SAINT LOUIS UNIVERSITY SCHOOL OF NURSING BAGUIO CITY

CASE PRESENTATION:
CHOLELITHIASIS

SUBMITTED BY: BULAYUNGAN, CHRISTAL DEPNAG, KIRSTY MACARAEG, JOY ANNE NIPAL, JENNIFER QUITON, FEMA LYN UNIAS, JAMILA MARIE

SUBMITTED TO: MRS. ELISA V. LARUAN, RN

ANATOMIC AND PHYSIOLOGIC OVERVIEW:

THE LIVER
an organ located in the upper right quadrant of the abdominal cavity, just inferior to the diaphragm. It is partially surrounded by the ribs, and extends from the level of the 5th intercostals space to the lower margin of the ribs. pink to reddish brown triangular

FUNCTIONS:  It plays a key role in carbohydrate metabolism by helping maintain concentration of blood glucose within the normal range.  Hepatic cells responding to hormones such as insulin and glucagon lower the blood glucose level by polymerizing glucose to glycogen, and raise the blood glucose by breaking down glycogen to glucose or by converting non carbohydrates into glucose.  Lipid metabolism oxidizes fatty acids; synthesizes lipoproteins, phospholipids and cholesterol; converts portions of carbohydrate and protein molecules into fats.  Protein metabolism deaminates amino acids; forms urea; synthesizes plasma proteins; converts certain amino acids to other amino acids  Storage stores glycogen, iron and vitamins A, D and B 12  Blood filtering Removed damage red blood cells and foreign substances by phagocytosis  Detoxification Removes toxins from blood  Secretion- Secretes bile

THE GALL BLADDER

A pear shaped, hollow, saclike organ, 7.5 to 10 cm (3 to 4 inches ) long, lies in a shallow depression on the interior surface of the liver, to which it is attached by loose connective tissue. It may contain 30 to 50 ml of bile. Its wall is composed largely of smooth muscle and is connected to the common bile duct by the cystic duct.

FUNCTIONS:  It functions as a storage depot for bile. Between meals, when the sphincter of oddi is closed, bile produced by the hepatocytes enters the gall bladder. During storage, a large portion of the water in bile is absorbed through the walls of the gall bladder, so that bile in the gall bladder is five to 10 times more concentrated than that originally secreted by the liver. When food enters the duodenum, the gall bladder contracts and the sphincter of Oddi ( located at the junction of the common bile duct with the duodenum ) relaxes. Relaxation of this sphincter allows the bile to enter the intestine. this responses is mediated by the secretion of the hormone cholecystokinin- pancreozymin (CCK- PZ) from the intestinal wall.

BILE:
Bile is a digestive juice that is secreted by the liver and stored in the gallbladder. Bile does not contain enzymes like other secretions from the gastrointestinal tract. Instead it has bile salts (acids) which can: 1. Emulsify fats and break it down into small particles. This is a detergent-like action of bile. 2. Helps the body absorb the breakdown products of fat in the gut. Bile salts bind with lipids to form micelles. This is then absorbed through the intestinal mucosa. The other important function of bile is that it contains waste products from hemoglobin break down. This is known as bilirubin and is normally formed by the body as it gets rid of old red blood cells which

are rich in hemoglobin. Bile also carries excess cholesterol out of the body and dumps it into the gastrointestinal tract where it can be passed out with other waste matter. Bile Production The liver cells (hepatocytes) produce bile which collects and drains into the hepatic duct. From here it can enter the small intestine to act on fats by traveling down the common bile duct, or it can enter the gallbladder through the cystic duct, where it is stored. The liver manufactures between 600ml to 1 liter of bile in a day. As bile travels down the ducts, the lining of these passages, secrete water, sodium and bicarbonate ions into the bile, thereby diluting it. These additional substances help to neutralize the stomach acid which enters the duodenum with partially digested food (chyme) from the stomach.

Bile Salts Bile salts are constantly recycled in the body. It is secreted into the duodenum along with other compounds as bile. It binds with lipids to form micelles and eventually reenters the blood stream. By passing through the portal cirulation, bile salts enter the liver. Here it goes through the venous sinuses of the liver and is absorbed by the liver cells (hepatocytes). It is then ready to be secreted again by the liver cells to make up bile. This allows for over 90% of bile salts to be recycled in this manner (enterohepatic circulation of bile) and after about 15 cycles, it is discarded in the feces. The liver, nevertheless, constantly produces small amounts of bile salts to replenish the amounts that cannot be recirculated. Bile Storage The liver is constantly secreting bile, up to 1 liter in a 24 hour period, but most of it is stored in the gallbladder. This hollow organ can only hold 30 to 60 ml of bile and is able to store the large quantities of bile from the liver by concentrating it. The gallbladder is able to achieve this by resorption of water, sodium, chloride and other electrolytes through its lining. The other constituents of bile, like the bile salts, cholesterol, lecithin and bilirubin, stays in the gallbladder. Bile Concentration The gallbladder has to concentrate the bile so that it can store the bile salts and waste products of the liver bile. It actively transports sodium through the gallbladder mucosa. The other constituents like water, chloride and electrolytes then diffuse through the gallbladder lining. By doing this, gallbladder bile is 5 to 20 times more concentrated than liver bile. At this point, gallbladder bile is mainly composed of bile salts, and smaller volumes of bilirubin, cholesterol, lecithin and other electrolytes stay in the gallbladder. Bile Composition Bile, whether from the liver or gallbladder, contains the following substances :

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water bile salts bilirubin cholesterol fatty acids lecithin sodium potassium calcium chlorine bicarbonate ions

As mentioned, gallbladder bile is concentrated compared to liver bile. Bile salts make up the largest volume of gallbladder bile and can be 6 times more concentrated than bile salts in liver bile. Liver bile, however, has higher concentrations of :
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water sodium chlorine bicarbonate

Bile Secretion Between 20 to 30 minutes after eating a meal, the partially digested food enters the duodenum of the small intestine from the stomach as chyme (gastric emptying). The presence of food, especially fatty foods, in the stomach and duodenum stimulates the gallbladder to contract due to the action of cholecystokinin (CCK). The gallbladder then forces out bile and relaxes the sphincter of Oddi thereby allowing bile to enter the duodenum. The other stimulus for gallbladder contraction is nerve impulses from the vagus nerve and enteric nervous system. If sufficiently stimulated for a prolonged period (due to the presence of fatty foods), the gallbladder can empty its entire contents within an hour. Secretin, the digestive hormone that stimulate pancreatic secretion, also increases bile secretion. Its main effect, however, is to increase the secretion of water and sodium bicarbonate from the lining of the bile duct. This bicarbonate solution, along with pancreatic bicarbonate, is essential for neutralizing the stomach acid that is present in the duodenum. Bilirubin excretion Bilirubin is a pigment derived from the breakdown of haemoglobin by cells of the reticuloendothelial system, including the Kupfer cells of the liver. Hepatocytes remove bilirubin from the blood and chemically modify it through conjugation to glucuronic acid, which makes the bilirubin more soluble in aqueos solutions. The conjugated bilirubin is secreted by the hepatocytes into the adjacent bile canaliculi and is eventually carried in the bile into the duodenum.

In the small intestine, bilirubin is converted into urobilinogen, which is in part excreted in the feces and in part absorbed through the intestinal mucosa into the portal blood. Much of this eabsorbed urobilinogen is removed by the hepatocytes and is excreted into the bile once again (enterohepatic circulation). Some of the urobilinogen enters the systemic circulation and is excreted by the kidneys in the urine. Elimination of bilirubin in the bile represents the major route of excretion for this compound, The bilirubin concentration in the blood may be increased in the presence of liver disease, when the flow of bile is impeded or with excessive destruction of red blood cells. With bile duct obstruction, bilirubin does not enter the intestine; as a consequence, urobilinogen is absent from the urine and decreased in the stool. BRIEF REVIEW ON GALLSTONE FORMATION: The process of gallstone formation is referred to as cholelithiasis. It is generally a slow process, and usually causes no pain or other symptoms. The majority of gallstones are either the cholesterol or mixed type. Gallstones can range in size from a few millimeters to several centimeters in diameter. Most gallstones are formed from cholesterol. Pigment stones are also very common; they are formed from a brown-colored substance called calcium bilirubinate. Patients can have a mixture of the two gallstone types. Cholesterol Stones. Although cholesterol makes up only 5% of bile, about three-fourths of the gallstones found in the US population are formed from cholesterol. Cholesterol gallstones typically form in the following way:
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Cholesterol is not very soluble, so in order to remain suspended in fluid it must be transported within clusters of bile salts called micelles. If there is an imbalance between these bile salts and cholesterol, then the bile fluid turns to sludge. This thickened fluid consists of a mucus gel containing cholesterol and calcium bilirubinate. If the imbalance worsens, cholesterol crystals form (a condition called supersaturation), which can eventually form gallstones

Supersaturation and cholelithiasis can occur as a result of various abnormalities, although the cause is not entirely clear. There are many events that may promote cholelithiasis:
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The liver secretes too much cholesterol into the bile. The gallbladder may not be able to empty normally, so bile becomes stagnant. The cells lining the gallbladder may not be able to efficiently absorb cholesterol and fat from bile. There are high levels of bilirubin. Bilirubin is a substance normally formed by the breakdown of hemoglobin in the blood. It is removed from the body in bile. Some experts believe bilirubin may play an important role in the formation of cholesterol gallstones.

Pigment Stones. Pigment stones are composed of calcium bilirubinate, or calcified bilirubin. Pigment stones can be black or brown.

Mixed stones. Mixed stones are a mixture of cholesterol and pigment stones. RISK FACTORS FOR CHOLELITHIASIS:  Obesity  Women, those who have had multiple pregnancies or who are of Native American or Hispanic descent  Frequent changes in weight  Rapid weight loss  Treatment with high dose estrogen  Ileal resection or disease  Cystic Fibrosis  Diabetes Mellitus

PATIENTS PROFILE:
NAME: Mr. Juan De la Cruz AGE: 63 ADDRESS: Urdaneta, Pangasinan OCCUPATION: Employee ( DAR ) STATUS: Married RELIGION: Methodist BIRTHDATE: March 19, 1948

HISTORY OF PRESENT ILLNESS:

One month prior to condition, the client experienced remittent right upper quadrant pain radiating to back, aggravated after food intake, with positive bloatedness and pain characterized as pricking pain and rated as 5/10 in severity. The client has no episode of vomiting and nausea but has experienced loss of appetite. There were no interventions given .Rest and prevention of stress was observed. 1 week prior to admission, the client has undergone annual medical check up and had his abdominal ultrasound wherein it revealed a multiple gallstone hence the client was scheduled for Lap chole hence admission.

HISTORY OF PAST ILLNESSES:

The client has been previously hospitalized due to abdominal pain. He had undergone operation of the urinary bladder due to stone at the year 1979 and based on endoscopy, he has multiple polyps. The client has hypertension and is taking Amlodipine as his maintenance. The client is previously a chain smoker and consumes two packs of cigarettes ever since he was 13 years old, he had stopped smoking

for 6 years. The client is an occasional alcohol drinker. The client admitted that he loves to eat fatty and salty foods and that he didn t drink enough water ( 500-1000 ml/ day ). His bowel elimination is regular ( one times a day ) and he describe his urination as normal ( painless, 7-10 times a day in estimation, yellowish in color ). The client has no history of diabetes and has no food and drug allergies. The client stated that he has sedentary lifestyle since he has no exercise. The client doesn t use family planning. DIAGNOSIS: cholelithiasis

SURGICAL PROCEDURES:

LAPAROSCOPIC CHOLECYSTECTOMY:
Indications: (i) Symptomatic gallstones - Pain, nausea and vomiting from gallstones (ii) Complications from gallstones - infection, pancreatitis, jaundice (iii) Polyps/suspicion of cancer of gallbladder(eg porcelain gallbladder) , Gallbladder polyps >0.5 cm CONTRAINDICATIONS Contraindications to laparoscopic cholecystectomy are primarily related to anesthetic concerns and include diffuse peritonitis with hemodynamic compromise and uncontrolled bleeding disorders The inability to tolerate general anesthesia is considered a relative contraindication, but successful laparoscopic cholecystectomy under spinal anesthesia has been reported .

Advantages: Laparoscopy has largely replaced open cholecystectomy because it offers some significant advantages:
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The patient can leave the hospital and resume normal activities earlier, compared to open surgery. The incisions are small, and there is less postoperative pain and disability than with the open procedure. There are fewer complications. It is less expensive than open cholecystectomy over the long term. The immediate treatment cost of laparoscopy may be higher than the open procedure, but the more rapid recovery and fewer complications translate into shorter hospital stays and fewer sick days, and therefore a greater reduction in overall costs.

Procedure:

The surgeon will make 4 small slits in the abdomen. A port ( nozzle ) is inserted into one of the slits and carbon dioxide gas inflates the abdomen. This process allows the surgeon to see the gall bladder more easily. A laparoscope is inserted through another port. Surgical instruments are placed into the other small openings and used to remove the gall bladder. The surgeon removes the gall bladder through the incision. The carbon dioxide comes out through the small slits and then the sites are closed with sutures, steri strips. Risk Factors for Conversion from Laparoscopy to an Open Procedure. In about 5 - 10% of laparoscopies, conversion to open cholecystectomy is required during the procedure. The rate of conversion to open surgery is higher in men than in women. This may be due to the higher rate of inflammation and fibrosis in men with symptomatic gallstones. Other reasons for conversion from laparoscopic to open surgery include:
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Possible or known injury to major blood vessels Internal structures are not clearly visible Unexpected problems that cannot be corrected with laparoscopy Common bile duct stones that cannot be removed with laparoscopy or subsequent ERCP A thickened gallbladder wall

Complications and Side Effects of Surgery

 Pain and fatigue are common side effects of any abdominal surgery. Patients should avoid light

recreational activities for about 2 days and from work and more strenuous activities for about a week. There is a relatively high incidence of nausea and vomiting after laparoscopic cholecystectomy, which can be treated with injections of metoclopramide. Patients may take anti-nausea medications such as granisteron before surgery to help prevent these effects. Local anesthesia at the incision sites (in addition to general anesthesia) before surgery may reduce pain and nausea afterwards. Injury to the bile duct is the most serious complication of laparoscopy. It can include leakage, tears, and the development of narrowing (strictures) that can lead to liver damage. In order to minimize such injuries, some experts recommend that surgeons perform laparoscopy with cholangiography. Bile duct injury has been a more common problem in laparoscopy compared to the open procedure, but increasing surgical experience and the use of cholangiography is reducing this complication. Studies are reporting more comparable rates between the two procedures. In about 6% of procedures, the surgeon misses some gallstones, or they spill and remain in the abdominal cavity. In a small percentage of these cases, the stones cause obstruction, abscesses, or fistulas (small channels) that require open surgery. As with all surgeries, there is a risk for infection, but it is very low.

Obese patients were originally thought to be poor candidates for laparoscopic cholecystectomy, but recent research indicates that this surgery is safe for them.

OPEN CHOLECYSTECTOMY:
Candidates for whom cholecystectomy may be a more appropriate choice:
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Patients who have had extensive previous abdominal surgery Patients with complications of acute cholecystitis (empyema, gangrene, perforation of the gallbladder)

Older patients. Patients who are over 80 years old are likely to have lower complication rates from open cholecystectomy than laparoscopy, although laparoscopy may also be appropriate in these patients. ADVANTAGES: compared to laparoscopy
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It is faster to perform. It poses less of a risk for bile duct injury compared with laparoscopy. However, open surgery has more overall complications than laparoscopy, and bile-duct injury rates with laparoscopy are declining.

PROCEDURE:

The surgeon makes an incision approximately 6 inches long in the upper right side of the abdomen and cuts through the fat and muscle to the gall bladder. The gall bladder is removed, and any ducts are clamped off. The site is stapled or sutured closed and a small drain maybe placed
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Despite its lower risks, surgical cholecystectomy has a high mortality rate (20% to 30% ) because of the underlying disease process.

RISK OF CHOLECYSTECTOMY: INFECTION COMMON BILE DUCT INJURY BLEEDING BILE LEAKAGE < 1 per 1000 patients in laparoscopic 1 per 1000 patients in open and 1-5 per 1000 in laparoscopic rare rare

RETAINED COMMON BILE DUCT STONE PNEUMONIA HEART PROBLEMS KIDNEY PROBLEMS

DEEP VEIN THROMBOSIS PREMATURE LABOR AND FETAL LOSS

INJURY TO THE INTESTINES OR ABDOMINAL ORGANS DEATH

A gallstone may pass after the surgery and block the bile from draining General anesthesia and lack of deep breathing exercises may contribute rare Kidney or urinary problem has been reported in 5 per 1000 patients. Dehydration and liver problems can increase the risk. No movement during surgery can lead to blood clots forming in the legs. Fetal loss is reported as 40 to 1000 pts. for uncomplicated chole and as high as 600 per 1000 patients when pancreatitis is present. Instrument insertion or used during laparoscopic procedure technique can injure the intestines. Death is extremely rare in healthy people and is reported as 0 to 1 per 1000 patients. The risk of death increases with gangrene, a burst gallbladder or severe diseases.

ERCP with Endoscopic Sphincterotomy (ES)

Reasons for performing the procedure:
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Before gallbladder surgeries, when there is a strong suspicion that common bile duct stones are present. At the end of a cholecystectomy, if the surgeon detects stones in the common bile duct (only if there are experts in ERCP present, and equipment is available). For patients with gallstone cholangitis (serious infection in the common bile duct). In such cases urgent ERCP and antibiotics are required. When acute pancreatitis is caused by gallstones, urgent ERCP, along with antibiotics, may be used. The use of ERCP compared to conservative treatment has been controversial.

The ERCP and ES Procedure A typical ERCP and endoscopic sphincterotomy (ES) procedure includes the following steps:
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The patient is given a sedative and asked to lie on his or her left side. An endoscope (a tube containing fiber optics connected to a camera) is passed through the mouth and stomach and into the duodenum (top part of the small intestine) until it reaches the point where the common bile duct enters. This does not interfere with breathing, but the patient may have a sensation of bloating. A thin catheter (tube) is then passed through the endoscope. Contrast material (a dye) is injected through the catheter into the opening of the duct. The dye allows x-ray visualization of the biliary tree (the system of ducts through which bile flows, including the common bile duct) and any stones contained in the area. Instruments may also be passed through the endoscope to remove any stones that are detected. The next phase of the procedure is known as endoscopic sphincterotomy (ES). (It is also sometimes referred to as papillotomy, although this is a slightly different variation.) ES widens the junction between the common bile duct and intestine (the ampulla of Vater) so that the stones can be extracted more easily. With ES, a tiny incision is usually made in the opening of the common bile duct and through the muscles that enclose the lower common bile duct (the sphincter of Oddi). One recent alternative to ES is the use of a small inflatable balloon (a procedure known as endoscopic balloon dilation) that opens up the ampulla of Vater to allow stones to pass. This variation does not involve cutting muscles. Once the junction has been opened, the stones may pass on their own, or they may be extracted with the use of tiny baskets or balloons.

Complications Complications of ERCP and ES occur in 5 - 8% of cases, and some can be serious. Mortality rates are 0.2 0.5%. Complications include the following:
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Pancreatitis (inflammation of the pancreas) occurs in 3 - 9% of cases and can be very serious. Younger adults are at higher risk than the elderly. The risk is also higher with more complex procedures. The drugs somatostatin or gabexate are sometimes used to reduce the risk, although recent evidence suggests somatostatin may not actually reduce this risk. Gabexate appears to be more effective, although studies are mixed on whether its benefits are significant, particularly with short-term treatment. Postoperative infection. Antibiotics may be given before the procedure to prevent infection, although one study reported that they had little benefit. Bleeding occurs in 2% of cases. There is an increased risk for bleeding in patients taking anticlotting drugs, and those who have cholangitis. This complication is treated by flushing the area with epinephrine. Perforations (rare) Long-term complications include stone recurrence and abscesses.

ERCP and ES are difficult procedures, and patients must be certain that their doctor and medical center are experienced. ERCP can usually be performed successfully by an experienced surgeon, even in critically ill patients who are on mechanical ventilators. ERCP and Gallbladder Removal (Cholecystectomy). ERCP is often performed after gallstones in the common duct are discovered during cholecystectomy. In some cases, stones in the gallbladder are detected during ERCP. In such cases, laparoscopic cholecystectomy is usually warranted. There is some debate about whether the gallbladder should be removed at the same time as ERCP, or if patients should wait.

NURSING DIAGNOSIS:
       Acute pain and discomfort related to surgical incision Imbalanced nutrition less than body requirements related to inadequate bile secretion Risk for constipation related to effects of surgery Risk for infection related Impaired skin integrity related to disruption of first line of defense Activity Intolerance Altered Role Performance

NURSING MANAGEMENT:
 Relieve pain because full expansion of the lungs and gradually increased activity are necessary to prevent post operative complications, administration of analgesics is necessary to relieve the pain and to promote well being.  Maintain Skin Integrity observed for indications of infections and observed handwashing.

 Improve nutritional Status encourage client to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery.  Monitor and manage potential complications closely monitor vital signs and inspects the surgical incisions. Assess the patient for increased tenderness and rigidity of the abdomen. Instruct patient and family to report any change in the color of stools, because this may indicate complications. Assess for anorexia, vomiting, pain, abdominal distention or disruption of the GI tract.  REFERENCES: Shier, D et al (2009). Hole s Essentials of Human Anatomy and Physiology, 10th edition Smeltzer,S. et al (2010). Brunner and Suddarth s textbook of Medical- Surgical Nursing, 12th edition http://www.mdguidelines.com/cholecystectomy/how-procedure-is-performed retrieved last January 14,2011