CHOLELITHIASIS

A Case Study submitted in partial fulfillment of the requirements in

Related Learning Experience, 2nd Semester SY 2018-2019

Submitted by:

Belle Roxanne Reginaldo

BSN III

Submitted to:

Mr. Jaymar Rogado RN

Clinical Instructor
 Introduction

Symptoms and complications of gallstone disease result from effects occurring

within the gallbladder or from stones that escape the gallbladder to lodge in the
common bile duct.

Asymptomatic gallstones

Gallstones may be present in the gallbladder for decades without causing

symptoms or complications. In patients with asymptomatic gallstones discovered
incidentally, the likelihood of developing symptoms or complications is 1%-2% per year.
In most cases, asymptomatic gallstones do not require any treatment.

Because they are common, gallstones often coexist with other gastrointestinal
conditions. There is little evidence to support a causal association between gallstones
and chronic abdominal pain, heartburn, postprandial distress, bloating, flatulence,
constipation, or diarrhea.

Dyspepsia that occurs reproducibly following ingestion of fatty foods is often

wrongly attributed to gallstones, when irritable bowel syndrome or gastroesophageal
reflux is the true culprit. Gallstones discovered during an evaluation for nonspecific
symptoms are usually innocent bystanders, and treatment directed at the gallstones is
unlikely to relieve these symptoms.

Biliary colic

Pain termed biliary colic occurs when gallstones or sludge fortuitously impact in
the cystic duct during gallbladder contraction, increasing the gallbladder wall tension. In
most cases, the pain resolves over 30 to 90 minutes as the gallbladder relaxes and the
obstruction is relieved.

Episodes of biliary colic are sporadic and unpredictable. The patient localizes the
pain to the epigastrium or right upper quadrant and may describe radiation to the right
scapular tip (Collins sign [11] ). The pain begins postprandially (usually within an hour
after a fatty meal), is often described as intense and dull, and may last from 1-5 hours.
From the onset, the pain increases steadily over about 10 to 20 minutes and then
gradually wanes when the gallbladder stops contracting and the stone falls back into the
gallbladder. The pain is constant in nature and is not relieved by emesis, antacids,
defecation, flatus, or positional changes. It may be accompanied by diaphoresis, nausea,
and vomiting.

Other symptoms, often associated with cholelithiasis, include indigestion,

dyspepsia, belching, bloating, and fat intolerance. However, these are very nonspecific
and occur in similar frequencies in individuals with and without gallstones;
cholecystectomy has not been shown to improve these symptoms.

Most patients develop symptoms prior to complications. Once symptoms of

biliary colic occur, severe symptoms develop in 3%-9% of patients, with complications in
1%-3% per year and a cholecystectomy rate of 3%-8% per year. Therefore, in people
with mild symptoms, 50% have complications after 20 years.

Zollinger performed studies in the 1930s in which the gallbladder wall or the
common bile duct was distended with a balloon; pain was elicited in the epigastric
region. Only if the distended gallbladder touched the peritoneum did the patient
experience right upper quadrant pain. Associated symptoms of nausea, vomiting, or
referred pain were present with distention of the common bile duct (CBD) but not of the
gallbladder
 Patient’s Profile

The patient localizes the pain on right upper quadrant. The abdominal pain last for a
week. The pain begins postprandially (usually within an hour after a fatty meal), is often
described as intense and dull, and may last from 1-5 hours. From the onset, the pain increases
steadily over about 10 to 20 minutes and then gradually wanes when the gallbladder stops
contracting and the stone falls back into the gallbladder. The pain is constant in nature and is
not relieved by emesis, antacids, defecation, flatus, or positional changes. It may be
accompanied by diaphoresis, nausea, and vomiting. Other symptoms, often associated with
cholelithiasis, include indigestion, dyspepsia, belching, bloating, and fat intolerance. However,
these are very nonspecific and occur in similar frequencies in individuals with and without
gallstones; cholecystectomy has not been shown to improve these symptoms.
 Anatomy and Physiology

Gallbladder is a muscular organ that serves as a reservoir for bile and present
inmost vertebrates. In humans, it is a pear-shaped membranous sac on the under
surface of the right lobe of the liver just below the lower ribs. It is generally about 7.5
cm (about 3 in) long and2.5 cm (1 in) in diameter at its thickest part; it has a capacity
varying from 1 to 1.5 fluid ounces. The body (corpus) and neck (collum) of the
gallbladder extend backward, upward, and the left. The wide end (fundus) points
downward and forward, sometimes extending slightly beyond theedge of the liver.
Structurally, the gallbladder consists of an outer peritoneal coat (tunicaserosa); a middle
coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner mucous
membrane coat (tunica mucosa). Once the gallbladder is removed, bile is delivered
directly from the liver ducts to the upper part of the intestine.

Anatomy of the Liver

The largest organ in the body located under the diaphragm more on the right
side of the body specifically at the upper right quadrant of the body. The dark, reddish
brown colored liver usually weighs 1.4 kg or about 3 lbs. It is enclosed by a fibrous
connective tissue known as capsule. It has four lobes and is suspended from the
diaphragm and abdominal wall by a delicate mesentery cord, the falciform ligament. It
has many metabolic and regulatory roles; however, its digestive function is to produce
bile. Bile leaves the liver through the common hepatic duct and enters the duodenum
through the bile duct. The functional unit of liver is lobule and hepatocyte is the major
cell. Bile is a yellow-to green, watery solution containing bile salts, bile pigments (chiefly
bilirubin, a breakdown product of hemoglobin), cholesterol, phospholipids, and a variety
of electrolytes. Of these components, only the bile salts (derived from cholesterol) and
phospholipids aid the digestive process. Bile does not contain enzymes, but its bile salts
emulsify fats by physically breaking large fat globules into smaller ones, thus providing
more surface area for the fat-digesting enzymes to work on. From the liver, bile drips
into the hepatic duct, which soon meets the cystic duct arriving from the gallbladder.
Converging, they form one duct, the common bile duct, which meets the pancreatic
duct, carrying enzymatic fluid from the pancreas. Like a smaller river meeting a larger
one, the pancreatic duct loses its own name at this confluence and becomes part of the
common bile duct, which empties on demand into the duodenum. When the sphincter
of the bile duct is closed, bile from the liver is forced to back up into the cystic duct, and
eventually into the gallbladder. There it is stored and concentrated until needed, when
it flows back down the cystic duct. Lobes of liver: Right and left lobes* liver receives
blood from 2 sources:

Hepatic artery-will supply oxygen blood to the liver cells

Hepatic portal vein- will bring deoxygenated

Pathophysiology