These are commonly found in individuals who are fat (obese), over forty (due to estrogen therapy), female, and fertile (use of oral contraceptives). Gallstones are primarily composed of cholesterol (80%), bile salts, calcium, bilirubin, and proteins.
Stone Formation Theory
- Metabolic factors e.g. obesity, pregnancy, DM, hypothyroidism may all lead to the stagnation of bile in the gallbladder.
- The water content of bile is reabsorbed to an excessive degree, leading to the formation of salts (stones).
Assessment Findings
- Most patients with gallstones are asymptomatic. If manifestations do occur, it is often pain in the Epigastric Region and and the RUQ, lasting for approximately 30 minutes when obstruction occurs.
- Fever and Leukocytosis (as a result of inflammation; cholecystitis)
- Charcot Triad: fever, jaundice, RUQ pain (ascending cholangitis)
- Fat Intolerance: resultant steatorrhea, nausea and vomiting, sensation of fullness
- Pruritus, Easy Bruising, Dark Amber Urine (bilirubin elevation in blood)
Diagnostic Examination
- Direct bilirubin, Transaminase, Alkaline Phosphatase, WBC, Amylase, Lipase are all increased.
- Oral cholecystogram (gallbladder series x-ray) is positive for a gallstone.
Nursing Interventions
- Administer analgesia as ordered and monitor for effects.
- Administer IVF as ordered
- Provide small, frequent feedings with low fat.
- Relieve pruritus.
- Assist in cholecystectomy or choledochostomy.
Post-op Considerations
- Semi-fowler’s or Side-lying opposite of incision site; reposition frequently.
- Splint incisions when turning, coughing, and deep breathing.
- Maintain and monitor T-Tube
- The tube should be connected to a closed gravity drainage system. Avoid kinks, clamping, and pulling on the tube.
- Expect 300 to 500 ml of bile-colored drainage for the first day, then 200 ml every day for the following 3 to 4 days.
- Watch out for peritonitis.
- Assess the skin around the T-tube for irritation. Cleanse and keep dry frequently.
- Stool and urine color can indicate effectivity of bile flow.
Discharge Planning and Education
- Adherence to dietary restrictions (low fat)
- Resumption of ADLs: avoid heavy lifting for 6 weeks, sexual activity if desired unless contraindicated.
- Recognition of Signs of Complications: fever, jaundice, pain (Charcot triad), dark urine and pale stools (benchmark of bile excretion), pruritus.
Medical Management
- NPO with NGT and IVF
- Administration of fat-soluble vitamins (ADEK) due to its depletion.
Pharmacologic Therapy
- NSAID (Ketorolac)
- Narcotic Analgesia (Morphine for pain)
- Anticholinergics (Atropine) may also relieve pain
- Antiemetics
Surgical Management
- Cholecystectomy with choledochotomy: removal of the gallbladder, and the insertion of a T-tube into the common bile duct.
- Choledochotomy: opening of the common bile duct, removal of the gallstone, and addition of a T-Tube for drainage.
- Laparoscopic Cholecystectomy: laparoscopy may be used for uncomplicated cases (and the pt. has had no previous abdominal surgeries).
- Cholecystostomy: creation of a stoma on the gallbladder.