BULACAN STATE UNIVERSITYCITY OF MALOLOS, BULACAN

COLLEGE OF NURDING

JOSE B. LINGAD REGIONAL MEMORIAL HOSPITAL(SURGERY WARD)

A CASE STUDY ABOUT

OBSTRUCTIVE JAUNDICE 2O TO CHOLEDOCHOLITHIASIS: CALCULUS CHOLECYSTITIS

SUDBMITTED BY:LACAS, JOHN PHILIPMANZANO, GOLDA JHADEMEDINA, DANIKKA MARIEPERALTA, MARICRISREYES, ABEGAILVICTORIA, JOSE LEMUEL(BSN III-D GROUP 3)

SUBMITTED TO:MRS. CHYNTIA DUENA-MENESES, R.N

(CLINICAL INSTRACTOR) INTRODUCTION

Definition

Cholecystitis is inflammation of the gallbladder wall, caused by obstruction of the cystic duct. This inflammation may be sterile or bacterial. Gallstones

usually (>90%) cause this obstruction (calculous cholecystitis) but may infrequently be acalculous or caused by sludge. This obstruction results in

gallbladder distention, gallbladder wall edema, and ischemia. Inflammatory mediators, specifically prostaglandins, are released resulting in increased

gallbladder inflammation. The wall of the gallbladder may undergo necrosis and gangrene (gangrenous cholecystitis).

Bacterial superinfection with gas-forming organisms may lead to gas in the wall or lumen of the gallbladder (emphysematous cholecystitis). Bacterial

infection is thought to be a consequence, not a cause, of cholecystitis. In the early stages of acute cholecystitis, bile is sterile. Approximately 20-75% of bile

cultures are eventually positive with the most common organisms being Escherichia coli, Klebsiella species, Enterococci, and Enterobacter. Common bile

duct stones (choledocholithiasis, 10%) are either secondary (from the gallbladder) or primary (formed in bile ducts).

Mortality/Morbidity

Asymptomatic gallstones result in morbidity and mortality when they become symptomatic.

The incidence of acute cholecystitis is falling, likely due to increased acceptance by patients of laparoscopic cholecystectomy as a treatment for symptomatic

gallstones.

Mortality can be as high as 15% in immunocompromised patients.

Complicated cholecystitis has 25% mortality (eg, gangrene, empyema of gallbladder). Perforation of gallbladder occurs in 3-15% of patients with

cholecystitis and is associated with 60% mortality.

Race

Racial or ethnic influences are important in gallbladder disease. Fair people of northern European descent are more likely to have gallstones.

African Americans are at decreased risk for gallstones unless they have a hematologic reason for stones (eg, sickle cell anemia).

Asians with stones are more likely than other populations to have pigmented stones. In elderly Pima Indians, incidence of gallstones is approximately 75%.

Increased incidence of stones may be observed in people of Hispanic ethnicity.

Sex

The phrase "fair, female, fat, and fertile" summarizes the major risk factors for development of gallstones. Although gallstones and cholecystitis are more

common in women, men with gallstones are more likely to develop cholecystitis than women with gallstones.

Whether women who are pregnant or have multiple pregnancies are more likely to develop stones or whether they are simply more symptomatic with stones

is unknown.

Some oral contraceptives or estrogen replacement therapy may increase the risk of gallstones.

Age

Age increases rates of gallstones, cholecystitis, and common bile duct stones. Elderly patients are more likely to go from asymptomatic gallstones to serious

complications of gallstones without gallbladder colic.

Children are more likely than adults to have acalculous gallstones. If stones exist, they are more likely pigmented stones from hemolytic diseases (eg, sickle

cell diseases, spherocytosis, G-6-PD deficiency) or chronic diseases (eg, total parenteral nutrition, burns, trauma).

Teenagers have the same etiologies of gallstones as adults, with a higher incidence in girls and during pregnancy.

GOALS AND OBJECTIVES

A. GENERAL OBJECTIVES

This case study aims to acquire knowledge and skills in providing a systematic, rational method of planning and providing nursing care to a Patient with

Obstructive Jaundice 2O to Choleducholithiasis; Calculous Cholecystitis. This also aims to develop the awareness of health care providers about this

particular kind of case.

B. SPECIFIC OBJECTIVES

To be able to collect and organize relevant and intact information about this particular kind of case.

To be able to use critical thinking skills and knowledge in interpreting assessment data that would be necessary in identifying actual and potential

problems on how to manage a Patient with Obstructive Jaundice 2O to Choleducholithiasis; Calculous Cholecystitis.

To be able to develop an individualized and fruitful nursing care plan with this particular kind of case and carry out appropriate interventions to meet

desired goals and objectives.

To apply all the theories, concept, knowledge and skills learned in the entire lecture by means of assessing the signs and symptoms, diagnosing the

problems and implementing the prevention and treatment of the problem.

To evaluate outcomes of the effectiveness of care to determine what nursing actions need to be modified or improved.

NURSING HEALTH HISTORY

A. BIOGRAPHIC DATA

NAME : Rex Olalia

ADDRESS : San Miguel, Betis, GuaGua, Pampanga

AGE : 33 Years Old

BIRTH DATE : June 19, 1976

GENDER : Male

RELIGION : Roman Catholic

RACE : Asian

STATUS : Married

OCCUPATION : Construction Foreman

SOURCE OF HEALTH FINANCING : Himself

ADMITTING DIAGNOSIS : RUQ Abdominal Pain

FINAL DIAGNOSIS : Obstructive Jaundice 2O to Choleducholithiasis; Calculous Cholecystitis

B. CHIEFT COMPLAINT

The patient complains of abdominal pain with generalized jaundice for about 17 days.

C. HISTORY OF PRESENT ILLNES

Since he was 18 years old, Rex often experience abdominal pain. According to him, first he thought that the pain which he felt is caused by a

hyperacidity attack and try to manage it by taking Aluminum Hydroxide (Kremil S) an antacid drug. As he verbalized “Pag nag umiinom ako ng

Kremil S nawawala naman, kaya kala ko nung una hyperacidity lang ito”. As time past by the abdominal pain became severe and even an antacid

drug cannot relieved the symptoms. Then he decided to consult a doctor, which is last January 2009. According to him the doctor gave him

Omeprazole (Prisolec) a Proton Pump Inhibitor which work to stop acid secretion of the stomach. Then it works and it can now relieve the abdominal

pain which he felt. After few months, this August of the same year, the abdominal pain came back and became more sever, then one day he woke up

and shock when hw saw his face in the mirror and it is already color yellowish to orange. Then last Sept. 09, 2009, they decided to bring him in

JBLRMH and seek for some medical explanation. The doctor said he have gallstone and he will going to undergo a surgery which is an Elective

Cholecystectomy with CBDE Possible Bypass.

D. PAST HISTORY OF ILLNESS

According to him he was complete in different immunization offered at that time. He already has Mumps and Varicella; do not have any known food

or drug allergies: and do not suffer from any minor or major injury when he was a child. Then he admitted in the hospital when he was 14 years old

with the same chief complaint (Abdominal Pain).

E. FAMILY HISTORY OF ILLNESS

His father has hypertension, as well as his 2 siblings who are Maritess and Roger. There is no any family history of DM,COPD,CVD, Malignant Neoplasm etc. in

his family both mother and father side. And according to him one of his father’s siblings (the eldest) also has cholecystisis and undergone cholecystectomy many

years ago.

GENOGRAM

LEGEND

MALE PATIENT ALIVE AND WELL N/A NOT AVAILABLE

FEMALE HYPERTENSION DECEASED CHOLECYSTITIS

N/A N/A

N/A N/A

N/A

N/A

72 N/A

N/AN/A

N/A N/A

N/A 67

33 24 27 42 53 49 37

FUNCTIONAL HEALTH PATTERN

PRIOR HOSPITALIZATION DURING HOSPITALIZATION

HEALTH PERCEPTION &

HEALTH MANAGEMENT

PATTERN

He does believed what herbal medication can do in his condition; he is a light smoker and drinking alcoholic beverages occasionally.

When I ask him if he can follow what doctor & nurse advices him, he verbalized “ pamimsanminsan kasi pag walang pera, kahit gusto mong bilhin ang mga pina bibili nila di mo naman mabili”

NUTRITIONAL METABOLIC

PATTERN

3 DAYS FOOD RECALL

DATE

FOOD FLUID

BREAKFAST LUNCH DINNER BREAKFAST LUNCH DINNER

SEPT. 06, 2009

N/A N/A N/A N/A N/A N/A

SEPT. 07, 2009

N/A N/A N/A N/A N/A N/A

SEPT. 08, 2009

Tuyo, 2 Eggs, 2 Cups of Rice

Adobong Baboy, 4 Cups of Rice

Pritong Baboy, 3 Cups of Rice

1 Mug of Coffee

1 Glass of Water, 2 Glasses of Pop Cola

2 Glasess of Water

He is taking vitamins, specifically Revicon but not continuously, he eats moderately mostly fishes & meat, he is fun of eating food rich in seasoning and drinking cola most of the time, and lately he experience weight lost unintentionally. There is no skin problem noted. There are 3 missing molars and there is no problem in wound healing.

3 DAYS FOOD RECALL

DATE

FOOD FLUID

BREAKFAST LUNCH DINNER BREAKFAST LUNCH DINNER

SEPT. 09, 2009

3 Pieces of Daing, 2 Cups of Sinagang

Sinigang na Baboy, 3-4 Cups of Rice

Sardines, 3-4 Cups of Rice

1 Mug of Coffee

2-3 Glasess of Popcola

2 Glasess of Water

SEPT. 10, 2009

6 Slices of Bread

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A

During hospitalization he cannot eat what his want. And there is sudden decreased in appetite.

ELIMINATION PATTERN

FECAL-URINARY ELIMINATION PATTERN FECAL-URINARY ELIMINATION PATTERN

CATEGORY FREQUENCY COLOR/CONSISTENCY DEVIATION

1. URINATON - 5 to 8 as estimated- Depends upon the weather

Straw None

2. DEFECATION 2 Brown/Formed None

CATEGORY FREQUENCY COLOR/CONSISTENCY DEVIATION

1. URINATON 3 Straw None

2. DEFECATION 3 ( shift 11-7pm) Watery Diarrhea

ACTIVITY-EXERCISE PATTERN

He considered his work as a form of exercise.

O Feeding O Bathing O Dressing O ToiletingO Shopping O Home Maintenance O Bed Mobility O General Mobility

Level O - IndependentLevel I - With help from othersLevel II - With equipmentLevel III - With help from others & equipmentLevel IV - Dependent

There is no form of exercise upon admittance to hospital.

I Feeding N/A Bathing I Dressing I ToiletingN/A Shopping N/A Home Maintenance I Bed Mobility II General Mobility

Level O - IndependentLevel I - With help from othersLevel II - With equipmentLevel III - With help from others & equipmentLevel IV - Dependent

SLEEP-REST PATTERN

Prior hospitalization, he sleep for approximately 7 hours each night from 10pm to 5 am, there is no sleep problem noted, he do not take naps every afternoon, the form of relaxation is thru watching his favorite TV program, chatting with his family or sometimes co-workers & reading news clippings.

During hospitalization, he only sleeps for about 6 hours each night, because of environmental & physiological factors.

COGNITIVE PERCEPTUAL

PATTERN

No hearing and eye problems. According to him, he often experience in tip of the tongue phenomenon together with slight confusion.

Still no change.

SELF PERCEPTION SELF CONCEPT

PATTERN

He is satisfied with his physical appearance; he felt easily tired and has a dry skin and hair. There is no major problem in his self as a whole, according to him he easily felt angry to those people whose are liars and do not know how to return dept of gratitude’s.

He experiences an inferiority complex upon having Jaundice, because of his physical appearance.

ROLE RELATIONSHIP PATTERN

He is already married, with 1 child. They are 3 in the family. His is working as a construction foreman at Angeles City, Pampanga. He is the one who responsible for most of the decision in their family. And these factors made their family as Nuclear in membership and Patriarchal in authority.

There is no major family problem encountered lately, and if there is a problem they handle it by means of having open forums. There is no problem in his community interaction & there is no feeling of isolation from others.

Sometimes he felt embarrassed when someone look stare at him and asking what happened in his color, why he looks like that!

SEXUALLY REPRODUCTIVE

PATTERN

He is sexually active; His wife is using Intra Uterine Device or IUD as a form of family planning method.

Still the same.

COPING STERSS PATTERN

If he has problem, he just kept those problem by himself without saying to others. Now he is on hospital he needs the help of other by means of sharing his personal problems to lessen the loads which he kept deep inside.

VALUE BELIEF PATTERN

For him religion is very important in his life, although he cannot go to church regularly.

Now he needs more the help of God, he seek for help by means of praying.

PATHOPHYSIOLOGY

MODIFIABLE FACTOR NON MODIFIABLE FACTOR

- LIFESYLE ` - HEREDITARY- DIET - AGE

SUPERSATURATION OF BILE WITHCHOLESTEROL & CALCIUM

PRESIPITATION OF SOLUTE FROMSOLUTION & BECOME CRYSTAL

CRYSTAL MUST COME TOGETHER& FUSE TO BECOME CALCULI

GALLSTONE OBSTRACTION OF BILE DUCT

SHARP PAIN IN THE CHOLELITHIASIS CHOLEDOCHOLITHIASIS RIGHT HYPOCHONDRIUM

BILIARY COLLIC DISTENTION OF OBSTRACTIVE THE GALLBLADDER JAUNDICE

VENOUS & LYMPHATIC LOCALIZED CELLULAR DRAINAGE ARE IMPAIRED OR INFILTRATION

PROLIFERATION OF BACTERIA ISCHEMIA

INFLAMMATION OF GALLBLADDER

CHOLECYSTITIS

DEVELOPMENTAL TASK

 

NAME: REX OLALIA AGE: 33 YEARS OLD HOSPITAL: JOSE B. LINGAD REGIONAL MEMORIAL HOSPITAL (SURGERY WARD) DATE: 09-10-09

THEORY

ERIK ERIKSON THEORY OF

PSYCHOSOCIAL DEVELOPMENT

SIGMUND FREUD THEORY OF

PSYCHOSEXUAL DEVELOPMENT

JEAN PIAGET THEORY OF COGNITIVE

DEVELOPMENT

LAWRENCE KOHLBERG THEORY

OF MORAL DEVELOPMENT

JAMES FOWLER THEORY OF FAITH

DEVELOPMENT

STAGE

INTIMACY VS ISOLATION

GENITAL STAGE FORMAL OPERATIONS

POST CONVENTIONAL

UNIVERSALIZING FAITH

DEFINITION

Once identity has been established, person is able to form closed contacts and relationship with other and to share themselves with others. A person who has not established an identity may developed a feeling of isolation as a negative feedback instead of intimacy

True maturity requires the timing of aggressive and sexual urges, allowing their to released their repress feeling in a more social and acceptable manner.

The person at this stage can think abstractive.

An individual reaches this stage acts out universal principles based upon the equality and worth of all human beings.

Unitive view of reality and enlightenment.

 

 

Our pt. has feeling of intimacy because he already have a stable relationship with his wife,

He has a healthy and active sex life and does not suffering from any sexual problem. His wife

Our pt. accepts opinions from other. He responds correctly and appropriate to situation and questions.

He can decide accurately and relevant to situation. And have a good moral insight in his life.

The religion of our pt. is Roman Catholic; there is no problem in terms of faith and devotion to God.

 

 

EXPLANATION

a good career as a foreman in a contraction company at Angeles City and have an identity and self acceptance. He also smiles as we talks about his life as a husband and a father of one child.

is using Intrauterine Device as a form of contraceptive method.

The pt. has relevance of thought and good insight in organization of vital event in his life.

 

ANATOMY & PHYSIOLOGY

Anatomy

Upper gastrointestinal tract

The upper GI tract consists of the mouth, pharynx, esophagus, stomach, and duodenum proximal to the ligament of Treitz.

The mouth contains the buccal cavity, which contains the openings of the salivary glands; the tongue; and the teeth.

Behind the mouth lies the pharynx which prevents food from entering the voice box and leads to a hollow muscular tube, the esophagus.

Peristalsis takes place, which is the contraction of muscles to propel the food down the esophagus which extends through the chest and pierces the

diaphragm to reach the stomach.

Lower gastrointestinal tract

The lower GI tract comprises the most of the intestines and anus.

Bowel or intestine

o Small intestine, two of the three parts:

Duodenum

Jejunum

Ileum

o Large intestine, which has three parts:

Cecum (the vermiform appendix is attached to the cecum).

Colon (ascending colon, transverse colon, descending colon and sigmoid flexure)

Rectum

Anus

Accessory organs

Accessory organs to the alimentary canal include the liver, gallbladder, and pancreas. The liver secretes bile into the small intestine via the bile duct, employing the

gallbladder as a reservoir. Apart from storing and concentrating bile, the gallbladder has no other specific function. The pancreas secretes an isosmotic fluid

containing bicarbonate, which helps neutralize the acidic chyme, and several enzymes, including trypsin, chymotrypsin, lipase, and pancreatic amylase, as well as

nucleolytic enzymes (deoxyribonuclease and ribonuclease), into the small intestine. Both of these secretory organs aid in digestion.

Physiology

Specialization of organs

Four organs are subject to specialization in the kingdom Animalia.

The first organ is the tongue which is only present in the phylum Chordata.

The second organ is the esophagus. The crop is an enlargement of the esophagus in birds, insects, and other invertebrates that is used to store food

temporarily.

The third organ is the stomach . In addition to a glandular stomach (proventriculus), birds have a muscular "stomach" called the ventriculus or "gizzard." The

gizzard is used to mechanically grind up food.

The fourth organ is the large intestine. An outpouching of the large intestine called the cecum is present in non-ruminant herbivores such as rabbits. It aids in

digestion of plant material such as cellulose

Transit time

The time taken for food or other ingested objects to transit through the gastrointestinal tract varies depending on many factors, but roughly, it takes 2.5 to 3 hours

after meal for 50% of stomach contents to empty into the intestines. Total emptying of the stomach takes 4 to 5 hours. Subsequently, 50% emptying of the small

intestine takes 2.5 to 3 hours. Finally, transit through the colon takes 30 to 40 hours.

The Gallbladder

The gallbladder is a thin, green, saclike structure located on the inferior portion of the liver that stores and modifies bile not immediately needed for digestion. It is

~8 cm long and 4 cm wide and has three layers: the inner mucosa, muscularis, and serosa. The inner mucosa is folded to allow for expansion. The muscularis

contains smooth muscle that allows for contraction. The serosa is the outer covering. The regions of the gallbladder itself include the fundus, body, and neck. It is

connected to the common bile duct via the cystic duct (Figures 5 & 6). Ingesting large amounts of lipids stimulate cholecystokinin (CCK) release into the

bloodstream causing Bile secretion into the duodenum.

THE PATIENT AND HIS CARE

MEDICAL MAGAEMENT

IVF DATE ORDERED GENERAL DESCRIPTION INDICATION CLIENTS RESPONSE

D5LR September 9, 2009 Lactated Ringer’s Solution is a solution that is isotonic with blood and intended for intravenous administration.

It is used for fluid resuscitation after a blood loss.

Fluid loss was replaced.

GENERIC/BRAND NAM DATE ORDERED GENERAL DESCRIPTION INDICATION CLIENTS RESPONSE

DATE ORDERED

Generic Name: Ceftriaxone

Brand Name: Rocephin

September 9,2009 IV; 500 mg q8 Ceftriaxone is a cephalosporin antibiotic. It works by interfering with the formation of the bacteria's cell wall so that the wall ruptures, resulting in the death of the bacteria.

Perioperative prophylaxis

Diarrhea

Generic Name: Ranitidine HCL

Brand Names: Zantac,

September 9,2009 IV; 50 mg q12 Ranitidine is in a group of drugs called histamine-2 blockers. Ranitidine works by reducing the amount of acid your stomach produces.Ranitidine is used to treat and prevent ulcers in the stomach and intestines.

Prevention of heartburn, acid indigestion and sour stomach.

Diarrhea

Brand Name: Phytonadione

Generic Name: Vitamin K September 9,2009 IV; amp / IVq8

Vitamin K is necessary for normal clotting of the blood. It is required for hepatic synthesis of blood coagulation factors II, VII, IX and X.

Hypothrombonemia secondary to obstructive jaundice and billiary fistula.

No manifestation noted.

NURSING RESPONSIBILITY:

CEFTRIAXONE

a. Assess the patient for infection at beginning and throughout therapy.

b. Before initiating therapy, obtain a history to determine previous use of and reactions to cephalosporin.

c. Monitor injection site frequently for phlebitis.

d. Instruct patient to notify health care professional if fever and diarrhea develop especially if stools contains blood, mpus, or mucus. Advise patient not to treat diarrhea

without consulting health care professional.

RANITIDINE

a. Assess patient from epigastric or abdominal pain and frank or occult blood in the stool or emesis.

b. Monitor CBC with differential periodically throughout therapy.

c. Note that it may cause an increase in serum transminates and serum creatinine.

d. Ranitidine may cause false positive results for urine-protein; test with sulfosalicyclic acid.

e. Instruct patient to report fever, tarry stools, dizziness and severe headache.

PHYTONADIONE

a. Monitor frank and occult bleeding. Monitor pulse and BP frequently.

b. Prothrombim time should be monitored prior to and throughout Vitamin K therapy to determine response to and need for further therapy.

DIET

TYPE OF DIET DATE STARTED GENERAL DESCRIPTION INDICATION SPECIFICT FOD TAKEN CLIENTS RESPONSE

Clear liquid diet then shift to diet as tolerated

September 9, 2009 For low-fat, low-sodium and high fiber diet.

To decrease gall bladder workload.

Whole grains, vegetables, fishes.

Elimination of formed stools.

EXERCISE & ACTIVITY

TYPE OR EXERCISE DATE ORDERED GENERAL DESCRIPTION INDICATION CLIENTS RESPONSE

ADL September 9, 2009 Continuing doing activities of daily living

To maintain healthy lifestyle. Prevent feeling weak.

SURGIGAL MANAGEMENT

TREATMENT OF GALLSTONE & GALLBLADDER DISEASE

Introduction

Gallstone disease represents a national health care problem, resulting in more than 750,000 cholecystectomies per year. The overwhelming majority of operations

are for symptomatic gallstone disease, and nearly 90% of cholecystectomies are performed laparoscopically. Alternative forms of treatment are palliative rather than

curative.

Symptoms and Diagnosis

Most patients with gallstones do not have symptoms. Natural history studies show that only 20% of patients with asymptomatic gallstones incidentally discovered

will ultimately develop symptoms. Presenting symptoms of gallstone disease include: biliary colic, cholecystitis (calculous and acalculous), gallstone pancreatitis,

and choledocholithiasis (common duct stones). Typical biliary pain due to gallstones is a temporary (between 1/2 hour to 24 hours) epigastric or right upper

abdominal pain following meals. The pain may at times radiate to the right flank or back and frequently is associated with nausea. In some patients, the symptoms

are mild and consist of vague indigestion or dyspepsia. The diagnosis of gallstones is usually established by ultrasonography. Ultrasound findings of a thickened

gallbladder wall and fluid around the gallbladder suggest the presence of acute cholecystitis. Radionuclide scanning is not a useful test for the diagnosis of

gallstones but is useful in detecting acute cholecystitis. Patients with biliary dyskinesia present with typical symptoms of biliary pain without radiographic evidence

of cholelithiasis. Often they will have a decreased gallbladder ejection fraction (<30%) on cholecystokinin stimulated radionucleide scanning.

Treatment

A surgeon should see the patient within a few weeks of an attack if the acute episode has resolved or symptoms are mild. Patients with significant right upper

quadrant tenderness, fever, or elevated white blood cell count should be seen the same day. The presence of gallstones without abdominal symptoms is not an

indication for cholecystectomy unless the patient is immunosuppressed or there is a predisposition for malignancy, i.e., the gallbladder wall is calcified or there is a

family history of gallbladder cancer. Once a patient with gallstones becomes symptomatic, elective cholecystectomy is indicated. The primary indication for urgent

cholecystectomy is acute cholecystitis. Gallstone pancreatitis, choledocholithiasis, and cholangitis require immediate surgical consultation. Patients with recurrent

symptoms typical of biliary pain, but without gallstones on ultrasound, should be referred for surgical evaluation. Consideration for cholecystectomy in these

patients might be supported by cholecystokinin stimulated biliary scitingraphy, Endoscopic evaluation, and/or gastroenterology consultation.

Cholecystectomy may be performed by laparoscopic techniques or by laparotomy. The advantages of the laparoscopic approach are less pain, shorter hospital stay,

faster return to normal activity, and less abdominal scarring. Oral dissolution therapy has limited efficacy and is costly. Percutaneous cholecystostomy is a viable

treatment option for critically ill patients presenting with acute cholecystitis. If the patient subsequently recovers, cholecystectomy should be considered when the

inflammatory changes have resolved in the appropriate patient.

Risks

The risks are low in patients undergoing elective cholecystectomy and include: injury to the bile ducts, retained stones in the bile ducts, or injury to surrounding

organs. The bile duct injury rate is approximately 0.5% for laparoscopic cholecystectomy. The presence of anatomic variations and/or inflammation contribute to an

increased risk of complications, as does the frequent coexistence of serious illnesses in the elderly. The mortality rate in a good-risk patient undergoing elective

operation is less than 0.1%. Operative risks usually arise from co-morbid conditions such as cardiac or pulmonary disease. The preoperative degree of coagulopathy,

rather than the Child's class, should guide the surgeon's approach and expectations when laparoscopic cholecystectomy is performed in a cirrhotic patient.

The Role of Open Cholecystectomy

Open cholecystectomy may be the proper approach for a certain subset of patients. This may include: cirrhosis, gallbladder mass, suspicion of malignancy,

extensive upper abdominal surgery, and late third trimester of pregnancy. Otherwise a laparoscopic approach is feasible in most patients. Conversion to an open

procedure may be required because of the presence of adhesions, difficulty in delineating the anatomy, or a suspected complication. Conversion is more often

necessary in elderly patients and those with prior upper abdominal operations, or acute cholecystitis. The incidence of conversion to an open procedure is between

2-5%, depending on the patient population.

Expected Outcomes

The majority of good-risk patients undergoing elective laparoscopic cholecystectomy can usually be discharged the same or next day. High-risk patients and those

undergoing emergency operations or open cholecystectomies typically, require longer hospital stays. Hospitalization may be prolonged in patients requiring

placement of abdominal drains, exploration of the bile duct, or those with complicated biliary tract disease. Laparoscopic surgery is now proving to be as safe as

open surgery in pregnancy, especially in the second trimester.

Nearly 95% of all patients undergoing cholecystectomy experience relief of biliary pain. The remaining 5% have something other than gallstones as the cause of

their pain. Cholecystectomy for biliary dyskinesia offers significant symptomatic relief over nonoperative therapy. Patients with dyspepsia or diarrhea before

surgery may find that these symptoms persist after operation.

Treatment of Common Duct Stones

Common duct stones may be removed either endoscopically or surgically. The endoscopic approach may be indicated for patients with cholangitis, obstructive

jaundice, and in selected patients with gallstone pancreatitis. Endoscopic clearance of common duct stones is an effective treatment, but may be complicated by

pancreatitis, bleeding or perforation in approximately 3% of cases. Surgical removal of common duct stones can be performed using open or laparoscopic

techniques with appropriate equipment and surgical expertise. Open cholecystectomy with common bile duct exploration is a safe and effective treatment, especially

in the acutely ill. Since most common duct stones arise from the gallbladder, cholecystectomy is also indicated.

Costs

Cholecystectomy is cost effective compared to alternative treatments since it definitively treats the disease and reliably alleviates the symptoms.

Qualifications for Performing Surgery on the Gallbladder

The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes. At a minimum, surgeons

who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should

perform operations for gallbladder disease. Gallbladder surgery should preferably be performed by surgeons with special knowledge, training and experience in the

management of gallbladder and biliary tract disorders. These surgeons have successfully completed at least 5 years of surgical training after medical school

graduation and are qualified to perform operations on the gallbladder and biliary tract.

The purpose of this review is to discuss the acute and chronic complications arising from the development of gallstones.  This will include both those conditions that arise within

the gallbladder and as a consequence of stone migration into the ductal system.  A variety of imaging modalities are useful in the diagnosing of these varying conditions and

examples will provided.

1. Biliary Stones

    a. Gallstones (cholelithiasis)

    b. Ductal stones (choledocholithiasis)

        We will be talking about secondary, not primary ductal stones

2. Complications

    a. Inflammation

    b. Obstruction/stasis

    c. Malignancy

3.  Epidemiology (more common with age, in patients over 60)

    a. 10-15% of men

    b. 20-40% of women

    c. Risk factors include childbearing, estrogen supplementation, birth control pills, hypertriglyceridemia, 

        inflammatory bowel disease, and hyperalimentation.

4. Etiology

     Composed largely of cholesterol, bilirubin/bile pigments, and calcium salts - cholesterol stones most 

     common in the West, pigment stones seen in cirrhosis, hemolytic anemias, and infection.  Supersaturation 

     and stone formation are the result of cholesterol overproduction, bile pigment underproduction, bacterial

     deconjugation and stasis.

5. Imaging

    a. KUB - only 15-20% have sufficient calcium to be visible.

    b. Ultrasound - 98+% sensitive

    c. CT - approximately 75% sensitivity, again dependent on composition

    d. MRI - similar or more sensitive than ultrasound, see stones as small as 2mm.

6. Acute Cholecystitis

     a. Risk in up to 1/3 of patients harboring stones

     b. First line of detection usually ultrasound, accuracy in excess of 88% - fast and portable.  Findings include

         stones, wall thickening, lumen distention, pericholecystic fluid, pain/Murphy sign (98% positive predictive 

         value in setting of stones and gallbladder-specific pain).

     c. HIDA helpful in indeterminant ultrasound

     d. CT also helpful in complicated cases

         1. Perforation

         2. Abscess formation

         3. Emphysematous complications

         4. Porcelain wall

     e.  Gangrenous cholecystitis

         1. 2-30% of cases

         2. Characterized by ischemia and wall necrosis

         3. Imaging findings include wall thickening, striations, intraluminal membranes, segmental absence of 

             wall enhancement

     f. Emphysematous cholecystitis

         1. Higher mortality, up to 15%

         2. More common in males (71%) and diabetics (50%).

     g. Perforated cholecystitis

         1. 8-12% of cases of acute cholecystitis

         2. Three patterns of spillage/complication

               i. Diffuse peritoneal spread

               ii. Focal abscess

  iii. Fistula

7. Chronic complications of gallstones

a. Chronic cholecystitis

1. 95% contain stones

2. Fibrotic, thickened wall

3. Compromised distensability and compliance.

4. May not have surrounding inflammatory changes/fluid

b. Mirizzi syndrome

1. Up to 2% of patients with symptomatic gallstone disease.

2. Obstruction of CHD or CBD secondary to stone or inflammation involving the cystic duct or gallbladder neck

c. Choledochoenteric fistula (Gallbladder ileus)

1. Obstruction of bowel, usually ileum secondary to stone passed via fistula between gallbladder

and duodenum

2. 1-5% of non-malignant causes of small bowel obstruction, in some series up to 25% in patients over 60.

3. Rigler's triad (seen in only 30%)

i. Bowel obstruction

ii. Pneumobilia

iii. Distal stone

d. Spilled gallstone

1. Occurs in up to 6-8% of cases

2. Complication uncommon - 1%, present with infection/abscess

3. Most common location is subhepatic, but can occur anywhere

4. Time of presentation variable, anywhere from 1 month to 10 years, most common around 4 months.

5. Requires stone removal.

e. Porcelain gallbladder

1. Consequence of chronic inflammation

2. Focal/diffuse calcification within wall

3. 20-50% risk of ultimate malignant degeneration

4. Indicator for elective cholecystectomy

f. Malignancy

Chronic irritation secondary to presence of stones felt to be a major contributor to occurrence, 65-90% of

cancers occur in setting of stones.

8. Ductal stones (choledocholithiasis)

Primary vs secondary

     a. 2-3%/year have migration of stones

     b. 1-2% symptomatic (colic, biliary obstruction, pancreatitis)

     c. Imaging

          1.  22-70% ultrasound sensitivity

          2. 65-88% sensitivity with MDCT, up to 95% with positive biliary contrast

          3. Sensitivity of 85-100% sensitivity with MRI/MRCP, detect stones down to 2 mm in size.