Laguna State Polytechnic University Bachelor of Science in Nursing

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OVERVIEW OF DISEASE
The most common disorder of biliary system are cholelithiasis and cholecystitis.
Gallbladder disease is most common health problem in united states. Cholelithiasis is the
medical term for gall stones . It is estimated that 8% to 10 % of adults in united states
has cholelithiasis . Actual number of patient with cholelithiasis is not known because
some are asymptomatic, however the incidence is higher than women, multiparous
women and persons over 40 years of age. Risk factors include estrogen therapy, taking
oral contraceptives, sedentary lifestyle, familial disease and obesity.
ASSESSMENT
Symptoms include spasms, biliary colic, excruciating pain accompanied by tachycardia,
diaphoresis and prostration . Jaundice and pruritus may occur. There is residual
tenderness in the right upper quadrant when pain subsides. Pain occurs 3 to 6 hours after

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a heavy meal or when client is in recumbent position. Changes in urine colour and
vitamin deficiency such as vitamin A,D,E,K may also occur.
PATHOPHYSIOLOGY
Gallstones are hard, pebble-like structures that obstruct the cystic duct. The formation of
gallstones is often preceded by the presence of biliary sludge, a viscous mixture of
glycoproteins, calcium deposits, and cholesterol crystals in the gallbladder or biliary
ducts. Most gallstones consist largely of bile, supersaturated with cholesterol. This
hypersaturation, which results from the cholesterol concentration being greater than its
solubility percentage, is caused primarily by hypersecretion of cholesterol due to altered
hepatic cholesterol metabolism. A distorted balance between pronucleating
(crystallization-promoting) and antinucleating (crystallization-inhibiting) proteins in the
bile also can accelerate crystallization of cholesterol in the bile. Mucin, a glycoprotein
mixture secreted by biliary epithelial cells, has been documented as a pronucleating
protein. It is the decreased degradation of mucin by lysosomal enzymes that is believed to
promote the formation of cholesterol crystals. Inflammation occurs when the gallbladder
is unable to contract completely because of gall stones. As a result swelling and pain
occurs.

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MEDICAL MANAGEMENT
Cholesterol solvents are given such as methyl tertiary terbutyl ether ( MTBE). Supportive
treatment similar to cholecystitis may be given. If stones causes obstruction, additional
treatment consists of replacement of fat soluble vitamins, administration of bile salts, and
a low fat diets are being initiated. Ursodeoxycholic ( UDCA) acid and chenodeoxycholic
acid (CDCA) had been used to dissolve stones mainly composed of cholesterol.
Ezetemibe lowers blood cholesterol level. Non surgical removal of stones includes
instilling MTBE via percutaneous catheter, endoscopic sphincterotomy and lithotripsy
can be done.

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DIAGNOSTIC TEST
 Ultrasonography
• Abdominal x-ray
• cholescyntigraphy
• Oral cholecystogram
• IV cholangiogram
• Liver function tests
• WBC and serum bilirubin
Percutaneous transhepatic cholangiography

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Endoscopic retrograde cholangiopacreatography
“both cholecystitis and colelithiasis has the same surgical managaement”
SURGICAL MANAGEMENT
Laparoscopic and incisional Cholecystectomy or removal of gallbladder is the most
indicated procedure. Surgical and percutaneous cholecystostomy can also be done.
Transhepatic biliary catheter can be used preoperatively in biliary obstruction secondary
to obstructive jaundice.
NURSING DIAGNOSIS
 Pain related to surgical procedure
 Ineffective management of therapeutic regimen related to lack of knowledge of
diet and post operative management

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NURSING MANAGEMENT
• assess pain
• Assess color , amount and consistency of urine
• Assess for signs of dehydration
• Monitor I and O
• Monitor for fluids and electrolyte imbalance
• Provide comfort and emotional support
• Emphasize low fat diet
• Assess effectiveness of treatment
• Monitor for complications such as fistula, rupture of gallbladder,cholangitis and
subphrenic abscess and pancreatitis.
• Administer analgesics as ordered
• Promote oral hygiene
• Prepare suction equipment
• Administer antiemetics as ordered
• Encourage use of lotions containing calamine to relieve itching
• Teach the patient use of knuckles instead of nails to avoid scratching
• Assess color and appearance of stool
• Assess for jaundice

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• Initiate TSB if fever occurs
• Assess for signs of bleeding
• Monitor vital signs
• Promote bed rest
• Emphasize NPO prior to surgery
• Encourage deep breathing exercise
• Place in sim’s position if dyspnea occurs