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INTRODUCTIONCholedocholithiasis is the presence of gallstones in
the common bile duct. The stone may consist of bile pigments or calcium and cholesterol salts. It has two types: Secondary Common Bile Duct Stones, common bile duct stones originally form in the gallbladder and pass into the common duct. They are then called secondary stones. Primary Common Bile Duct Stones,the stones form in the common duct itself (called primary stones). Primary common duct stones are usually of the brown pigment type and are more likely to cause infection than secondary common duct stones.
Choledocholithiasis is one of the complications of cholelithiasis (gallstones), so the initial step is to confirm the diagnosis of cholelithiasis. Typically patients with cholelithiasis present with pain in the right upper quadrant of the abdomen with the associated symptoms of nausea and vomiting, especially after a fatty meal. The physician can confirm the diagnosis of cholelithiasis with an abdominal ultrasound that shows the ultrasonic shadows of the stones in the gallbladder.
The diagnosis of choledocholithiasis is suggested when the liver function blood test shows an elevation in bilirubin. The diagnosis is confirmed either with a magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. If the patient must have the gallbladder removed for gallstones, the surgeon may choose proceed with the surgery, and obtain a cholangiogram during the surgery. If the cholangiogram shows stone in the bile duct, the surgeon may attempt to treat the problem by flushing the stone into the intestine or retrieve the stone back through the cystic duct.
Stones may form in the bile duct when bile backs up because a duct has narrowed or after the gallbladder has been removed. While stones can frequently pass through the common bile duct into the duodenum, some stones may be too large to pass through the common bile duct and may cause an obstruction. One risk factor for this is duodenal diverticulum. This obstruction leads to elevation in alkaline phosphatase, increase in conjugated bilirubin in the blood and increase in cholesterol in the blood. It can also cause acute pancreatitis and ascending cholangitis.
The reasons why we have chosen this case are:
To be more knowledgeable of the diseaseTo determine the cause and effect of having gallstones in the common bile ductTo determine different ways on how to handle patients with choledocolithiasis
PATIENT’S PROFILE Patient’s Name: Mr. V.M
Date of Birth: Nov. 11, 1979
Place of Birth: Manila
Age: 30 yrs. old
Gender: Male
Religion: Roman Catholic
Nationality: Filipino
Civil Status: Married
Admission Date: February 2, 2010
Admission time: 1:10 pm
Attending Physician: Dr. Garrido
Chief Complaint: Rub Pain
History of past illness:
2 ½ months PTA with epigastric pain, coli not aggravated by food intake
With no presence of jaundice ,no alcholic stools and tea colored urine
No fever – consult with ER, given IV meds HNBB, Ketorolac & Omeprazole
relief – went home and OPD follow up follow up at OPD diagnostic done HBt = with choledecho – taken
Physical AssessmentEYES:Anicteric sclerapink supple neck palpebral conjunctiva
SKIN:No presence of jaundiceNo edemaGenerally uniform skin color except in areas exposed to the sun.Good skin turgorBrowned skinned colorNAILS:Highly vascular and pink fingernail and toenail bed color.Intact epidermisPrompt return of pink color for less than 4 seconds in Capillary refill test.ABDOMEN:FlabbyNormal active bowel soundSoftNo direct and indirect tenderness on all quadrantsNo mass palpated
LIVER
An adult human liver normally weighs between 1.4–1.6 kg (3.1–3.5 lb),[4] and is a soft, pinkish-brown, triangular organ. It is both the largest internal organ (the skin being the largest organ overall) and the largest gland in the human body.
It is located in the right upper quadrant of the abdominal cavity, resting just below the diaphragm. The liver lies to the right of the stomach and overlies the gallbladder.
GALLBLADDER
The gallbladder is a hollow organ that sits in a concavity of the liver known as the gallbladder fossa. In adults, the gallbladder measures approximately 8 cm in length and 4 cm in diameter when fully distended. It is divided into three sections: fundus, body, and neck. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct.
The adult human gallbladder stores about 50 millilitres (1.8 imp fl oz; 1.7 US fl oz) of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats in partly digested food.
After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats.
COMMON BILE DUCT
The common bile duct (ductus choledochus) is a tube-like anatomic structure in the human gastrointestinal tract. It is formed by the union of the common hepatic duct and the cystic duct (from the gall bladder). It is later joined by the pancreatic duct to form the ampulla of Vater. There, the two ducts are surrounded by the muscular sphincter of Oddi.
When the sphincter of Oddi is closed, newly synthesized bile from the liver is forced into storage in the gall bladder. When open, the stored and concentrated bile exits into the duodenum. This conduction of bile is the main function of the common bile duct. The hormone cholecystokinin, when stimulated by a fatty meal, promotes bile secretion by increased production of hepatic bile, contraction of the gall bladder, and relaxation of the Sphincter of Oddi.
Several problems can arise within the common bile duct. If clogged by a gallstone, a condition called choledocholithiasis can result. In this clogged state, the duct is especially vulnerable to an infection called ascending cholangitis. Very rare deformities of the common bile duct are cystic dilations (4 cm), choledochoceles (cystic dilation of the ampula of Vater (3-8 cm)), and biliary atresia.
CYSTIC DUCT
Bile can flow in both directions between the gallbladder and the common hepatic duct and the (common) bile duct.
In this way, bile is stored in the gallbladder in between meal times. The hormone cholecystokinin, when stimulated by a fatty meal, promotes bile secretion by increased production of hepatic bile, contraction of the gall bladder, and relaxation of the Sphincter of Oddi.
HEPATIC DUCT
The common hepatic duct is the duct formed by the convergence of the right hepatic duct (which drains bile from the right functional lobe of the liver) and the left hepatic duct (which drains bile from the left functional lobe of the liver). The common hepatic duct then joins the cystic duct coming from the gallbladder to form the common bile duct. The duct is usually 6–8cm length and 6mm in diameter in adults.
PATHOPHYSIOLOGYModifiable
Diet (fried,salty &fatty foods)
Obesity
Non modifiableAge (30 yrs. Old above)
Bile is composed of bile salts and very small amount of cholesterol
An imbalance between the bile salt and cholesterol turns bile fluid into sludge.
If worsens, cholesterol crystal form (a condition called Supersaturation) that eventually form gallstones
Secondary common bile duct stones
Bile duct obstruction occurs leads to inflamed gall bladder
Signs and symptoms-intermittent pain in the right upper quadrant in epigastric area-inflammation of the gall bladder
Choledocholithiasis
MEDICAL MANAGEMENT (DOCTOR’S ORDER)
DATE ORDER RATIONALE
February 2, 2010 Please admit to 4N under the service of Dr.Garrido Charity
-For further managements.
Secure consent for admission and management
-To know if the client agrees to undergo management and confinement.
Low salt, low fat diet -Increase salt and fat intake contributes to gall stones formation.
Labs:
HBT,UTZ
- To visualize abnormalities present in the liver, common bile and gall bladder
B1 (Bilirubin 1)
B2 Bilirubin 2)
-Increase bilirubin indicates presence of jaundice and liver damage.
CBC -To know blood components.
Hepatitis Profile -To know whether the patient has history of hepatitis.
Alkaline Phosphatase -Aids in diagnosing liver disorder.
PT
PTT
BT
-Test done to prevent increase blood loss during the surgical procedure.
SGPT
SGOT
-Initial step in detecting liver damage.
CXR PA -To check for cardio pulmonary clearance, if the patient can tolerate surgery.
Attach lab results to chart
-For easy accessibility of the doctor and the whole health care team.
February 3, 2010 Continue low fat / low cholesterol diet
-Increase salt and fat intake contributes to gall stones formation.
For cholecystectomy on Friday
-Removal of gallstones.
Secure consent and needs for procedure
-It is important to know whether the patient has agreed to undergo a certain procedure.
February 4, 2010 For cholecystectomy with possible CBDE
-Removal of gallstone and to locate the gallstone in the bile
duct. Continue low fat, low salt diet
-Increase salt and fat intake contributes to
gall stones formation. February 5, 2010 For cholecystectomy
possibly on Tuesday-Removal of
gallstones February 8, 2010 Still for
cholecystectomy -Removal of
gallstones low fat, low salt diet -Increase salt and fat
intake contributes to
gall stones formation.
For cholecystectomy, CBDE tomorrow
-Removal of gallstone; to locate the gallstone
in the bile duct. Secure consent -It is important to
know whether the patient has agreed to undergo a certain
procedure. NPO post midnight -Preparation prior to
surgery; to empty stomach in preventing vomiting leading to
aspiration Ceftriaxone 2g/IV on call to OR ANST(-)
-Antibiotic for early prevention of infection
Ranitidine 50mg/IV q8
while on NPO -To prevent gastrointestinal
discomfort.
Start hemolysis = D5LR 1L x 8 hrs over on NPO
-For replacement of
fluids and electrolytes.
7:20 pm Anesthesia pre-op medicine
-Preparation prior to surgery.
NPO post midnight -Preparation prior to surgery; to empty stomach in preventing vomiting leading to
aspiration IVF: D5LR 1L x 8 hrs
once on NPO -For replacement of
fluids and electrolytes. Meds:
Nalbuphine 10mg -For pre-op analgesia, supplement to
balanced anesthesia Promethazine 25 mg -Lowers BP, induced
sleep. Temporary
sedation
Ranitidine 50mg IV q 8 once on NPO
-To prevent gastrointestinal
discomfort. Secure the following:
1.) Epidural catheter set # 1
2.)Bupivacaine Isobaric 0.50% 10 ml
amp # 5
-Where anesthetic pre op medicines are injected
.-Anesthetic
Monitor VS before giving premeds, refer
if BP < 90/60
-If the BP is <90/60, Promethazine should not be given and elevate the patient’s feet for 30mins and recheck the BP after
February 9, 2010 For cholecystectomy today
-Removal of
gallstones
February 10, 2010 For cholecystectomy
on Friday -Removal of
gallstones Continue low fat & cholesterol diet
-Increase salt and fat intake contributes to gall stones formation.
Follow-up examination shows the gall bladder measuring 8.4 x 3.3 cms (previously 4.9 x 2.5 cms., December 9,2009). Its wall measures 4.2mm in thickness there is an echogenic structure noted lodged in the proximal cystic duct measuring 8.5mm in diameter at its widest.
The liver is normal in size and echotexture. The intra-hepatic ducts are not dilated. The common bile duct measures 5.2 mm.
The pancreas is normal in size and echotexture. No focal mass noted. The head measures 2.2 x 1.7cms. The body measures 1.2cms while the tail measures 0.9cms in thickness.
IMPRESSION:Choledocolithiasis, probably causing biliary duct
obstruction.Thickened gall bladder wall, beginning cholecystitis is
highly considered.Suggest close monitoring to rule out beginning
Hydrops.Ultrasonically normal liver,pancreas and spleen.
ULTRASOUND OF THE UPPER ABDOMEN:
LABORATORY RESULTSSpecimen: Serum Date: January 29, 2010Examination: Bilirubin
Results:
Normal Values
Patient’s Result
Clinical Significance
Total Bilurubin
3.42 – 20.52 22.35 umol/l Indicates hemolytic anemia
Direct Bilirubin
0 – 8.55 5.55 umol/l In normal range
Indirect Bilurubin
3.42 – 11.97 16.80 umol/l Indicates hepatocellular
damage
Specimen: Blood Date: January 14,2010Examination: Serum
Results:
Normal Values
Patient’s Results
Clinical Significance
SGPT (ALT)
8-35 units 20.0 units In normal range
SGOT (AST)
18-40 units 18.0 units In normal range
ULTRASOUND OF HEPATOBILIARY TREE
Date: December 9, 2009
The liver is normal in size and echo pattern. No focal mass noted. The intrahepatic, extrahepatic as well as common bile ducts measures 4.8mm.
The gall bladder measures 4.9x2.5cms.
Impression:
Ultrasonically normal liver, common bile and gall bladder.
TPR Monitoring Sheet
February 8, 2010
8am 12nn 4pm 8pm 12mn
BP 110/80 120/80 110/70 120/80 120/80
PR 61 60 80 80 78
RR 18 18 20 18 18
Temp 36 36.2 36 36.2 36
February 9, 2010
8am 12nn 4pm 8pm 12mn
BP 120/80 110/80 120/80 120/80 120/80
PR 82 67 65 72 64
RR 20 18 17 20 22
Temp 36 36.7 36.2 36.2 36.2
February 10, 2010
8am 12nn
BP 120/80 130/70
PR 68 87
RR 22 19
Temp 36 .3 36.5
DRUG STUDYBrand Name Action Indication
Zantac
Generic Name:
Ranitidine
Classification:
Gastrointestinal/ Hepatobiliary
drugs
Dosage:
50mg
Preparation:
IV
Frequency:
TID / every 8 hours once NPO
Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits
gastric acid secretion
Used in the management of
various GI disorders such as dyspepsia, gastro-esophageal reflux
(GERD), Prophylaxis of GI
hemorrhage in patients at risk of developing acid aspiration during
general anesthesia
Contraindication Side Effect Nursing Consideration
Hypersensitivity. History of acute pophyria. Long term therapy
Cardiac arrhythmias, bradycardia. Headache, somnolence, fatigue, dizziness, hallucinations, depression, insomnia. Alopecia, rash, erythema multiforme. Nausea, vomiting, abdominal discomfort, diarrhea, constipation pancreatitis.
-Ensure right dosage, route, and client before administering the drug.
-Always monitor the pt for possible manifestations of any adverse effects of the drug
-Monitor heart rate of the patient upon administration of the drug
-Assess for renal and hepatic impairment
Brand Name Action Indication
Xtenda
Generic Name:
Ceftriaxone
Classification:
Antibiotic
Dosage:
2gm
Preparation:
IV
Frequency:
On call to OR
Inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death
Pre-operative prophylaxis to reduce chance of post-op surgical infections
Contraindication Side Effect Nursing Consideration
Hypersensitivity to cephalosporins and penicillins, lidocaine or any other local anaesthetic product of the amide type. Neonates and premature infants with bilirubin encephalopathy
Pain, induration, phlebitis after IV administration, rash, diarrhea, casts in urine, thrombocytosis, leucopenia. Elevation of aspartate transaminase (AST), alanine transaminase (ALT), blood urea nitrogen (BUN) and creatinine
-Always watch out for manifestations of any adverse effects.
-Assess urine and stool of the patient
-Assess patient previous sensitivity reaction to penicillin or other cephalosporins
Brand Name Action Indication
Nubain
Generic Name:
Nalbuphine
Classification:
Analgesic, muscle relaxants and uricosurics
Dosage:
10mg
Preparation:
IM
Frequency:
On call to OR
Binds with opiate receptors in the CNS, ascending pain pathways in limbic system, thalamus, midbrain, hypothalamus, altering perception of and emotional response to pain. Relieves pain
Relief of moderate to severe pain; for pre-op analgesia, supplement to balanced anaesthesia, surgical anaesthesia.
Contraindication Side Effect Nursing Consideration
Hypersensitivity. Pregnancy (Category D-only if used for prolonged periods or high doses at term
Sedation, drowsiness, sweating, phenothiazine, sedatives, hypnotics, alcohol
- Inform patient of possible side effects.
-Ensure that the client has no sensitivity/ allergy
-Assess pain characteristics
-Monitor respiratory rate depression
Brand Name Action Indication
Phenergan
Generic Name:
Promethazine HCl
Classification:
Anti-allergic
Antihypertensive
Dosage:
25mg
Preparation:
IM
Frequency:
On call to OR
May increase, prolong, or intensify the sedative action of other CNS depressants such as alcohol, sedatives/ analgesics, general anaesthetics
Anaphylactic reactions, as adjunctive therapy to epinephrine and other standard measures, after the acute manifestations have been controlled.
Contraindication Side Effect Nursing Consideration
Antihistamine are contraindicated for use in the treatment of lower respiratory tract symptoms including asthma
Drowsiness is the most prominent CNS effect of this drug. Sedation, somnolence, blurred vision, dizziness, confusion, disorientation and extra pyramidal symptoms such as oculogyric crisis
-Accompany the patient if he / she is experiencing blurring of vision
-Always monitor blood pressure and respiration
Patient’s initial: V. M.
Nursing diagnosis: Acute pain related to bile duct obstruction as evidence by inflammed gall bladder
Medical diagnosis: Choledocholithiasis
Short term goal: After 8 hours of rendering nursing care intervention, the patient’s pain scale will reduce from 5/10 – 2/10
Long term goal: After hospitalization, the patient will report total relief from pain.
Cues Problem Scientific Reason
Subjective:
“medyo nasakit yung bandang tiyan ko”, as verbalized by the patient.
Pain scale: 5/10
Character of pain: intermittent
Objective: Facial mask of painGuarding behaviorIrritable
Acute pain Abdominal pain is caused by inflammation by stretching or distention of an organ for example, blockage of a bile duct by gallstones
Intervention Rationale Evaluation
INDEPENDENT:
>Observe and document the location, severity and character of pain.
>Promote bed rest, allowing patient to assume position of comfort.
>Encourage use of relaxation techniques, such as deep breathing exercises. Provide diversional activities.
>Assist in differentiating cause of pain, and provides information about effectiveness of interventions.
>Bed rest in low fowler’s position reduces the intra abdominal pressure; however, patient will naturally assume least painful position.
>Promotes rest, redirects attention, may enhance coping.
Short term goal:
GOAL MET, the patient’s pain scale reduced from 5/10 to 3/10.
Patient’s Initial: V. M.
Nursing Diagnosis: Anxiety related to expressed concerns due to surgery
Medical Diagnosis: Choledocholithiasis
Short term goal: After 8 hours of rendering nursing care intervention, the patient will appear relax and will verbalized decrease in anxiety.
Long term goal: After hospitalization, the patient will be free from anxiety and will go back to its normal activities
Cues Problem Scientific Reason
Subjective:
“Medyo kinakabahan ako sa operasyon” as verbalized by the patient.
Objective:conscious and coherentanxiousirritable
Anxiety Discomfort or dread feeling accompanied by an automatic response of apprehension caused by anticipation of danger during an upcoming surgical procedure.
Intervention Rationale Evaluation
INDEPENDENT:Assess client’s level of anxiety. Validate observation
Encourage verbalization of feelings and concerns
Provide accurate information about the situation
Anxiety is highly individualized normal physical and psychological response to internal and external life events.
Affirms patient understanding of an ultimate solution of feelings
Helps client to identify what is reality based
Short term goal:
GOAL MET, the patient’s anxiety decreased as verbalized by the patient, “ok na ako, hindi na ako gaanong kinakabahan”
Long Term Goal:
GOAL MET, the patient was free from anxiety