the most common surgery for gallstones. Your
doctor passes a narrow tube called a laparoscope into your belly through a small cut. It
holds instruments, a light, and a camera. They take out your gallbladder through another
small cut. You’ll usually go home the same day.
Open cholecystectomy. Your doctor makes bigger cuts in your belly to remove your
gallbladder. You’ll stay in the hospital for a few days afterward.
If gallstones are in your bile ducts, your doctor may use ERCP to find and remove them
before or during surgery.

Surgical Management
Cholecystectomy is removal of the gallbladder after ligation of the cystic
duct and artery. Inform the client that a T-tube will be inserted to drain
blood; serosanguineous fluids, and bile and that the T-tube must be taped
below the incision
Choledochostomy is an incision into the common bile duct for calculi removal.
Cholecystostomy is the surgical opening of the gallbladder for removal of

stones, bile, or pus, after which a drainage tube is placed.
Complication
● Inflammation of the gallbladder. A gallstone that becomes lodged in the neck of the gallbladder can
cause inflammation of the gallbladder (cholecystitis). Cholecystitis can cause severe pain and fever.
● Blockage of the common bile duct. Gallstones can block the tubes (ducts) through which bile flows
from your gallbladder or liver to your small intestine. Severe pain, jaundice and bile duct infection can
result.
● Blockage of the pancreatic duct. The pancreatic duct is a tube that runs from the pancreas and
connects to the common bile duct just before entering the duodenum. Pancreatic juices, which aid in
digestion, flow through the pancreatic duct.
A gallstone can cause a blockage in the pancreatic duct, which can lead to inflammation of the pancreas
(pancreatitis). Pancreatitis causes intense, constant abdominal pain and usually requires hospitalization.
● Gallbladder cancer. People with a history of gallstones have an increased risk of gallbladder cancer.
But gallbladder cancer is very rare, so even though the risk of cancer is elevated, the likelihood of
gallbladder cancer is still very small.
Prevention
● Don't skip meals. Try to stick to your usual meal times each day. Skipping meals or
fasting can increase the risk of gallstones.

● Lose weight slowly. If you need to lose weight, go slow. Rapid weight loss can increase
the risk of gallstones. Aim to lose 1 or 2 pounds (about 0.5 to 1 kilogram) a week.
● Eat more high-fiber foods. Include more fiber-rich foods in your diet, such as
fruits, vegetables and whole grains.

● Maintain a healthy weight. Obesity and being overweight increase the risk of
gallstones. Work to achieve a healthy weight by reducing the number of calories you
eat and increasing the amount of physical activity you get. Once you achieve a healthy
weight, work to maintain that weight by continuing your healthy diet and continuing to
exercise.

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CHOLELITHIASI

Choledocholithiasis refers to the presence of one or more gallstones in

many gallstones at the same time.

Signs of serious infection and inflammation

Need to rush in the hospital

digestion. It usually dissolves cholesterol. But when it can’t do that, the

● Are over age 40

● Have a diet high in fat and cholesterol but low in fiber

● Don’t get much exercise

● Use birth control pills or hormone replacement therapy

● Lose a lot of weight in a short time

Laparoscopic cholecystectomy (usually outpatient surgery) is performed

gallbladder. You’ll stay in the hospital for a few days afterward.

before or during surgery.

Cholecystostomy is the surgical opening of the gallbladder for removal of

fasting can increase the risk of gallstones.

fruits, vegetables and whole grains.

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