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 sicklecell 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.

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 bodys 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
PREDISPOSING 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
PREDISPOSING 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
PREDISPOSING 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
PREDISPOSING 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
PRECIPITATING 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
PRECIPITATING 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
PRECIPITATING 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
PRECIPITATING 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

C. SIGNS AND SYMPTOMS

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

C. SIGNS AND SYMPTOMS

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 pains intensity. Pain
may persist for a few hours or several days and
the interval between attacks is variable.

C. SIGNS AND SYMPTOMS

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 ILLNESS
Patient 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
fathers side. She also added they dont have history of
cholelithiasis or any problem in the bile.

IV. Gordons 11 Functional Pattern

A. Health-Perception and Health Management Pattern
Patients 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.

IV. Gordons 11 Functional Pattern

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.

IV. Gordons 11 Functional Pattern

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.

IV. Gordons 11 Functional Pattern

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.

IV. Gordons 11 Functional Pattern

D. Activity-Exercise Pattern
Prior to hospitalization, patient do the household chores daily and
served it as her regular exercise.
But upon admission, patients only means of exercise is active
range of motion. With patients 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.

IV. Gordons 11 Functional Pattern

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 shes quite worried about her current
condition. During assessment, patient has been responsive
and cooperative to our questions being asked.

IV. Gordons 11 Functional Pattern

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.

IV. Gordons 11 Functional Pattern

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.

VI. PHYSICAL ASSESSMENT

Vital signs

VI. PHYSICAL ASSESSMENT

Head to Toe Assessment

VI. PHYSICAL ASSESSMENT

VI. PHYSICAL ASSESSMENT

VII. LABORATORY
FINDINGS/DIAGNOSTIC
EXAMINATIONS
Urinalysis (August 24, 2015)

VII. LABORATORY
FINDINGS/DIAGNOSTIC
EXAMINATIONS
Complete Blood Count (August 24, 2015)

VII. LABORATORY
FINDINGS/DIAGNOSTIC
EXAMINATIONS
Complete Blood Count (August 24, 2015)

VII. LABORATORY
FINDINGS/DIAGNOSTIC
EXAMINATIONS
Blood Chemistry (August 24, 2015)

VII. LABORATORY
FINDINGS/DIAGNOSTIC
EXAMINATIONS
Blood Chemistry (August 24, 2015)

VII. LABORATORY
FINDINGS/DIAGNOSTIC
EXAMINATIONS
Ultrasound (August 23, 2015)

VII. LABORATORY
FINDINGS/DIAGNOSTIC
EXAMINATIONS
Ultrasound (August 23, 2015)

VIII. ANATOMY AND PHYSIOLOGY

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.

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

X. DRUG STUDY

X. DRUG STUDY

X. DRUG STUDY

X. DRUG STUDY

X. DRUG STUDY

XI. NURSING CARE PLAN

XI. NURSING CARE PLAN

XI. NURSING CARE PLAN

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.