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A Case Study On Choledocholithiasis - Compress
A Case Study On Choledocholithiasis - Compress
A Case Study On Choledocholithiasis - Compress
Choledocholithiasis
Submitted by:
Introduction
Objectives
This case study will help and serve us to enhance
o u r k n o w l e d g e t o u n d er s t a n d Choledocholithiasis by
assessing, analyzing and interpreting the collected data. This will
in turn give us a better idea of how we could give proper nursing
care making the right evaluation and right intervention to our
clients with this condition; And so that we may apply them on our
future exposures as students and eventually as nurses. We also
did this case study as part of our requirement in our clinical
exposure.
Patient’s Data
PERSONAL DATA
Patients Name: Mrs. Ling
Age: 39
Gender: Female
Birth Date: January 1, 1977
Civil Status: Married
Occupation: None
City Address: Osmeña, Compostella PRU-2
Nationality: Filipino
Religion: Roman Catholic
Educational Attainment: College Undergraduate
Source: Patient’s Chart
CLINICAL/ADMITTING DATA
Date of admission: 4/18/2016
Time of admission: 1:20 PM
Hospital: Davao Medical School Foundation
Ward: Surgical
Room No: 324 - 4
Attending Physician:Dr. Velasco
Admitting Diagnosis: Choledocholithiasis
Family History
The patient’s family does not exhibit any history of Hypertension,
Diabetes Mellitus, Asthma, Cancer, Angina, Abdominal Pain, Flank
Pain, Heat and Cold, Headache.
Definition of Complete
Diagnosis
1. Choledocholithiasis is the presence of at least one gallstone
in the common bile duct. The stone may be made up of bile
pigments or calcium and cholesterol salts.
Reference: https://www.nlm.nih.gov/medlineplus/ency/article/000274.htm
Nursing Theories
Environmental Theory
Florence Nightingale
Nursing is an act of utilizing the environment of the patient to assist him in
his recovery that involves the nurse`s initiative to configure environmental
settings appropriate for the gradual restoration of the patient`s health, and
that external factors associated with the patient`s surroundings affect life on
biologic and physiologic process and his development.
Rationale:
Us nurses need to give care and comfort to our patient because Florence
Nightingale believed that the environment has a big participation for faster
recovery of the patient. Similar to our patient, Ling, she surrounds herself in
a good environment so that she was able to achieve faster recovery not only
with the help of the health care team but as well as the environment.
Rationale:
As nurses, we not only provide care for our patients but encourage the
patient’s ability to care for himself. This can only be attained by promoting
the patient’s independence. This theory was applied with our patient, Ling,
who just came from having a major operation done, Cholecystectomy, and
was limited in movement due to pain from surgery, by assisting her in
transferring from bed to chair but allowing her to use her arms and legs as
well. In due time, she will gain back her strength and be able to do things on
her own again.
Rationale:
Us nurses give therapeutic care and provide for teaching and learning
activities to our patient. We have a goal, an intervention and planning for the
patient’s care in order for him/her to get well. This includes giving medication
and other means of treatments. We provide therapeutic care by educating
our patient with their health, proper self-care and by diverting the patient’s
attention from their pain to recovery. One way we accomplish this is by
providing entertainment and well-meaning conversations.
Developmental
Milestone
Erikson’s (1959) theory of psychosocial development has eight distinct stages. Like
Freud, Erikson assumes that a crisis occurs at each stage of development. For Erikson
(1963), these crises are of a psychosocial nature because they involve psychological
needs of the individual (i.e. psycho) conflicting with the needs of society (i.e. social).
Kohlberg`s Theory
The significance of this theory is focused on the moral
development of an individual. Moving from an orientation of
selfishness of the law and order stage, without passing through
the good boy/girl stage. This theory helps us understand that
morality starts from the early childhood years and can be affected
by several factors.
Vital Signs:
HAIR: The patient’s scalp is lighter than the color of his skin and has
no areas of tenderness. The hair is evenly distributed thick and it has
little white hair no presence of lice, no scars noted or papules.
EAR: The Auricles are symmetrical and has the same color with
his facial skin. The auricles are aligned with the outer canthus of
eye. When palpating for the texture, the auricles are mobile, firm
and not tender. The pinna recoils when folded. During the
assessment of Watch tick test, the client was able to hear ticking
in both ears.
Esophagus
Stomach
Pancreas
Liver
The liver has multiple functions, but its main function within the
digestive system is to process the nutrients absorbed from the
small intestine. Bile from the liver secreted into the small
intestine also plays an important role in digesting fat. In addition,
the liver is the body’s chemical "factory." It takes the raw
materials absorbed by the intestine and makes all the various
chemicals the body needs to function. The liver also detoxifies
potentially harmful chemicals. It breaks down and secretes many
drugs.
Gallbladder
The gallbladder stores and concentrates bile, and then releases it
into the duodenum to help absorb and digest fats.
The colon is a 6-foot long muscular tube that connects the small
intestine to the rectum. The large intestine is made up of the
cecum, the ascending (right) colon, the transverse (across) colon,
the descending (left) colon, and the sigmoid colon, which
connects to the rectum. The appendix is a small tube attached to
the cecum. The large intestine is a highly specialized organ that is
responsible for processing waste so that emptying the bowels is
easy and convenient.
Rectum
The anus is the last part of the digestive tract. It is a 2-inch long
canal consisting of the pelvic floor muscles and the two anal
sphincters (internal and external). The lining of the upper anus is
specialized to detect rectal contents. It lets you know whether the
contents are liquid, gas, or solid. The anus is surrounded by
sphincter muscles that are important in allowing control of stool.
The pelvic floor muscle creates an angle between the rectum and
the anus that stops stool from coming out when it is not supposed
to. The internal sphincter is always tight, except when stool enters
the rectum. It keeps us continent when we are asleep or
otherwise unaware of the presence of stool. When we get an urge
to go to the bathroom, we rely on our external sphincter to hold
the stool until reaching a toilet, where it then relaxes to release
the contents.
The Gallbladder
The gallbladder is a pear-shaped, hollow structure located under
the liver and on the right side of the abdomen. Its primary
function is to store and concentrate bile, a yellow-brown digestive
enzyme produced by the liver. The gallbladder is part of the
biliary tract, which are the organs and ducts that create and
store bile and release it into the duodenum (the small intestine).
The gallbladder serves as a reservoir for bile while it’s not being
used for digestion. The gallbladder's absorbent lining
concentrates the stored bile. When food enters the small
intestine, a hormone called cholecystokinin is released, signaling
the gallbladder to contract and secrete bile into the small
intestine through the common bile duct.
The cystic duct joins the gallbladder to the bile duct and is one of
the important structures needing proper identification and
division during a standard cholecystectomy. The cystic duct may
run a straight or a fairly convoluted course. Its length is variable
and usually ranges from 2 to 4 cm. Around 20% of cystic ducts
are less than 2 cm. Hence there may be very little space to put
clips or ligatures. True absence of the cystic duct is extremely rare
and if the duct is not seen is more likely to be hidden. The cystic
duct is usually 2–3 mm wide. It can dilate in the presence of
pathology (stones or passed stones). The normal bile duct is also
around 5 mm and hence can look like a mildly dilated cystic duct.
In general, a cystic duct larger than 5 mm (or the need to use a
very large clip to completely occlude the duct) should arouse a
suspicion of mistaken identity with the bile duct before it is
clipped or ligated.
The cystic duct joins the gallbladder at the neck and this angle
may be fairly acute. Also the mode of joining may be smooth
tapering or abrupt. On the bile duct side its mode of union shows
significant variations. Since such variations are not uncommon it
may not be safe to try and dissect the cystic duct to its junction
with the bile duct. It is important to remember that even in the
low insertion variety the cystic duct rarely goes behind duodenum
and therefore a ductal structure passing behind the duodenum is
more likely to be the bile duct itself. Double cystic ducts are
described but are exceedingly rare and therefore two ductal
structures entering the gallbladder should always be viewed with
suspicion. Also the cystic duct does not have vessels traveling on
its surface whereas the bile duct has such visible vessels.
C
holecystitis (ko-luh-sis-TIE-tis) is inflammation of the gallbladder.
Your gallbladder is a small, pear-shaped organ on the right side of
your abdomen, beneath your liver. The gallbladder holds digestive
fluid that's released into your small intestine (bile).
Etiology
PREDISPOSING PRESENT/ABSEN RATIONALE JUSTIFCATION
FACTOR T
Women
between 20 -
60 years of
age are twice
as likely to
develop
gallstone
than men.
Female The patient is
Estrogen female.
increases
cholesterol
levels in bile
and decrease
gallbladder
movement;
both of which
can lead to
gallstone
formation.
Many of the
body’s
system and
protective
Age: 39 Years mechanism The patient is
Old become less 39 years old.
efficient with
age.
Body system
and
processes
become
sluggish.
Asians are
more
Race: Asian genetically Our patient is
predisposed Filipino.
to having
pigmented
stones
compared to
those living in
Western
Countries.
Patient with
diabetes
generally
have high
Diabetes
X
levels of fatty The patient
Mellitus acids called has no
Triglyceride. diabetes.
These fatty
acids
increase the
risk for
gallstone
formation.
PRECIPATATING PRESENT/ABSEN RATIONALE JUSTIFICATION
FACTOR T
Excess
X
estrogen from
Pregnancy pregnancy The patient is
increases risk not pregnant.
of gallstone
formation.
Birth control
pills appears
to increase
cholesterol
Pills levels in bile, The patient is
resulting in using birth
the decrease control pills.
of gallbladder
movement;
both of which
can lead to
gallstone
formation.
The body
Rapid
X
metabolizes No rapid
Weight fat during weight loss
Loss weight loss, was noted by
which causes the patient.
the liver to
secrete extra
cholesterol
into the bile,
contributing
to gallstone
formation.
Obesity most
likely tends to
reduce the
amount of
bile salt in
Pain bile, resulting The patient is
in more obese.
cholesterol
build up.
Obesity
decreases
gallbladder
emptying.
Pain that is
localized to The patient
the verbalized that
epigastrium the pain is
Pain or RUQ, present in the
sometimes RUQ of the
radiating to abdomen and
the right radiates to the
scapular tip back of the
because of shoulder.
forming of
stone in the
gallbladder.
When the
common bile
duct becomes Our patient
Chills clogged by a verbalized
gallstone, that it is very
there is cold.
blockage of
bile to the
common bile
duct.
Symptoms
Nausea and and The patient
Vomiting complications always vomits
result from
effects
occurring
within the
gallbladder or
from stones
that escape
the
gallbladder to
lodge in the
CBD.
Symptomatology
SYMPTOMS PRESENT/ABSENT RATIONALE JUSTIFICATION
Pain that is
localized to
the The patient
Pain in the epigastrium verbalized that
RUQ that or right upper the pain is
radiates to quadrant, present in the
the back of sometimes RUQ of the
the shoulder radiating to abdomen and
the right radiate to the
scapular tip back of the
because of shoulder
forming of
stone in the
gall bladder
Symptoms
and
Nausea & complications
Vomitting result from The patient
effects always vomits
occurring
within the
gallbladder or
from stones
that escape
the
gallbladder to
lodge in the
CBD.
Jaundice
X Not present
with our
patient
Dark Urine
X Not present
with our
patient
Fever
X Not present
with our
patient
When the
common bile
duct clogged Our patient
Chills by a gall stone said
there was a that it’s very
blockage of cold
bile in the
common bile
duct
Pathophysiology
Doctor’s Order
MEDICAL ORDER SHEET
Gender: Female
CBC
-Blood test used to
evaluate your
overall health and
detect a wide range
Tramadol of disorder.
-Our patient is
experiencing pain,
April 19, 2016 ERCP Tramadol is an
analgesic which
relieves pain.
-Is to provide
framework for
considering cardiac
Ampimax risk of non-cardiac
surgery in a variety
of the patient and
operative.
-Treatment for
following infection.
Tranexamic.
-Replacement of
fluid.
-done ERCP.
-UDCA
-for monitoring.
-Tranexamic Acid
-antibacterial.
-Prevent excessive
bleeding.
BLOOD CHEMISTRY
Test Results Unit Normal Rationale
Value
Sodium 135.6 mmol/L 135-148 Used to
detect
abnormal
concentrat
ion of the
urine.
Potassium 3.57 mmol/L 3.5-5.3 This test
measures
the
amount of
potassium
in fluid
protein.
Calcium 1.15 mmol/L 1.13-1.15 Is ordered
to screen
for
diagnose.
Chlorine mmol/L 95-108 Is used to
detect
abnormal
concentrat
ion of
chloride.
Magnesium mmol/L 0.74-0.99 Used to
measure
the level
of
magnesiu
m in the
blood.
HEMATOLOGY
Test Result Norm Clinical Indication
al
Values
Hemoglobin 121 120- Measures the amount of
150 Hemoglobin in your blood
hemoglobin is a protein in
your red blood cells and
used to detect low
hemoglobin and describe as
being anemic, nutritional
iron polycythemia etc.
Hematocrit 0.36 0.38- The ratio of the volume of
0.40 red blood cells to the total
volume of blood.
Decreased,
Bleeding, bone marrow
Nutritional problems.
Decreased
Leukemia
Tuberculosis
Hyperplenism
MCV 85 80-
100
MCH 29 27-32
MCHC 34 32-36
Decrease
Fasting
Times of severe
physical stress
Use of corticosteroids
(such as prednisone)
Chemotherapy and/or
radiation therapy for
cancer
Decrease:
Decrease
Chronic myelogenous
leukemia, Churg-Strauss
syndrome, Crohn's disease,
Drug allergy, Eosinophilic
leukemia, Hay fever,
Hodgkin's lymphoma
(Hodgkin's disease)
Decreased
in anaphylaxis,
asthma,
atopic dermatitis
hay fever
Thrombocytes 235 150-450 Platelets, also
called thrombocytes
(thromb + cyte, "blood
clot cell"), are a
component of blood
whose function is to
stop bleeding by
clumping and clotting
blood vessel injuries.
Decreased
Bruising easily.
A lot of or long-lasting
bleeding from a small
cut or injection site.
Vomiting blood or
something that looks
like coffee grounds.
Constant headache,
blurred vision or
change in level of
consciousness.
URINALYSIS
Parameters Result Results Rationale
Range Unit Reference Reference
Range
Physical
Examination
Color Light The color of
Yellow the urine is
helpful in
predicting the
concentration
of the
specimen.
Clarity Clear Useful in
predicting the
presence of
the
contaminants
such as cells
or mucus.
Chemical
Analysis
pH 7.0 Urine pH level
test is a test
that analyzes
the acidity or
alkalinity.
Specific Gravity 1.0% Is a measure
of the
concentration
of the solute in
the urine.
Glucose Negative Test measures
the level of
glucose or
sugar in your
urine.
Protein Negative A protein urine
test measures
the amount of
the protein in
the urine.
Urine
Flowcytometry
WBC 3 0- 1 Is help to
17/uL 0-3 diagnose and
infection.
RBC 1 0- 0 To check if
17/uL 0-3 there was
bleeding.
Epith Cells 3 0- 1 Used in guided
17/uL 0-3 tissue
regeneration.
Cast 0- 0 0- Urinary casts
1/uL 03 are tiny tube
shaped
particles that
can be found
when urine is
examined
under the
microscope.
Bacteria 115 0- 21 0- To check what
278/uL 50 specific
bacteria.
Mucus Thread To identify if
there was a
serious
condition that
medical
needs.
Crystal Is the rationale
for urinary
alkalization in
patient.
Drug Study
SULTAMICILLIN
Brand: Ampimax, Alfasid, Ampisid, Amplipen, Bactesul, Bactesyn,
Bitammon, Combicid, Devasid, Duobak, Duobaktam, Duocid,
Fipexiam, Nobecid, Picyn, Sulamp, Sulbamox IBL, Sulcid, Sultamat,
Sultamicilina, Sultasid, Sultibac, Unacid PD oral, Unasyna,
Viccillin-SX, Ampigen SB, Begalin, Bitammon, Sinif, Unacid PD
oral, Unasyn
Generic: Sultamicillin Tocilate
Classification: antibiotic
Dosage: Oral dosage
Uncomplicated gonorrhea
Nursing Responsibilities:
1 Assess patient’s condition before starting therapy and
regularly thereafter to monitor drug’s effectiveness.
2 Be alert for adverse reactions and drug interactions.
3 If adverse GI reaction occurs, monitor patient’s hydration.
4 Assess patient’s and family’s knowledge of drug therapy
5 Give tablets or capsules 30 minutes before meals; powder
for oral suspension 1 hour before meals.
6 Use 2 tbs of water to mix 1 packet of powder for oral
suspension; don’t use any other liquids or food
7 Lower doses aren’t needed for patient’s with renal or hepatic
impairment
8 Explain importance of taking drug exactly as prescribed.
9 Warn patient not to crush or chew tablets or capsules.
10Explain to patient how to reconstitute powder for oral
suspension: Empty packet contents into a small cup
containing 2 tbsp. of water; stir well and drink immediately.
Refill cup with water and drink.
TRAMADOL
Nursing Responsibilities:
1. Assess type, location, and
intensity of pain before and 2-3 hr (peak) after administration.
2. Assess BP & RR before and periodically during
administration. Respiratory depression has not occurred with
recommended doses.
3. Assess bowel function routinely. Prevention of constipation
should be instituted with increased intake of fluids and bulk
and with laxatives to minimize constipating effects.
4. Assess previous analgesic history. Tramadol is not
recommended for patients dependent on opioids or who
have previously received opioids for more than 1 wk; may
cause opioid withdrawal symptoms.
5. Prolonged use may lead to physical and psychological
dependence and tolerance, although these may be milder
than with opioids. This should not prevent patient from
receiving adequate analgesia. Most patients who receive
tramadol for pain d not develop psychological dependence. If
tolerance develops, changing to an agonist may be required
to relieve pain.
6. Tramadol is considered to provide more analgesia than
codeine 60 mg but less than combined
aspirin650mg/codeine 60 mg for acute postoperative pain.
7. Monitor patient for seizures.
8. May occur within recommended dose range. Risk increased
with higher doses and inpatients taking antidepressants
(SSRIs, tricyclics, or Mao inhibitors), opioid analgesics, or
other drugs that decrease the seizure threshold.
9. Overdose may cause respiratory depression and seizures.
Naloxone (Narcan)may reverse some, but not all, of the
symptoms of overdose. Treatment should be symptomatic
and supportive. Maintain adequate respiratory exchange.
10. Encourage patient to cough and breathe deeply every 2
hr to prevent atelactasis and pneumonia.
METOCLOPRAMIDE
Brand Name: Plasil
Dosage: Tab Adult: 1tab tid, Syr Adult: 10 ml tid, children: 5-14 yr
2.5-5 mg tid, 3-5 yr 2mg bid
Nursing responsibilities:
1. Assess client for abdominal pain distention, bowel sound
2. Assess client for extrapyramidal reactions
3. Monitor for tardive dyskinesian
TRANEXAMIC ACID
Nursing Responsibility:
1. Dosage modification required in patients with renal
impairment
2. Watch out for any signs of bleeding
Reference/Sources:
https://www.scribd.com/doc/201340912/Tranexamic-Acid-drug-
study
URSODEOXYCHOLIC ACID
Brand:
Generic Name: Ursodiol, UDCA
Classification:
Indications: Note: Bracketed information in the indications section
refers to uses that are not included in U.S product labeling
Mechanism of Action: Anticholelithic—Although the exact
mechanism of ursodiol's anticholelithic action is not completely
understood, it is known that when administered orally ursodiol is
concentrated in bile and decreases biliary cholesterol saturation
by suppressing hepatic synthesis and secretion of cholesterol, and
by inhibiting its intestinal absorption. The reduced cholesterol
saturation permits the gradual solubilization of cholesterol from
gallstones, resulting in their eventual dissolution.
Adverse Effects: Ursodiol increases bile flow. In chronic cholestatic
liver disease, ursodiol appears to reduce the detergent properties
of the bile salts, thus reducing their cytotoxicity. Also, ursodiol
may protect liver cells from the damaging activity of toxic bile
acids (e.g., lithocholate, deoxycholate, and chenodeoxycholate),
which increase in concentration in patients with chronic liver
disease.
Precautions to Consider
Carcinogenicity/Tumorigenicity
Pregnancy/Reproduction
Pregnancy—
Adequate and well-controlled studies have not been done in
humans {05}.
Breast-feeding
It is not known whether ursodiol is distributed into breast
milk {05} {13}. However, problems in humans have not been
documented.
Pediatrics
Appropriate studies on the relationship of age to the effects of
ursodiol when used as an anticholelithic have not been performed
in the pediatric population. However, studies performed to date in
children and infants with cholestatic liver disease and biliary
atresia have not demonstrated pediatrics-specific problems that
would limit the usefulness of ursodiol in children. {33} {34} {40}
Geriatrics
Appropriate studies on the relationship of age to the effects of
ursodiol have not been performed in the geriatric population.
However, geriatrics-specific problems that would limit the
usefulness of this medication in the elderly are not expected. {13}
PROCEDURE
You lie on your side on a couch. The doctor will ask you to swallow
the first section of the endoscope. Modern endoscopes are quite
thin (thinner than an index finger) and quite easy to swallow. The
doctor then gently pushes it down your esophagus into your
stomach and duodenum.
Inject a dye into the bile and pancreatic ducts. X-ray pictures
taken immediately after the injection of dye show up the detail of
the ducts. This may show narrowing (stricture), stuck gallstones,
tumors pressing on the ducts, etc.
Take a small sample (biopsy) from the lining of the duodenum,
stomach, or pancreatic or bile duct near to the papilla. The biopsy
sample can be looked at under the microscope to check for
abnormal tissue and cells.
If the X-rays show a gallstone stuck in the duct, the doctor can
widen the opening of the papilla to let the stone out into the
duodenum. A stone can be grabbed by a 'basket' or left to be
passed out with the stools (feces).
If the X-rays show a narrowing or blockage in the bile duct, the
doctor can put a stent inside to open it wide. A stent is a small
wire-mesh or plastic tube. This then allows bile to drain into the
duodenum in the normal way. You will not be aware of a stent,
The endoscope is gently pulled out when the procedure is
finished. An ERCP can take anything from 30 minutes to over an
hour, depending on what is done.
CHOLECYSTECTOMY
Cholecystectomy (koh-luh-sis-TEK-tuh-me) is a surgical procedure
to remove your gallbladder — a pear-shaped organ that sits just
below your liver on the upper right side of your abdomen. Your
gallbladder collects and stores bile — a digestive fluid produced in
your liver.
PROCEDURE
Placement of ports and instruments
A 1.5-cm longitudinal incision is made at the inferior aspect of the
umbilicus, then deepened through the subcutaneous fat to the
anterior rectus sheath. A Kocher clamp is used to grasp the
reflection of the linea alba onto the umbilicus and elevate it
cephalad.
A 1.2-cm longitudinal incision is made in the linea alba with a No.
15 blade. Two U stitches, one on either side of the fascial incision,
are placed with 0 polyglactin suture on a curved needle.
The peritoneum is elevated between two straight clamps and
incised so as to afford safe entry into the abdominal cavity. An 11-
mm blunt Hasson trocar is placed into the abdominal cavity, and
insufflation of carbon dioxide is initiated to a maximum pressure
of 15 mm Hg.
A 1.2-cm incision is made three fingerbreadths below the xiphoid
process and deepened into the subcutaneous fat. An 11-mm
trocar is advanced into the abdominal cavity under direct vision
(see the image below) in the direction of the gallbladder through
the abdominal wall, with care taken to enter just to the right of
the falciform ligament.
The table is then adjusted to place the patient in a reverse
Trendelenburg position with the right side up to allow the small
bowel and colon to fall away from the operative.
Treatment
Treating gallstones in the bile duct focuses on relieving the
blockage. These treatments may include:
stone extraction
fragmenting stones (lithotripsy)
surgery to remove the gallbladder and stones
(cholecystectomy)
surgery that makes a cut into the common bile duct to
remove stones or help them pass (sphincterotomy)
biliary stenting
Patients with gallstones in the bile duct and gallstones still in the
gallbladder may be treated with cholecystectomy (gallbladder
removal). While performing the surgery, your doctor will also
inspect your bile duct to check for remaining gallstones.
H ealth Teaching
Provide written and oral instruction about wound
care, activity, diet recommendations, medication
and follow up visits.
Instruct patient to limit his activity for 24 to 48 hrs.
after discharge.
O ut Patient Follow Up
Patient will be advised to go back in the hospital in a
specific date to have follow–up checkup after
discharge.
Consult doctors for are any problems or complication
encountered.
D iet
Encourage patient to increase protein intake for
tissue repair.
Advice patient to eat smaller-than-normal amount of
at mealtime.
S piritual
Encourage patient to communicate with God.
Encourage patient to communicate with other
people.
References
http://www.uptodate.com/contents/choledocholithiasis-clinical-
manifestations-diagnosis-and-management
https://www.nlm.nih.gov/medlineplus/ency/article/000274.htm
http://radiopaedia.org/articles/choledocholithiasis
http://www.myvmc.com/diseases/common-bile-duct-stone-
choledocholithiasis-cholangitis-obstructive-jaundice/
http://www.drugs.com/mmx/ursodeoxycholic-acid.html
https://www.scribd.com/doc/201340912/Tranexamic-Acid-drug-study