GRAND CASEPRESENTATION

“CHOLEDOCHOLITHIASIS”

BSN III- FGROUP 18

INTRODUCTIONCholedocholithiasis is the presence of gallstones in

the common bile duct. The stone may consist of bile pigments or calcium and cholesterol salts. It has two types: Secondary Common Bile Duct Stones, common bile duct stones originally form in the gallbladder and pass into the common duct. They are then called secondary stones. Primary Common Bile Duct Stones,the stones form in the common duct itself (called primary stones). Primary common duct stones are usually of the brown pigment type and are more likely to cause infection than secondary common duct stones.

Choledocholithiasis is one of the complications of cholelithiasis (gallstones), so the initial step is to confirm the diagnosis of cholelithiasis. Typically patients with cholelithiasis present with pain in the right upper quadrant of the abdomen with the associated symptoms of nausea and vomiting, especially after a fatty meal. The physician can confirm the diagnosis of cholelithiasis with an abdominal ultrasound that shows the ultrasonic shadows of the stones in the gallbladder.

The diagnosis of choledocholithiasis is suggested when the liver function blood test shows an elevation in bilirubin. The diagnosis is confirmed either with a magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. If the patient must have the gallbladder removed for gallstones, the surgeon may choose proceed with the surgery, and obtain a cholangiogram during the surgery. If the cholangiogram shows stone in the bile duct, the surgeon may attempt to treat the problem by flushing the stone into the intestine or retrieve the stone back through the cystic duct.

Stones may form in the bile duct when bile backs up because a duct has narrowed or after the gallbladder has been removed. While stones can frequently pass through the common bile duct into the duodenum, some stones may be too large to pass through the common bile duct and may cause an obstruction. One risk factor for this is duodenal diverticulum. This obstruction leads to elevation in alkaline phosphatase, increase in conjugated bilirubin in the blood and increase in cholesterol in the blood. It can also cause acute pancreatitis and ascending cholangitis.

The reasons why we have chosen this case are:

To be more knowledgeable of the diseaseTo determine the cause and effect of having gallstones in the common bile ductTo determine different ways on how to handle patients with choledocolithiasis

PATIENT’S PROFILE Patient’s Name: Mr. V.M

Date of Birth: Nov. 11, 1979

Place of Birth: Manila

Age: 30 yrs. old

Gender: Male

Religion: Roman Catholic

Nationality: Filipino

Civil Status: Married

Admission Date: February 2, 2010

Admission time: 1:10 pm

Attending Physician: Dr. Garrido

Chief Complaint: Rub Pain

History of past illness:

2 ½ months PTA with epigastric pain, coli not aggravated by food intake

With no presence of jaundice ,no alcholic stools and tea colored urine

No fever – consult with ER, given IV meds HNBB, Ketorolac & Omeprazole

relief – went home and OPD follow up follow up at OPD diagnostic done HBt = with choledecho – taken

Physical AssessmentEYES:Anicteric sclerapink supple neck palpebral conjunctiva

SKIN:No presence of jaundiceNo edemaGenerally uniform skin color except in areas exposed to the sun.Good skin turgorBrowned skinned colorNAILS:Highly vascular and pink fingernail and toenail bed color.Intact epidermisPrompt return of pink color for less than 4 seconds in Capillary refill test.ABDOMEN:FlabbyNormal active bowel soundSoftNo direct and indirect tenderness on all quadrantsNo mass palpated

ANATOMY and PHYSIOLOGY

LIVER

An adult human liver normally weighs between 1.4–1.6 kg (3.1–3.5 lb),[4] and is a soft, pinkish-brown, triangular organ. It is both the largest internal organ (the skin being the largest organ overall) and the largest gland in the human body.

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.

GALLBLADDER

The gallbladder is a hollow organ that sits in a concavity of the liver known as the gallbladder fossa. In adults, the gallbladder measures approximately 8 cm in length and 4 cm in diameter when fully distended. It is divided into three sections: fundus, body, and neck. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct.

The adult human gallbladder stores about 50 millilitres (1.8 imp fl oz; 1.7 US fl oz) of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats in partly digested food.

After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats.

COMMON BILE DUCT

The common bile duct (ductus choledochus) 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). It is later joined by the pancreatic duct to form the ampulla of Vater. There, the two ducts are surrounded by the muscular sphincter of Oddi.

When the sphincter of Oddi is closed, newly synthesized bile from the liver is forced into storage in the gall bladder. When open, the stored and concentrated bile exits into the duodenum. This conduction of bile is the main function of the common bile duct. The hormone cholecystokinin, when stimulated by a fatty meal, promotes bile secretion by increased production of hepatic bile, contraction of the gall bladder, and relaxation of the Sphincter of Oddi.

Several problems can arise within the common bile duct. If clogged by a gallstone, a condition called choledocholithiasis can result. In this clogged state, the duct is especially vulnerable to an infection called ascending cholangitis. Very rare deformities of the common bile duct are cystic dilations (4 cm), choledochoceles (cystic dilation of the ampula of Vater (3-8 cm)), and biliary atresia.

CYSTIC DUCT

Bile can flow in both directions between the gallbladder and the common hepatic duct and the (common) bile duct.

In this way, bile is stored in the gallbladder in between meal times. The hormone cholecystokinin, when stimulated by a fatty meal, promotes bile secretion by increased production of hepatic bile, contraction of the gall bladder, and relaxation of the Sphincter of Oddi.

HEPATIC DUCT

The common hepatic duct is the duct formed by the convergence of the right hepatic duct (which drains bile from the right functional lobe of the liver) and the left hepatic duct (which drains bile from the left functional lobe of the liver). The common hepatic duct then 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.

PATHOPHYSIOLOGYModifiable

Diet (fried,salty &fatty foods)

Obesity

Non modifiableAge (30 yrs. Old above)

Bile is composed of bile salts and very small amount of cholesterol

An imbalance between the bile salt and cholesterol turns bile fluid into sludge.

If worsens, cholesterol crystal form (a condition called Supersaturation) that eventually form gallstones

Secondary common bile duct stones

Bile duct obstruction occurs leads to inflamed gall bladder

Signs and symptoms-intermittent pain in the right upper quadrant in epigastric area-inflammation of the gall bladder

Choledocholithiasis

MEDICAL MANAGEMENT (DOCTOR’S ORDER)

DATE ORDER RATIONALE

February 2, 2010 Please admit to 4N under the service of Dr.Garrido Charity

-For further managements.

Secure consent for admission and management

-To know if the client agrees to undergo management and confinement.

Low salt, low fat diet -Increase salt and fat intake contributes to gall stones formation.

Labs:

HBT,UTZ

- To visualize abnormalities present in the liver, common bile and gall bladder

B1 (Bilirubin 1)

B2 Bilirubin 2)

-Increase bilirubin indicates presence of jaundice and liver damage.

CBC -To know blood components.

Hepatitis Profile -To know whether the patient has history of hepatitis.

Alkaline Phosphatase -Aids in diagnosing liver disorder.

PT

PTT

BT

-Test done to prevent increase blood loss during the surgical procedure.

SGPT

SGOT

-Initial step in detecting liver damage.

CXR PA -To check for cardio pulmonary clearance, if the patient can tolerate surgery.

Attach lab results to chart

-For easy accessibility of the doctor and the whole health care team.

February 3, 2010 Continue low fat / low cholesterol diet

-Increase salt and fat intake contributes to gall stones formation.

For cholecystectomy on Friday

-Removal of gallstones.

Secure consent and needs for procedure

-It is important to know whether the patient has agreed to undergo a certain procedure.

February 4, 2010 For cholecystectomy with possible CBDE

-Removal of gallstone and to locate the gallstone in the bile

duct. Continue low fat, low salt diet

-Increase salt and fat intake contributes to

gall stones formation. February 5, 2010 For cholecystectomy

possibly on Tuesday-Removal of

gallstones February 8, 2010 Still for

cholecystectomy -Removal of

gallstones low fat, low salt diet -Increase salt and fat

intake contributes to

gall stones formation.

For cholecystectomy, CBDE tomorrow

-Removal of gallstone; to locate the gallstone

in the bile duct. Secure consent -It is important to

know whether the patient has agreed to undergo a certain

procedure. NPO post midnight -Preparation prior to

surgery; to empty stomach in preventing vomiting leading to

aspiration Ceftriaxone 2g/IV on call to OR ANST(-)

-Antibiotic for early prevention of infection

Ranitidine 50mg/IV q8

while on NPO -To prevent gastrointestinal

discomfort.

Start hemolysis = D5LR 1L x 8 hrs over on NPO

-For replacement of

fluids and electrolytes.

7:20 pm Anesthesia pre-op medicine

-Preparation prior to surgery.

NPO post midnight -Preparation prior to surgery; to empty stomach in preventing vomiting leading to

aspiration IVF: D5LR 1L x 8 hrs

once on NPO -For replacement of

fluids and electrolytes. Meds:

Nalbuphine 10mg -For pre-op analgesia, supplement to

balanced anesthesia Promethazine 25 mg -Lowers BP, induced

sleep. Temporary

sedation

Ranitidine 50mg IV q 8 once on NPO

-To prevent gastrointestinal

discomfort. Secure the following:

1.) Epidural catheter set # 1

2.)Bupivacaine Isobaric 0.50% 10 ml

amp # 5

-Where anesthetic pre op medicines are injected

.-Anesthetic

Monitor VS before giving premeds, refer

if BP < 90/60

-If the BP is <90/60, Promethazine should not be given and elevate the patient’s feet for 30mins and recheck the BP after

February 9, 2010 For cholecystectomy today

-Removal of

gallstones

February 10, 2010 For cholecystectomy

on Friday -Removal of

gallstones Continue low fat & cholesterol diet

-Increase salt and fat intake contributes to gall stones formation.

LABORATORY RESULTS

Follow-up examination shows the gall bladder measuring 8.4 x 3.3 cms (previously 4.9 x 2.5 cms., December 9,2009). Its wall measures 4.2mm in thickness there is an echogenic structure noted lodged in the proximal cystic duct measuring 8.5mm in diameter at its widest.

The liver is normal in size and echotexture. The intra-hepatic ducts are not dilated. The common bile duct measures 5.2 mm.

The pancreas is normal in size and echotexture. No focal mass noted. The head measures 2.2 x 1.7cms. The body measures 1.2cms while the tail measures 0.9cms in thickness.

IMPRESSION:Choledocolithiasis, probably causing biliary duct

obstruction.Thickened gall bladder wall, beginning cholecystitis is

highly considered.Suggest close monitoring to rule out beginning

Hydrops.Ultrasonically normal liver,pancreas and spleen.

ULTRASOUND OF THE UPPER ABDOMEN:

LABORATORY RESULTSSpecimen: Serum Date: January 29, 2010Examination: Bilirubin

Results:

Normal Values

Patient’s Result

Clinical Significance

Total Bilurubin

3.42 – 20.52 22.35 umol/l Indicates hemolytic anemia

Direct Bilirubin

0 – 8.55 5.55 umol/l In normal range

Indirect Bilurubin

3.42 – 11.97 16.80 umol/l Indicates hepatocellular

damage

Specimen: Blood Date: January 14,2010Examination: Serum

Results:

Normal Values

Patient’s Results

Clinical Significance

SGPT (ALT)

8-35 units 20.0 units In normal range

SGOT (AST)

18-40 units 18.0 units In normal range

ULTRASOUND OF HEPATOBILIARY TREE

Date: December 9, 2009

The liver is normal in size and echo pattern. No focal mass noted. The intrahepatic, extrahepatic as well as common bile ducts measures 4.8mm.

The gall bladder measures 4.9x2.5cms.

Impression:

Ultrasonically normal liver, common bile and gall bladder.

TPR Monitoring Sheet

February 8, 2010

8am 12nn 4pm 8pm 12mn

BP 110/80 120/80 110/70 120/80 120/80

PR 61 60 80 80 78

RR 18 18 20 18 18

Temp 36 36.2 36 36.2 36

February 9, 2010

8am 12nn 4pm 8pm 12mn

BP 120/80 110/80 120/80 120/80 120/80

PR 82 67 65 72 64

RR 20 18 17 20 22

Temp 36 36.7 36.2 36.2 36.2

February 10, 2010

8am 12nn

BP 120/80 130/70

PR 68 87

RR 22 19

Temp 36 .3 36.5

DRUG STUDYBrand Name Action Indication

Zantac

Generic Name:

Ranitidine

Classification:

Gastrointestinal/ Hepatobiliary

drugs

Dosage:

50mg

Preparation:

IV

Frequency:

TID / every 8 hours once NPO

Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits

gastric acid secretion

Used in the management of

various GI disorders such as dyspepsia, gastro-esophageal reflux

(GERD), Prophylaxis of GI

hemorrhage in patients at risk of developing acid aspiration during

general anesthesia

Contraindication Side Effect Nursing Consideration

Hypersensitivity. History of acute pophyria. Long term therapy

Cardiac arrhythmias, bradycardia. Headache, somnolence, fatigue, dizziness, hallucinations, depression, insomnia. Alopecia, rash, erythema multiforme. Nausea, vomiting, abdominal discomfort, diarrhea, constipation pancreatitis.

-Ensure right dosage, route, and client before administering the drug.

-Always monitor the pt for possible manifestations of any adverse effects of the drug

-Monitor heart rate of the patient upon administration of the drug

-Assess for renal and hepatic impairment

Brand Name Action Indication

Xtenda

Generic Name:

Ceftriaxone

Classification:

Antibiotic

Dosage:

2gm

Preparation:

IV

Frequency:

On call to OR

Inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death

Pre-operative prophylaxis to reduce chance of post-op surgical infections

Contraindication Side Effect Nursing Consideration

Hypersensitivity to cephalosporins and penicillins, lidocaine or any other local anaesthetic product of the amide type. Neonates and premature infants with bilirubin encephalopathy

Pain, induration, phlebitis after IV administration, rash, diarrhea, casts in urine, thrombocytosis, leucopenia. Elevation of aspartate transaminase (AST), alanine transaminase (ALT), blood urea nitrogen (BUN) and creatinine

-Always watch out for manifestations of any adverse effects.

-Assess urine and stool of the patient

-Assess patient previous sensitivity reaction to penicillin or other cephalosporins

Brand Name Action Indication

Nubain

Generic Name:

Nalbuphine

Classification:

Analgesic, muscle relaxants and uricosurics

Dosage:

10mg

Preparation:

IM

Frequency:

On call to OR

Binds with opiate receptors in the CNS, ascending pain pathways in limbic system, thalamus, midbrain, hypothalamus, altering perception of and emotional response to pain. Relieves pain

Relief of moderate to severe pain; for pre-op analgesia, supplement to balanced anaesthesia, surgical anaesthesia.

Contraindication Side Effect Nursing Consideration

Hypersensitivity. Pregnancy (Category D-only if used for prolonged periods or high doses at term

Sedation, drowsiness, sweating, phenothiazine, sedatives, hypnotics, alcohol

- Inform patient of possible side effects.

-Ensure that the client has no sensitivity/ allergy

-Assess pain characteristics

-Monitor respiratory rate depression

Brand Name Action Indication

Phenergan

Generic Name:

Promethazine HCl

Classification:

Anti-allergic

Antihypertensive

Dosage:

25mg

Preparation:

IM

Frequency:

On call to OR

May increase, prolong, or intensify the sedative action of other CNS depressants such as alcohol, sedatives/ analgesics, general anaesthetics

Anaphylactic reactions, as adjunctive therapy to epinephrine and other standard measures, after the acute manifestations have been controlled.

Contraindication Side Effect Nursing Consideration

Antihistamine are contraindicated for use in the treatment of lower respiratory tract symptoms including asthma

Drowsiness is the most prominent CNS effect of this drug. Sedation, somnolence, blurred vision, dizziness, confusion, disorientation and extra pyramidal symptoms such as oculogyric crisis

-Accompany the patient if he / she is experiencing blurring of vision

-Always monitor blood pressure and respiration

NURSING CARE PLAN

Patient’s initial: V. M.

Nursing diagnosis: Acute pain related to bile duct obstruction as evidence by inflammed gall bladder

Medical diagnosis: Choledocholithiasis

Short term goal: After 8 hours of rendering nursing care intervention, the patient’s pain scale will reduce from 5/10 – 2/10

Long term goal: After hospitalization, the patient will report total relief from pain.

Cues Problem Scientific Reason

Subjective:

“medyo nasakit yung bandang tiyan ko”, as verbalized by the patient.

Pain scale: 5/10

Character of pain: intermittent

Objective: Facial mask of painGuarding behaviorIrritable

Acute pain Abdominal pain is caused by inflammation by stretching or distention of an organ for example, blockage of a bile duct by gallstones

Intervention Rationale Evaluation

INDEPENDENT:

>Observe and document the location, severity and character of pain.

>Promote bed rest, allowing patient to assume position of comfort.

>Encourage use of relaxation techniques, such as deep breathing exercises. Provide diversional activities.

>Assist in differentiating cause of pain, and provides information about effectiveness of interventions.

>Bed rest in low fowler’s position reduces the intra abdominal pressure; however, patient will naturally assume least painful position.

>Promotes rest, redirects attention, may enhance coping.

Short term goal:

GOAL MET, the patient’s pain scale reduced from 5/10 to 3/10.

Patient’s Initial: V. M.

Nursing Diagnosis: Anxiety related to expressed concerns due to surgery

Medical Diagnosis: Choledocholithiasis

Short term goal: After 8 hours of rendering nursing care intervention, the patient will appear relax and will verbalized decrease in anxiety.

Long term goal: After hospitalization, the patient will be free from anxiety and will go back to its normal activities

Cues Problem Scientific Reason

Subjective:

“Medyo kinakabahan ako sa operasyon” as verbalized by the patient.

Objective:conscious and coherentanxiousirritable

Anxiety Discomfort or dread feeling accompanied by an automatic response of apprehension caused by anticipation of danger during an upcoming surgical procedure.  

Intervention Rationale Evaluation

INDEPENDENT:Assess client’s level of anxiety. Validate observation

Encourage verbalization of feelings and concerns

Provide accurate information about the situation

Anxiety is highly individualized normal physical and psychological response to internal and external life events.

Affirms patient understanding of an ultimate solution of feelings

Helps client to identify what is reality based

Short term goal:

GOAL MET, the patient’s anxiety decreased as verbalized by the patient, “ok na ako, hindi na ako gaanong kinakabahan”

Long Term Goal:

GOAL MET, the patient was free from anxiety

VS closely monitored

Provide comfort measures

To identify physical response associated with both medical and emotional conditions

Comfort measures such as calm and quiet environment for the patient to divert his/her feelings to other things