Running head: CHOLELITHIASIS
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Cholelithiasis
Taylor Nolen
University of South Florida
College of Nursing
NUR 4216L
November 26th 2013
CHOLELITHIASIS
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Cholelithiasis
The gallbladder helps with the digestion process; but the gallbladder is not a “vital”
organ. This paper will discuss a common disease processes affecting the liver, Cholelithaisis (
gallstones).
Pathophysiology
In the digestive system, there is an organ known as the gallbladder. The function of the
gallbladder is to store and concentrate bile. Bile is an enzyme that helps with the digestion of fats
in the intestines. Bile is made by the liver, however, the excess bile is stored in the gallbladder
until needed for digestion; the gallbladder stores about 90ml of bile (Huether & McCance, 2012).
Approximately 30 minutes after food has entered the digestive tract, the gallbladder is stimulated
and starts to release bile.
The gallbladder begins to contract and the spincter of Oddi relaxes, forcing bile into the
duodenum through the major duodenal papilla. During the cephalic and gastric phases of
digestion, gallbladder contraction is derived primarily from the release of cholecystokinin
and motilin secreted by the duodenal mucosa in the presence of fat” (Huether&
McCance, 2012, pp. 887).
Once the bile has entered the duodenum is helps with the breakdown of lipids.
Cholelitahasis
Cholelitahasis (interchangeable with gallstones, which will be used throughout this
paper) is a common disease process that is seen in “20 to 25 million Americans…, representing
10% to 15% of the adult population” (Stinton, Myers & Shaffer, 2010, para. 3). Roughly 10% to
15% of the people infected with gallstones are white adults; the other 60% to 70% of the
population affected are Native Americans (Huether & McCance, 2012). Gallstones account for
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most gastrointestinal hospital admissions, but generally has a good prognosis, “gallstone disease
has a low mortality rate of 0.6%” (Stinton, Myers& Shaffer, 2010, para. 3).
Types of Gallstones
Gallstones can be composed of different materials; there are three types of gallstones
commonly seen: cholesterol gallstones, black pigment stones and brown pigment stones.
Cholesterol stones are produced by bile that is supersaturated with cholesterol produced in the
liver. According to Stinton, Myers & Shaffer (2010), cholesterol stones have a yellow or brown
color, are Crystalline, and commonly found in the gallbladder and/or the common bile duct.
Cholesterol stones begin to crystalize in the gallbladder, then more crystals aggregate on the
existing “microstones” forming a “macrostone”. Once the gallstone becomes large enough, the
stone can get lodged in a duct and cause decreased motility. At first gall stones can be
asymptomatic, then over time as they become further formed, the stones can start to decrease
motility in the digestive system. Risk factors associated with cholesterol gallstones include:
family history, obesity, female gender and age (Stinton, Myers& Shaffer, 2010).
A pigmented stone also commonly seen is associated with chronic liver disease. Black
pigmented stones are composed of calcium bilirubinate polymer, are hard, opaque in color, and
are commonly found in the gallbladder and/or the common bile duct (Stinton, Myers & Shaffer,
2010). Risk factors associated with black pigmented stones include: hemolysis, cirrhosis, cystic
fibrosis, Crohn disease, and advanced age (Stinton, Myers, Shaffer, 2010, table 2). Brown
pigmented stones are composed of unconjugated bilirubin, calcium soaps (palmitate, stearate)
cholesterol and mucin (Stinton, Myers & Shaffer, 2010). These stones are brown in color, often
appear greasy and soft, are found in the bile duct and are seen because of infection, inflammation
and/or infestation (Stinton, Myers, Shaffer, 2010, table 2).
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The different types of stones have specific risk factors which contribute to the cause of
each type of stone. Modifiable risk factors include diet, female sex hormone use, obesity, rapid
weight loss, low activity, TPN, and underlying disease processes associated with the liver and
pancreas (Stinton, Myers & Shaffer, 2010). Non-modifiable risk factors include family history,
genetics, ethnicity, age and gender (Stinton, Myers, Shaffer, 2010, table 3).
Clinical Presentation
According to Huether & McCance (2012), patients with gallstones are often
asymptomatic. When they do begin to have symptoms, they are often triggered by something the
patient has eaten. The patient’s symptoms can range from heartburn, flatulence, epigastric
discomfort, abdominal pain, food intolerances and/or jaundice. Symptoms are often times
triggered after the patient eats a meal high in fats. Symptoms will begin to occur about 30
minutes after eating (Huether & McCance, 2012).
Diagnosis
According to Huether & McCance (2012), diagnosis of gallstones is based on a “history,
physical examination, and ultra sound or computed tomography” (pp. 923). An oral
cholecystogram is performed to see the outlines of the stones. If the cholecystogram provides a
negative result, meaning no stones were outlined, an intravenous cholangiography is then
performed. An intravenous cholangiography is used to differentiate cholelithasis from other
causes of extrahepatic biliary obstruction. Endosocopic or percutaneous cholangiography are
other diagnostic test that can be performed to check for the presence of gallstones. (Huether &
McCane, 2012).
Treatment
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Once the patient has a confirmed case of gallstones, they have a few choices of treatment
options. According to Huther & McCane 2012, one treatment option the patient has is to take an
oral bile acid. Oral bile acids help dissolve cholesterol stones and can be used for prevention. If
the stones are too large and/or oral bile acids are not suitable for the type of gall stones, it may be
necessary for the patient to have endoscopic removal of the stones. Lithotripsy many also be
another treatment option if the patient qualifies (Huther & McCance, 2012).
Case Study
On October 11th 2013, a 36 year old female presented to the emergency room will severe
abdominal pain. The patient stated that the pain began around the 10th of October. The patient
was admitted for epigastric discomfort. Vitals were as follows: T- 98.1, RR- 19. BP- 106/70,
HR- 75, and SPO2- 99% on room air. The patient described the pain as severe with radiation to
the mid to lower back. The patient has a history of gallstones. Based on the presenting symptoms
and history, the patient had an ultrasound. The ultrasound reveled gallstones in the right upper
quadrant as well as a dilated bile duct. The patient was then transferred to 6 west for observation
and further health care. The patient was scheduled for a cholecystectomy on October 15th 2013.
After the cholecystectomy, the patient returned to 6 west for observation, and pain management.
Patient tolerated procedure well and the next plan of care is to advance diet as tolerated and
ambulate. Once patient returns to regular diet and tolerates activities well, the patient will be
discharged with a follow-up appointment with attending physician.
Conclusion
Gallstones can negatively impact a patient’s life when their symptoms become
symptomatic. Gallstones generally are asymptomatic until the gallstones become too large and
begin to occlude the bile ducts (Gurusamy & Davidson, 2010). When a person begins
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experiencing pain from a gallstone, they report to see a provider. Thankfully in today’s society
there are a number of treatment options available. Although there is a high recurrence rate of
gallstones after treatment, following the doctor’s dietary recommendation can reduce the chance
of recurrence.
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References
Gurusamy, k. & Davidson, R. (2010). Surgical treatment of gallstones. Gastroenterology Clinics,
Volume 39, Issue 2, 229-244.
Huether , S & McCane, k. (2012). Alterations of digestive function. Understanding
Pathophysiology, pp. 923-924
Stinton, L., Myers, R., & Shaffer, E. (2010). Surgical treatment of gallstones. Gastroenterology
Clinics, Volume 39, Issue 2,157-169.