cholelithiasis case pres

A CASE PRESENTATION ABOUT CHOLELITHIASIS

ALCOVER, LLEWELL T.

DAVID, KYNA B.

DEUNIDA, RONECAR V.

OBIDA, ARIANNE A.

TARROJA, CYRILLE AGNES

I. INTRODUCTION

• The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is the pathologic state of stones or calculi within the gallbladder lumen. A common digestive disorder worldwide, the annual overall cost of cholelithiasis is approximately $5 billion in the United States, where 75-80% of gallstones are of the cholesterol type, and approximately 10-25% of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones predominate, although recent studies have shown an increase in cholesterol stones in the Far East.

I. INTRODUCTION

• Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation. First, bile may undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation.

I. INTRODUCTION

• Gallstones, or cholelithiasis, are hard masses that form in the gallbladder or bile ducts. They occur particularly in women. Approximately 80% of gallstones are composed of cholesterol, with the remainder consisting of various mixtures of bile pigment (bilirubin) and calcium. Cholesterol stones are due to metabolic defects that decrease cholesterol solubility. Increased bilirubin metabolism due to certain blood diseases, such as sickle-cell disease, leads to the formation of pigment stones. When gallstones migrate, they may block the gallbladder or bile duct causing pain, backup of bile leading to jaundice, or severe infection of the gallbladder, bile ducts, or blood.

I. INTRODUCTION

• Bile is fluid and formation in the liver of, among other things, cholesterol and wastes, including billirubin (colored product from dead red blood cells) and assembled in the gallbladder, which sits in close relation to the liver. When you eat, headed bile through the deep bile times to gut, where bile is necessary for digestion of essential fats and neutralizing stomach acid. While waste is then excreted in faeces, which is why its dark color.

I. INTRODUCTION

• When the balance between the substances in the bile pushed too much towards high cholesterol can be deposited in cholesterol crystals, which are the most common basis for gallstones. Blocks grows when bile ingredients bind to the solid crystals and is composed of cholesterol, bile pigment and lime (calcium). There may be many small stones or some large, which may be larger than a hen. Large stones do not need to give serious symptoms.

A. TYPES OF GALLSTONE

1. Cholesterol stones

Are the most common type; the incidence increases with age, and the prevalence is higher in women. Stones are usually smooth and whitish yellow to tan.

2. Pigment stones

In here, bile contains an excess of unconjugated bilirubin. They may be black (associated with hemolysis and cirrhosis) or earthy calcium bilirubinate (associated with infection of the biliary system).

Stones made of bilirubin, which can occur when red blood cells are being destroyed (hemolysis). This leads to too much bilirubin in the bile.

http://www.nlm.nih.gov/medlineplus/ency/article/002372.htm

A. TYPES OF GALLSTONE

3. Mixed stones

May be a combination of cholesterol and pigment stones or either of these with some other substance. Calcium carbonate, phosphates, bile salts, and palmitate make up the more common minor constituents

B. RISK FACTORS

• PREDISPOSING FACTORS

1. Age (40 and above)

Most internal functions decline as one ages. Inevitably resulting an organ degeneration which also affects the body’s metabolism of lipids.

2. Gender

Gallstones is more frequent on woman especially who had have had multiple pregnancies or who are taking oral contraceptives. Increase level of estrogen reduces the synthesis of bile acid in women.

B. RISK FACTORS


Female sex hormones have long been suspected to have a side effect of gallstone formation by altering respective bile constituents (mainly the fat metabolism)

3. Ileal disease/resection

People who have disease of the terminal ileum or who have undergone resection of the terminal ileum deplete their bile salt pool and run a greater risk of developing cholesterol gallstones.

B. RISK FACTORS


4. Race

Cholesterol stones are common in Northern Europe in North and South America.

5. Genetics

Most clinicians have an impression that gallbladder disease characterizes some families. Indeed, the younger sisters of women with gallstone prove to have bile more highly saturated with cholesterol than the younger sisters of women without gallstones, all of which suggests that cholelithiasis does run in families.

B. RISK FACTORS


6. Inflammation and infection of the gallbladder

Inflammation or infection in the biliary structures may provide a focus for stone formation or may alter the solubility of the constituents, fostering the development of a stone.

7. Hemolytic Disease and Hepatic Cirrhosis

In cirrhosis, at least two fifths of patients have gallstones. One possible mechanism behind the appearance of pigment softness, so far unproven, is the excretion of unconjugated bilirubin directly into the bile, something that might happen in patient with hemolysis or in the cirrhotic with his high incidence of pigment stones, currently estimated at 27%.

B. RISK FACTORS


8. Bile stasis

Brown pigment gallstones from when there is stasis of bile (decreased flow), for example, when there are narrow, obstructed bile ducts.

B. RISK FACTORS

• PRECIPITATING FACTORS

1. Faulty Diet

Excessive intake of high fat or cholesterol food such as pork meat, animal skin (e.g. chicharon and chicken skin) can result to an increase in cholesterol level in the body, making it hard for the liver to make bile enough to metabolized the all cholesterol present. Excess cholesterol present builds up and increases the cholesterol serum level. Normal liver function would then try to compensate and excrete excess cholesterol to the bile plus the body would reabsorb water from the bile making it more concentrated. Supersaturation of cholesterol along with other constituents of the bile (bilirubin, lecithin etc.) builds up mictocrystalis. When microcrystalis aggregate it would result to gallstones.

B. RISK FACTORS


2. Weight loss

Weight loss is associated with an increased risk of gallstones because weight loss increase bile cholesterol supersaturation, enhances cholesterol crystal nucleation, and decreases gallbladder contractility.

3. Obesity

Obesity is a major risk factor for gallstones, especially in women. A large clinical study showed that being even moderately overweight increases the risk for developing gallstones. The most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting in more cholesterol. Obesity also decreases gallbladder emptying.

B. RISK FACTORS


4. Pregnancy

Altered physiology of the biliary system during pregnancy may play a role in accelerating the formation of stones in susceptible women.

5. Treatment with estrogen/ contraceptives

The contraceptive pill not only promotes thrombophlebitis but points to an endocrine background of gallstones by the risk of gallstones in young women taking the pill. This is largely as a result of increased cholesterol secretion into the bile and a decreases in chenodeoxycholic acid content, along with impaired emptying of the gallbladder brought about by estrogen.

B. RISK FACTORS


6. Frequent Starvation and prolonged parenteral nutrition

Starvation decreases gallbladder movement causing the bile to become over concentrated with cholesterol. The liver also secretes extra cholesterol into bile adding to the supersaturation causing stone formation. Also fasting persons have diminished bile salt pool and lithogenic bile. Gallbladder stasis plays a key role in permitting stone formation. Defective or infrequent gallbladder emptying occurs in the settings of prolonged fasting, rapid weight loss, pregnancy, and spinal cord injury.

B. RISK FACTORS


7. Clofibrate use and other antillipemic drugs

Drugs that lower the serum level of cholesterol, notably clofibrate, are associated with an increased incidence of gallstones. Clofibrate pressurably increases the secretion of cholesterol into the bile and apparently also decreases bile acid synthesis, so increasing the cholesterol saturation of the bile. Clinical reflection of these physiologic abnormalities has been found in the overwhelming association between clofibrate therapy and gallstones.

B. RISK FACTORS

• NON MODIFIABLE

1. Family history

2. Genetic

3. Ethnic background

4. Female

5. Age

• MODIFIABLE

1. Obesity

2. Rapid weight loss

3. Diet

C. SIGNS AND SYMPTOMS

1. Pain in the right upper or middle upper abdomen (biliary colic) May be constant May be sharp, cramping, or dull May spread to the back or below the right

shoulder blade

2. Fever

3. Yellowing of skin and whites of the eyes (jaundice)

4. Other symptoms that may occur with this disease include: Clay-colored stools Nausea and vomiting Bloating


Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles.


• Fewer than half of the clients with gall stones report any distress because gall stones cause no symptoms unless complications develop. The primary symptom is pain or biliary colic. The pain usually follows the temporary obstruction of the gall bladder outlet. Characteristically, the pain starts in the midline area. It may radiate around to the back and right shoulder blade.

• The client is often restless, changing positions frequently to relieve the pain’s intensity. Pain may persist for a few hours or several days and the interval between attacks is variable.


• Jaundice only appears when common duct obstruction is present. Nausea and vomiting may occur, and occasionally self induced vomiting alleviates the symptoms. Assessment may further reveal a history of flatulence , bloating, dyspepsia, belching, an intolerance to fatty foods and vague upper abdominal sensations.

• This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct).

II. BIOGRAPHIC DATA

• NAME OF THE PATIENT: Ma. Heidy Panganiban• ADDRESS: Mandaluyong City• GENDER: Female• AGE: 49 years old• CIVIL STATUS: Married• DATE OF BIRTH: Nov. 25,1965 • PLACE OF BIRTH: Mandaluyong City• EDUCATIONAL ATTAINMENT: (-)• OCCUPATION: Housewife• RELIGION: Catholic

II. BIOGRAPHIC DATA

• CHIEF COMPLAINT: Abdominal pain at the right upper quadrant

• PRIMARY MEDICAL DIAGNOSIS: Cholelithiasis• PHYSICIAN:(-)• DATE AND TIME OF ADMISSION: August 24,2015 (2:05

pm)

III. HEALTH HISTORY

A. HISTORY OF PRESENT ILLNESS

One month prior to admission, the patient experienced epigastric pain at first she tolerates it and she limits herself to do strenuous activities in order to decrease the pain she feels. When the pain became more intense she consulted a doctor and an ultrasound was done which revealed presence of stones in her gallbladder. Three days prior to admission, Patient started to feel pain in the right upper quadrant accompanied with fever. This RUQ pain radiates in her right shoulder as verbalized by her. She also complains of tenderness whenever she touches her abdomen. According to her, though she did not vomit, her abdomen felt bloated.

III. HEALTH HISTORY

B. HISTORY OF PAST ILLNESSPatient had already experienced childhood

illnesses such as chickenpox and mumps. She also said that he had complete immunizations. She has no allergies to drugs and medications. She also recently had her asthma attack.

According to patient, she was hospitalized last year due to the same complain. She also said that she was supposedly operated but due to financial problem the operation did not push through.

III. HEALTH HISTORY

C. FAMILY HISTORY

According to the patient the familial disease she knows that they have in their family was the hypertension that in on her father’s side. She also added they don’t have history of cholelithiasis or any problem in the bile.

IV. Gordon’s 11 Functional Pattern

A. Health-Perception and Health Management Pattern• Patient’s General Appearance

Upon assessment, the patient appears well nourished and he appears weak, calm, oriented and responsive to questions being asked

• Habits

The patient is a smoker and used to smoke 3-5 sticks per day and drinks alcoholic beverages occasionally

• She has no known allergies to medications or foods. • She has no maintenance medications.


B. Nutrition and Metabolic Pattern

Prior to hospitalization, patient had a good appetite and she can consume her whole share of meals which usually consists of 2 cups of rice and 2 servings of viand (more on vegetables, pork, and dried seafood). She also drinks approximately 1.5 L of water a day. She is not taking any supplements.


C. Elimination Pattern• Bowel

Before admission, patient usually defecates twice a day with pale-colored or yellowish colored stool, with soft consistency. She does not feel any discomforts when defecating and there are no problems with hemorrhoids or incontinence. According to her, the last time he defecates is on August 23, 2015.


C. Elimination Pattern• Bladder

Prior to admission, she usually urinates 4-5 times a day to a yellowish colored urine with approximately 1-1 1/2 glass (210-230cc) of urine per voiding. There are no discomforts reported.

During the duration of care, patient X usually urinates 2-3 times to a dark colored urine for about 120-240 ml per 8 hours shift. She reported no discomforts or any problem in control.


D. Activity-Exercise Pattern

Prior to hospitalization, patient do the household chores daily and served it as her regular exercise.

But upon admission, patient’s only means of exercise is active range of motion. With patient’s activities of daily living, she is assisted with person

E. Cognitive-Perceptual Pattern

Upon assessment, she is conscious, and in a calm state. She is oriented to time, person, and place.

Her primary language is Filipino; no speech deficits noted but she speaks at slow pace. There are no learning difficulties reported.


F. Sleep-Rest Pattern

She usually sleeps 4-5 hours at night prior to admission. Although, upon her admission her sleeping pattern is quite disturbed considering the pain at right upper quadrant with pain scale of 7/10. She also takes a 1-2 hours nap in the afternoon. She is not insomniac.

G. Self-Perception and Self-Concept Pattern

The patient stated that she’s quite worried about her current condition. During assessment, patient has been responsive and cooperative to our questions being asked.


H. Role-Relationship Pattern

She is married, with 3 children. She currently lives with her family. Her family and nearest relatives are worried about her condition and she is also eager to go home. Her husband supports her and family through. They have no known familial history of any serious illnesses.

I. Sexuality-Reproductive Pattern

Patient has no reported sexual problems and does not practice monthly self-breast examination. No discharges were observed and no presence of nodules or lesions noted.


J. Coping-Stress Tolerance pattern

During the duration of care, patient did not experience any stressful event in her life. Her form of relaxation is napping especially in the afternoon and sometimes slight conversation to her husband.

K. Value-Belief Pattern

She is a Catholic by faith and she believes that God is the source of everything. Their religious practice is going to church every Sunday.

V. ACTIVITIES OF DAILY LIVING

VI. PHYSICAL ASSESSMENT

• General Survey

Patient is 49 y/o has abdominal pain with pain scale of 7/10. She was scheduled of cholecystectomy. She was pale and weak in appearance, conscious and coherent. She has no sign of vomiting but has feeling of nauseated and fullness.


• Vital signs

VI. PHYSICAL ASSESSMENT• Head to Toe

Assessment

VII. LABORATORY FINDINGS/DIAGNOSTIC

EXAMINATIONSUrinalysis (August 24, 2015)


EXAMINATIONSComplete Blood Count (August 24, 2015)


EXAMINATIONSBlood Chemistry (August 24, 2015)


EXAMINATIONSUltrasound (August 23, 2015)

VIII. ANATOMY AND PHYSIOLOGY

VIII. ANATOMY AND PHYSIOLOGY• GALLBLADDER:• Pear shaped• Hollow structure• Under the liver and on the right side

of the abdomen• Part of the Biliary Tract FUNCTION:• Store and concentrate BILE.• Serves as a reservoir for bile while its

not being used for digestion. Gallbladder BILE:• 97% water• 0.7% bile salts• 0.2% bilirubin• 0.51% cholesterol• Cholecystokinin Pancreozynin

VIII. ANATOMY AND PHYSIOLOGY RIGHT HEPATIC DUCT

LEFT HEPATIC DUCT

COMMON HEPATIC DUCT

COMMON BILE DUCT

CYSTIC DUCT

VIII. ANATOMY AND PHYSIOLOGY

• GALLSTONE:• An excess cholesterol,

bilirubin, and bile salts.

• Generally small, hard deposits inside the gallbladder that are formed when stored bile crystallizes.

IX. PATHOPHYSIOLOGY

X. DRUG STUDY

XI. NURSING CARE PLAN

XII. DISCHARGE PLANNING

M – MEDICINE

Advice patient to continue taking his prescribed medicines like

E – ENVIRONMENT AND EXERCISE

Maintain a quiet, pleasant, environment to promote relaxation.

Provide clean and comfortable environment.

Encourage walking everyday.

T – TREATMENT

Continue home medications.

Teach patient about wound care

Encourage patient to take multivitamins for immunity

XII. DISCHARGE PLANNING

H – HEALTH TEACHING

Provide written and oral instructions about wound care, activity, diet recommendations, medications, and follow-up visits.

Instruct patient to limit his activity for 24 to 48 hrs after discharge.

O – OUT PATIENT FOLLOW-UP

Patient will be advised to go back in the hospital in a specific date to have a follow-up check up after discharge.

Consult doctor for are any problems or complications encountered.

D – DIET

Encourage patient to increase protein intake for tissue repair

Advice patient to eat smaller-than-normal amounts of food at mealtime.

S – SPIRITUALITY

Encourage patient to communicate with God.

Encourage patient to communicate with other people.

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