Cholelithiasis, (calculi or gallstones) usually form in the gallbladder from solid constituents of bile and vary greatly in size,

shape, and
composition.
Types of gallstones:
Pigment gallstones- probably form when unconjugated pigments in the bile precipitate to form stones,
Unconjugated bilirubin is a waste product of hemoglobin breakdown that is taken up by the liver
Cholesterol stones- most common form,
In gallstone-prone patients, there is decreased bile acid synthesis and increased cholesterol synthesis in the liver, resulting in
bile supersaturated with cholesterol, which precipitates out of the bile to form stones. The cholesterol-saturated bile predisposes to
the formation of gallstones and acts as an irritant, producing inflammatory changes in the gallbladder
are thought to develop because of an imbalance in the chemical make-up of bile inside the gallbladder. In most cases the
levels of cholesterol in bile become too high and the excess cholesterol forms into stones.

Sign and symptoms

• Biliary colic (abdominal cramping and pain that worsens after a fatty meal)
• Abdominal pain (especially in the right upper and middle upper quadrants; may radiate to the back or right shoulder)
• Abdominal distension
• Nausea and vomiting
• Jaundice (yellowing of the skin)
• Clay-colored stools (due to the lack of bile)
•Fever
• Leukocytosis
Abdominal ultrasound An ultrasound scan is ➧Pretest Normal Result In cholelithiasis ,
commonly done to clarify Explain the test purpose and • Normal position and ultrasound detects
the diagnosis. procedure. Assure the patient appearance of the liver, gallstones as small as
This is a painless test that no radiation is employed gallbladder, bile 2mm.
which uses sound waves to and that the test is painless. ducts, pancreas, kidneys,
scan the abdomen. An adrenals, and spleen, as
ultrasound scan can Instruct the patient to avoid well as the
usually detect gallstones, oral intake (remain NPO) for a abdominal aorta, inferior
and also minimum of 8 hours before the vena cava, and their
whether the wall of the examination to fully dilate the major tributaries.
gall bladder is thickened gallbladder and to improve the
(as occurs with visualization of all structures. • Sizes of organs:
cholecystitis). Gallbladder: Length,
Explain that a coupling gel will diameter, and wall
be applied to the skin and that thickness within normal
a sensation of warmth or limits
wetness may be felt. Although
the couplant does not stain,
advise the patient to avoid
wearing non washable
clothing.

➧Intratest
Explain to the patient that it is
necessary to regulate the
breathing pattern as instructed.

Provide support and assure the

patient that the test is
proceeding normally.

Instruct the patient that it is

necessary to lie quietly during
test, even though it may be
uncomfortable.

➧Posttest
Remove any residual gel from
the skin.

Normal diet and fluids may be

resumed, unless
 contraindicated by
the test results.

Evaluate the outcomes and

counsel the patient
appropriately
regarding further tests or
possible treatments.
Percutaneous It supports the diagnosis Before
Transhepatic of obstructive jaundice Instruct the patient to fast and
Cholangiogram (PTC) and reveals calculi in the restrict fluids for 4 to 8 hr, or
ducts. as ordered, prior to the
procedure. Fasting is ordered
To visualize and assess because an empty stomach
biliary ducts for causes of provides better visualization
obstruction and jaundice, and as a precaution against
such as stones. aspiration related to possible
nausea and vomiting.
Inform the patient this
procedure can assist in
assessing the bile ducts of the
gallbladder
Biliary ducts are normal In cholelithiasis ,, PTC
in diameter, with no detects gallstones and
evidence of dilation, reveals obstructive
filling defects, duct jaundice.
narrowing, or
extravasation
Contrast medium fills
the ducts and flows
freely
Gallbladder appears
normal in size and
shape.

Explain that the patient may

feel discomfort when the
needle penetrates the liver,
pressure, or brief discomfort
in the right subscapular area.

Reassure the patient that

medication will be given to
enhance comfort.
The patient will need to
remain still and hold his or her
breath for short periods during
the test.

Tell the patient testing usually

takes between 30 and 60
minutes.

Instruct the patient to remove

jewelry and other metallic
objects from the area of
examination.

After

Assess vital signs frequently

according to policy.

The patient should remain bed

rest for 6 hours post
procedure.

Monitor for bleeding from

puncture site, swelling around
puncture site. Notify the
physician immediately if the
patient has right abdominal or
shoulder pain (indicates
bleeding), fever, dizziness,
drop in blood pressure,
 Continue antibiotics as
schedule.
LABORATORY TEST PURPOSE/INDICATION
2. ULTRASONOGRAPHY The procedure is most accurate
if the patient fasts overnight so
that the gallbladder is distended.
The use of ultrasound is based
on reflected sound waves.
Ultrasonography can detect
calculi in the gallbladder and
distinguishes obstructive and
non obstructive jaundice.
NURSING Normal Analysis
RESPONSIBILITIES
• Ask patient to lie quietly on Normal Ultrasonography
the examination table in the can detect calculi in
supine or decubitus position. • Normal size, the gallbladder or a
position, and dilated common bile
• Cover skin with a layer of configuration of duct. It is reported
coupling gel, oil, or lotion. gallbladder and bile to detect gallstones
ducts. with 95% accuracy
• Ask the patient to regulate
breathing as instructed. • No evidence of
calculi.
• Examination time is
approximately 10–30 minutes. • Normal adjacent
liver tissue
➧Pretest
• Explain the purpose,
benefits, and procedure of the
test.
• Instruct the patient to remain
NPO at least 8 hours before
the examination to fully dilate
the gallbladder and to improve
anatomic visualization. Some
laboratories prefer that the last
meal before the study should
contain low quantities of fat.

• Assure the patient that there

is no pain involved. However,
the

patient may feel

uncomfortable lying quietly
for a long period.

• Explain that a liberal coating

of coupling agent must be
applied. A sensation of
warmth or wetness may be
felt.

• Explain that the patient will

be instructed to control
breathing patterns while the
images are being taken.

➧Posttest

• Patient may resume normal

diet and fluid intake.

• Remove the gel, or instruct

the patient to clean the
remaining gel from the
abdomen.

• Evaluate the outcome and

counsel appropriately about
further treatment or
procedures.
4. Oral cholangiography Oral cholangiography may be
performed to detect gallstones
and to assess the ability of the
gallbladder to fill, concentrate its
contents, contract, and empty.
The patient takes iodine-
containing tablets by mouth. The
iodine is absorbed from the
intestine into the bloodstream,
removed from the blood by the
liver, and excreted by the liver
into the bile. Contrast agents
include iopanoic acid
(Telepaque), iodipamide
meglumine (Cholografin), and
sodium ipodate (Oragrafin).
5. ENDOSCOPIC RETROGRADE The examination of the
CHOLANGIOPANCREATOGRAPHY hepatobiliary system is carried
out via a side-viewing flexible
fiberoptic endoscope inserted
into the esophagus to the
descending duodenum. Multiple
position changes are required
during the procedure, beginning
in the left semi-prone position to
pass the endoscope.
The nurse must ask the patient Oral
about allergies to iodine or cholangiography in
seafood. If no allergy is cholelithiasis detect
identified, the patient receives gallstone
the oral form of the contrast
agent the evening before the x-
rays are obtained.
Instruct patient to take the
contrast agent 10 -12 hrs
before the x-ray study. To
prevent contraction and
emptying of the gallbladder,
the patient is permitted
nothing by mouth after the
contrast agent is administered.
The procedure requires a
cooperative patient to permit
insertion of the endoscope
without damage to
thegastrointestinal tract
structures, including the
biliary tree. Before the
procedure, the patient is given
an explanation of the
procedure and his or her role
in it. The patient takes nothing
by mouth or several hours
before the procedure.
Moderate sedation is used with
this procedure, so the sedated
patient must be monitored
closely. Most endoscopists use
a combination of an opioid and

6. PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY
This procedure can be carried
out even in the presence of liver
dysfunction and jaundice. It is
useful for distinguishing
jaundice caused by liver disease
a benzodiazepine. Medications
such as glucagon or
anticholinergics may also be
necessary to eliminate
duodenal peristalsis to make
cannulation easier. The nurse
observes closely for signs of
respiratory and central nervous
system depression,
hypotension, oversedation, and
vomiting (if glucagon is
given). During ERCP, the
nurse monitors intravenous
fluids, administers
medications, and positions the
patient.
After the procedure, the nurse
monitors the patient’s
condition, observing vital
signs and monitoring for signs
of perforation or infection. The
nurse also monitors the patient
for side effects
of any medications received
during the procedure and for
return of the gag and cough
reflexes after the use of local
anesthetics.
Although the complication rate
after this procedure is low, the
nurse must closely observe the
patient for symptoms of
bleeding, peritonitis, and
 from that caused by biliary
obstruction, for investigating the
gastrointestinal symptoms of a
patient whose gallbladder has
been removed, for locating
stones within the bile ducts, and
for diagnosing cancer involving
the biliary system.
septicemia. The nurse should
immediately report pain and
indicators of these
complications.
Antibiotic agents are often
prescribed to minimize the risk
of sepsis and septic shock.

Drug Study

DRUG MECHANISM OF SIDE EFFECTS ADVERSE CONTRAINDICATION NURSING RESPONSIBILITIES

ACTION EFFECTS S

Generic Name: Bile ducts can become
Ursodeoxycholic acid blocked and cause cirrhosis
in one or more parts of the
Brand Name: liver. Ursodeoxycholic acid
Urosodiol is a naturally occurring bile
acid which is taken as either
Dosage&Frequency&Rou
a tablet or liquid to try and
te:
prevent liver disease in
people with cystic fibrosis.
-Severe right-sided Gastrointestinal -Hypersensitive to ● Assess patient carefully for suitability of
upper abdominal disorders: abdominal ursodiol, the formulation, ursodiol therapy. Alternative therapy should
pain during the discomfort, abdominal or with other bile acid be reviewed before using ursodiol.
treatment of pain, constipation, agents hypersensitivity. ● Give drug in two to three divided doses.
primary biliary diarrhea, dyspepsia, ● Do not administer drug with aluminum-
cirrhosis. nausea, vomiting. -Ursodiol is based antacids. If such drugs are needed,
contraindicated in patients
General disorders and administer 2–3 hr after ursodiol.
with complete biliary
administration site ● Schedule patients for periodic oral
conditions: malaise, cholecystograms or ultrasonograms to
● Solubilization of -Skin rash. peripheral edema, obstruction. evaluate drug effectiveness at 6-mo intervals
gallstones: 8–10 pyrexia. Hepatobiliary until resolution, then every 3 mo to monitor
mg/kg/day PO given in disorders: jaundice (or stone formation. Stones recur within 5 yr in
two to three divided aggravation of more than 50% of patients. If gallstones
doses. preexisting jaundice). appear to have dissolved, continue treatment
● Resolution of the for 3 mo and perform follow-up ultrasound.
gallstones requires ● Monitor LFTs periodically. Carefully assess
months of therapy; patient if any change in liver function occurs.
condition needs to be
monitored with
ultrasound at 6-mo and 1-
yr intervals.
●Treatment of biliary
cirrhosis: 13–15
mg/kg/day PO
administered in two to
four divided doses with
food; readjust dosage
based on patient response
(URSO).

● Prevention of
gallstones: 300 mg PO
bid or 8–10 mg/kg/day
PO in two to three
divided doses.

Route: ORAL

Drug Classification:Bile
Acids
Drug Data Classification Mechanism of Indications Contraindications Side Effects Adverse Effects Nursing
Action Responsibilities
Generic Name: Analgesic, Inhibits used for the short- -patients with active -headache - yellowing of the - Monitor vital signs
Ketorolac anti- prostaglandin term treatment of peptic ulcer disease -dizziness skin or eyes - Inform the patient
inflammatory. synthesis, reduces moderate to -patients with recent -drowsiness - excessive tiredness about the possible
Trade Name: prostaglandin levels severe pain gastrointestinal -diarrhea - unusual bleeding side effect of the
Toradol in aqueous humor. bleeding or -constipation or bruising drug
Therapeutic Effect: perforation - lack of energy - Advise patient to
Reduces intensity -patients with a - nausea report any
of pain stimulus, history of peptic - loss of appetite discomfort
reduces intraocular ulcer disease or - flu-like symptoms - Assess for
inflammation gastrointestinal - pale skin therapeutic
bleeding - fast heartbeat response: relief of
-pediatric patients pain, stiffness,
swelling; increased
joint mobility;
reduced joint
tenderness;
improved grip
strength.