RTRMF – BSN LEVEL III BATCH TOPAZ

NCM 116 (MEDICAL-SURGICAL NURSING II) LECTURER: MRS. IVY ROSALES

GASTROINTESTINAL sodium
phosphate)
TREATMENT MODALITIES Hypotonic 500-1000 mL Distends 15-20 Fluid and
AND NURSING CARE OF of tap water colon,
stimulates
minutes electrolyte
imbalance,
CLIENTS WITH ORAL peristalsis,
and softens
water
intoxication
DISORDERS feces

ENEMA
Isotonic 500-1000 mL Distends 15-20 Possible
- a procedure of evacuating waste materials (feces or
of normal colon, minutes sodium
stool) from a person’s lower bowel saline (9 mL stimulates retention
In EVMC ward, we have the fleet enema. This is to evacuate to 1,000 mL peristalsis,
feces. water) and softens
Common reasons for fleet enema are to relieve constipation, feces
impacted stool, and also for procedures like colonoscopy,
endoscopy, etc. Soapsuds 500-1000 mL Irritates 10-15 Irritates and
soap to 1,000 mucosa, minutes may
*from the video
mL water distends damage
Large volume enema
colon, mucosa
Prep time: 1-2 minutes
Skill time: 15 minutes
Follow-up: Check your patient’s comfort and bowel output RETENTION ENEMA
Supplies: ● introduces oil or medication into the rectum and
● Gloves sigmoid colon
● Pre-packed enema ● Acts to soften the feces and to lubricate the rectum
● Enema solution and anal canal, thus facilitating passage of feces
● Lubricant
● Bath blanket RETURN FLOW ENEMA
● Waterproof pad ● Used to occasionally expel flatus, alternating flow of
● Commode or bedpan 100-200 mL of fluid into and out of the rectum and
Essential Step: Know your patient’s current bowel status and sigmoid stimulates peristalsis
keep them comfortable ● Repeated 5 or 6 times until flatus is expelled and
- larger than fleet enema when the distention is relieved
- it is packed with soap suds which we can add to PRECAUTIONS:
make a little sudsy or we can leave it out if we just ● Enemas SHOULD NOT be the first line of treatment
want a water for constipation
- fill with warm water (cold water can cause cramping ● Must be used with caution in cardiac patients who
- lubricate 3-4 inches of the tube have arrhythmias or have had recent MI
- hold for 15 minutes or longer before going to the ● SHOULD NOT be given to patients with undiagnosed
toilet to defecate abdominal pain. Peristalsis can cause an inflamed
https://www.youtube.com/watch?v=tbdGw97gVMA appendix to rupture.
● SHOULD NOT be used to patients with rectal
TYPES OF ENEMAS bleeding or prolapse of rectal tissue Inserting can
● Cleansing further cause bleeding or cause damage to rectal tissue.
● Retention ● DO NOT FORCE enema catheter into rectum against
● Return Flow resistance. Lubricate with water-soluble lubricant. If
there is resistance, you may instruct the patient to relax
CLEANSING ENEMA and do deep-breathing. If nursing interventions won’t
Position: left lateral sims position work, inform the physician.
- Prepare the intestine for certain diagnostic ● Use only mild castile soap (hard white unperfumed
procedure such as x-ray or visualization tests (e.g. soap made from olive oil and lye) for soap suds
colonoscopy). enemas.
What is the purpose why we need to remove the feces from GUIDELINES:
the lower bowel?
ADULT
- for a clearer vision for visualization tests because the
feces can interfere or impede the visualization.
Size of rectal tube Fr. # 22-30
After doing the cleansing enema, you have to check the bowel
of the patient by checking the toilet/bowl before flushing.
Amount of solution 500-1,000 ml
Continue the procedure until the lower bowel is clear of feces.
Stop doing the enema if the patient has already clear bowel
Distance of tube 7.5 - 10cm (3 - 4 inches)
movement.

Solution Temperature 40.5 - 43 C

Solutions used in Cleansing Enema
*Cold solution can cause
cramping
SOLUTION CONSTITUENTS ACTION TIME TO ADVERSE
EFFECT EFFECTS
Reference Video: https://www.youtube.com/watch?
Hypertonic 90-120 mL of Draws water 5-10 Retention of v=O9ykpNR-x2A
solution (e.g. into the colon minutes sodium

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RTRMF – BSN LEVEL III BATCH TOPAZ
NCM 116 (MEDICAL-SURGICAL NURSING II) LECTURER: MRS. IVY ROSALES

NASOGASTRIC TUBE INSERTION STEPS IN NGT INSERTION

Safety Consideration: 1. Perform hand hygiene and gather supplies
● perform hand hygiene ● Pad (Incopad)
● check room for additional precautions ● Nasogastric tube
● introduce yourself to the patient ● Water with straw
● confirm patient ID using two patient identifiers ● Tape
● explain process to patient ● pH indicator strip (used for checking placement)
● listen and attend to patient cues ● Water soluble jelly
● ensure patient’s privacy and dignity ● Bulb syringe (Asepto syringe)
● assess ABC’s/suction/oxygen/safety ● Clean gloves
● apply principles of asepsis and safety
● check vital signs
● complete necessary focused assessments
● should stay in place no more than 4 weeks

GASTROINTESTINAL INSERTION
- insertion of a flexible tube into stomach or beyond
the pylorus into the duodenum or jejunum
Purpose:
● Decompress the stomach and remove gas or fluid
● Lavage 2. Visually inspect condition of patient’s nasal and oral
● Diagnose GI disorders cavities
● Administer tube feeding/medications 3. Assess for the best nostril before you begin
● Compress a bleeding site ● Do this by occluding one side and asking the
● Aspirate GI contents for GI analysis patient to sniff. Ask the patient about previous
injuries or history of a deviated septum.
TUBE TYPES 4. Palpate the patient’s abdomen for distention, pain,
● Levin Tube and/or rigidity. Auscultate for bowel sounds.
- Has only one port 5. Assess the patient’s level of consciousness and
understanding of procedure.
6. Check doctor’s orders for the type of NG tube to be
placed and reason for placement.
7. Check doctor’s orders to determine whether the NG
tube is to be attached to suction or a drainage bag. A
suction bag is used for decompression, and a
drainage bag is used for lavage.
8. Position the patient sitting up to 45 to 90 degrees
● Salem (Double Lumen) Pump (unless contraindicated by the patient’s condition),
- Most common nasogastric tube with a pillow under the head and shoulder.
- Used for irrigation of stomach and tube feedings 9. Raise bed to a comfortable working height.
- Sizes 14-18 French 10. Agree on a signal the patient can use if they wish you
- 120 cm long to pause during the procedure.
- If suction is needed, connect the larger bore to 11. Place a towel on the patient’s chest and provide facial
suction tissues and an emesis basin. Kanina we don’t put
- Blue vent is always open to air for continuous towel in the picture but we also have an inco pad.
atmospheric irrigation. 12. Provide a drinking water and straw if the patient is
- Prevent reflux by having the blue vent port above not fluid restricted.
patient’s waist. 13. Stand to the patient’s right side if they’re right
handed, and left side if left handed.
14. Measure distance of the tube from the tip of the
nose, to the earlobe, to the xiphoid process and then
mark the tube at this point. How do we mark the
measurement?You may use a plaster pero an iba na
mag tube mayda na iton nira calibration mayda iton
number, and you take note of the number. So this is
how you estimate the length of the tube. Again, tip of
the nose, earlobe, xiphoid process. This is standard
measurement.
ENTERIC TUBES
15. Lubricate NG tube tip according to your agency
● Nasoenteric Tubes
policy
● Nasoduodenal Tubes
16. Curve 10 to 15 cm of the end of the NG tube around
● Nasojejunal Tubes
your gloved finger, and the release it. Why do we
- Insertion of enteric tubes should be avoided in
need to curve the tip of the tube? Kay inen nga tip
Basilar skull fractures, maxillofacial surgery,
asya it imo ig insert. Pag straight hiya, kukurian ka.
uncontrolled coagulation abnormalities
Kun curve ngani ito mas madagmit pag insert. Kay
- Use with caution in patients with esophageal
curve man tikadi may esophagus.
varices.
17. Have a patient drop head forward and breathe
through the mouth.

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RTRMF – BSN LEVEL III BATCH TOPAZ
NCM 116 (MEDICAL-SURGICAL NURSING II) LECTURER: MRS. IVY ROSALES

18. Insert NG tube tip slowly into the patient’s nostril and
advance it steadily, in a downward direction, along
the bottom of the nasal passage, with the curved end
pointing downward in the direction of the ear on the
same side of the nostril. That’s why we need to curve
the tube before insertion.
19. You may feel slight resistance as you advance along
the nasal passage.Twist the tube slightly. apply
downward pressure, and continue trying to advance
the tube. If significant resistance is felt, remove the
tube and allow the patient to rest before trying again
in the other nostril. If this happens dire ka makaka
insert smoothly which is dire comfortable, or may
resistance. Remove the tube and insert again on the
other nostril. Let it dry so the patient can rest for 5-
10 minutes then you may insert the tube.
20. If there is difficulty in passing the NG tube, you may
ask the patient to sip water slowly through a straw
unless oral fluids are contraindicated. If oral fluids
are not allowed, ask the patient to try dry swallowing
while you advance the tube. If pt is NPO instruct the
pt to swallow. Pag swallow niya dida kana ma insert.
21. Continue to advance NG tube until you reach the
mark/ tape you had placed for measurement.
22. Temporarily anchor the tube to the patient’s cheek
with a piece of tape until you can check for correct
placement.
23. Verify tube placement according to agency policy.
Colour-colored pH paper is usually used, as an initial
and interim check, to confirm that acidic contents are
present. Then an X-ray is taken tp confirm placement
prior to using NG tube for feeding Before you do
feeding, it nagbabassa la hit X-ray it doctor. We are
not allowed to read, cause it’s not our responsibility.
The the doctor should rewrite on the doctor’s order
“may use NGT tube for feeding.” Once masurat na
han doctor that’s the safest time we can use the NGT.
Protect yourself, ayaw pag insert dayon.
24. Secure the tube to the patient’s gown with a safety
pin, allowing enough tube length for comfortable
head movement.
25. Document the procedure according to agency policy,
and report any unexpected findings to the
appropriate health care provider.
TUBE OBSTRUCTION
● Warm water irrigation
What will you do if your tube is irrigated? Use warm water kay
bangin nagpupundok la dida an imo medisana
● Milking the tube
● Infusing digestive enzymes
● Mechanical decloging devices
Note: Feeding tube are more successfully declogged when
intervention is initiated immediatley after obstruction is noted
(so ikaw na nurse on your shift na obstruct na hiya don’t wait
for the next shift to do the decloging kay the more time mag
stay an clog the more magigin sticky ngan makukurian kana
pag tanggal. Because the principle is it is more successfully
decloged when intervention is initiated immediatley after
obstruction is noted)
● Provide oral and nasal hygiene
● Change nasal tape every 3 days or as needed
● Maintain patency by irrigating with water every
feeding and medication delivery (30ml before and
after feeding)
POTENTIAL COMPLICATIONS
● FLUID VOLUME DEFICIT
Why? remember the nutritional feeding is a thick formula,
viscous , so kun dri ka nag fluflushing pag hatag hin water ma
dedehydrated tim patient
● PULMONARY COMPLICATIONS
● ASPIRATION PNEUMONIA (elevated head atleast 45
degrees or 90 degrees)
Risk for aspiration pneumonia:
- Older than 70 yrs old
- Altered mental status
- Mechanical ventilation
- Gastric and enteral tubes
- Supine position (always elevate the pt every
feeding)
SIGNS AND SYMPOTMS
- coughing (stop kay bangin na aspirate na ito, that’s
why very important pag check it placement hit tube)
- tachypnea
- desaturation
- fever (late) kay an imo food kumadto na ha lungs na
infect na
PREVENTION
● Semi fowlers position, head elevated 35 to 45
degrees
● Maintain position at least 1 HOUR after intermittent
feeding
● If continuous feeding, maintain on semi fowlers
ADMINISTRATION METHOD
BOLUS: divided into 3 to 4 feedings daily.
● Delivered as quickly as patient can tolerate, but
initiate slowly, increasing the rate as tolerated
● Amount and rate based on patients reaction
INTERMITTENT
● Feeding over 30 minutes or longer at designated
intervals, with flow rate regulated by roller clamp or
automated pump
CONTINUOUS FEEDING
● Delivery by slow infusion
over long periods
● Uses enteral feeding
pumps
● Alarms (kun ubos na or
may hangin)
CYCLIC FEEDING
● Infused feeding via enteral pump over 8 to 18 hrs
Use of 30 mL Water for Tube Feeding:
1. Before and after intermittent tube feedings and
medication administration (5 mL in between
individual medication) therefore, we do not mix
multiple medications in one glass. You give the
feeding first, flush 30 mL of water; then, you may
give the medications with 5 mL flushings in between
medications. After feeding and medication
administration, flush 30 mL of water
2. After checking gastric residuals and gastric pH
3. Every 4 hours with continuous feeding (this type of
feeding is 24 hours)
4. When tubing is discontinued or interrupted
5. When tube is not used, minimum of once daily
flushing as recommended to prevent clogging

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RTRMF – BSN LEVEL III BATCH TOPAZ
NCM 116 (MEDICAL-SURGICAL NURSING II) LECTURER: MRS. IVY ROSALES

NOTE: Medications should NOT be mixed with feeding formulas

(mixing or putting medications with feeding formulas is not
efficient because the patient might become easily full during
the feeding, and so, the medication might not be given in
complete dose; it might cause drug-to-drug interactions; and it
might result to clogging of the tube. Also, mixing medications
may disguise the side effects of one drug to the other making
it hard for us to determine which medication caused the
reaction.)

OPEN SYSTEM TUBE FEEDING FORMULA

Packaged as
liquid or a
powder to be
mixed with water
● Change feeding
container every
24 hours
● Hang time, no
more than 4 to 8
hours to prevent
bacterial
contamination

CLOSED DELIVERY SYSTEM PARENTERAL NUTRITION

● Prefilled sterile container of about 1 L formula, - sometimes called as TPN or Total parenteral
allows a hang time of 24 to 48 hours at room nutrition
temperature - providing nutrients to the body by an IV route

POSSIBLE SIDE EFFECT OF TUBE FEEDING Clinical Indications

DIARRHEA ● Inability to ingest adequate oral food or fluids within a
● Malnutrition 7 to 10 day time frame
● Medication based therapy (elixir based medication,
magnesium, antibiotics)
● Clostridium difficile
● Zinc deficiency

CONSTIPATION
● Inadequate water intake
● Fiber free feeding formula
● Use of opioids

PARENTERAL NUTRITION FORMULA

● 1 to 3 liters of
solution given over
24 hour period.
POTENTIAL COMPLICATION OF ENTERAL THERAPY
you should take
note the date and
time when you open
the solution
● Before infusion,
inspect solution for
separation, oily appearance or any precipitate (white
crystals). If present, it is expired and do not use it.
● gin prepress la iron hiya, makita kamo iron ha doctor’s
order nga Start Kabiven. It is very expensive.

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RTRMF – BSN LEVEL III BATCH TOPAZ
NCM 116 (MEDICAL-SURGICAL NURSING II) LECTURER: MRS. IVY ROSALES

- If abruptly terminated, give Isotonic dextrose for 1-2

hours at the same rate as parenteral nutrition to
ADMINISTRATION METHOD prevent rebound hypoglycemia
1. Peripheral Method
- formulations with dextrose concentrations of more
than 10% should not be given through peripheral INSERTION (from reviewer of last batch):
veins. 1. The patient is placed supine in the Trendelenburg
2. Central Method position to produce dilation of neck and shoulder
different ways or methods vessels, which makes insertion easier and decreases
● Percutaneous central catheters the risk of air embolus.
- used for short term (less than 6 weeks) 2. Patient is instructed to turn their head away from the
- the most commonly used vein is Subclavian vein site of venipuncture and to remain motionless while
but it should be avoided in advanced kidney the catheter is inserted, and the wound is dressed.
disease and HD because an fistula amo an nagamit 3. The position of the tip of the catheter is verified with
han vein x-ray or fluoroscopy to confirm its location in the
- basilic, brachial or cephalic vein superior vena cava at the junction of the right atrium
- Jugular vein and to rule out a pneumothorax resulting from
- Femoral vein is the last option because it is in the inadvertent puncture of the pleura.
thigh and also difficult iya access and prone to 4. Monitor the access ports every now and then for
bacterial contamination. infection and it it’s still patent.
- For example: Subclavian Vein Triple Lumen &
Jugular Vein Triple Lumen. One for parenteral POTENTIAL COMPLICATIONS OF PARENTERAL NUTRITION
nutrition, another can be used for blood extraction
and another can be used for medication.
- Percutaneous central catheters insertion:
- Trendelenberg position to dilate veins and
shoulder vessels
- Skin cleaned with 2% Chlorhexidine
- Prevent CLABSI (Central Line Associated Blood
Stream Infection)
- Sterile field, sterile gloves, cap, gown and mask.
- Can be done bedside, done usually by cardiologist
- Needs consent (invasive procedure)
● Peripherally inserted central catheters (PICC)
- used for short term (less than 6 weeks)
- Used for intermediate-term (several days to
months)
- The basilic, brachial, or cephalic vein is accessed
above the antecubital space, and the catheter is
threaded to the superior vena cava/right atriocaval
junction.
- Taking of blood pressure and blood specimens
from the extremity with the PICC is avoided.
● Surgically placed central catheters
- For long-term use and may remain in place for
many years.
- These catheters threaded (or tunneled) under the
skin (reducing the risk of ascending infection) to the
subclavian vein and advanced into the superior
vena cava.
- Example: Permacath
● Implanted vascular access ports
- Used for long-term IV therapy
- Instead of exiting from the skin, the end of the
catheter is attached to a small chamber that is
placed in a subcutaneous pocket, either on the
anterior chest wall or on the forearm.

DISCONTINUING PARENTERAL NUTRITION

- When do we discontinue parenteral nutrition?
Of course, there should be a doctor’s order, but by
principle we do not just suddenly stop. You should
gradually decrease the rate to allow the patient’s
adjust to the decreased glucose level. Parenteral
nutrition is hypertonic, may dextrose, may glucose, a
large amount and if you suddenly stop infusion, ● Fluid overload - Very important to take note, ha fluid
rebound hypoglycemia occurs. overload, naka infusion pump talag hiya. In medical ward,
when they have patient na naka parenteral nutrition, they

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RTRMF – BSN LEVEL III BATCH TOPAZ
NCM 116 (MEDICAL-SURGICAL NURSING II) LECTURER: MRS. IVY ROSALES

use infusion pump, mayda didto infusion pump ha gilid, - Factors: Nutrition (high carbohydrates diet), soft drinks
kasi it is used incases of parenteral nutrition is high in sugar, genetic
● Dental Plaque - gluey, gelatin like substance that
adheres to the teeth.

NURSING INTERVENTIONS Prevention

For our important nursing intervention, ano, these are not ● Mouth Care
important nursing intervention ● Diet: decrease sugar and starch
● Fluoridatiton
● Continuous uniform infusion over 24hr period using
● Pit and fissure sealants
infusion pump. So again your infusion should be given for
over 24 hr period, by policy by principle. Kay ano? more
PERIAPICAL ABSCESS
than 24 hrs, it is considered as contaminated, it is
considered as expired.
- collection of pus in
● Cyclic PN (10-15 hour period, titrated up at the
the apical dental
beginning, titrated down at the conclusion. We also periosteum and
have cyclic parenteral nutrition. This is uncommon the tissue
but if the patient is on cyclic, it is given only given on surrounding the
10 to 15 hour period, it should be titrated up at the apex of the tooth.
beginning, titrated down at the conclusion to prevent - It forms at the root
rebound hypoglycemia. tip

If ever the parenteral nutrion na ubos na, dri pa available,

again this is expensive, sometimes it will take time to order ha
pharmacy. ikaw na nurse, you should ask the pharmacy before Clinical Manifestations
the time na mag duduty ka. That is why we indicate the time ● Dull, gnawing, continuous pain, often with surrounding
due and is also endorsed sa next nurse na an parenteral cellulitis and edema of adjacent facial structures.
nutrition is due on 10pm tonight. So start pala an imo shift ma ● Mobility involved tooth
order ka na for 10pm. kay ano? danay dri available, danay Medical Management
● Needle aspiration or drill
waray talaga ha pharmacy, so danay an patient talaga an ma
● Incision and drainage
buy.
● Tooth Extraction
● Infuse 10% dextrose and water at the same rate, if solution ● Antibiotics if infected
runs out until next PN solution is available. If ever the ● Analgesics for pain
parenteral nutrition is not available, you should use 10% Nursing Management
dextrose and water (D10 Water) at the same rate with the ● assess for bleeding after treatment
nutrition. Dapat dri mo hiya tigda tatangalon, pag waray na ● Warm saline or warm mouth rinse (We use warm water
available, you should infuse D10 water. Make sure na to promote healing)
meron pang available kun an imo patient with ongoing ● medication as prescribed
parenteral nutrition ● Liquid (soup, water, milk) to soft diet (lugaw, ice cream,
● Weigh daily. if stable, 2 or 3x per week. We should weight yogurt) as tolerated
the patient daily, but if the patient is stable, it can be done
for 2 or 3x per week. Remember that if we weight the TEMPOROMANDIBULAR DISORDERS
patient, ideally, same cloth, same time same weighing scale 3 DISORDERS
and before breakfast. ● MYOFASCIAL PAIN - a discomfort in the muscles
● Monitor I&O controlling jaw function and in neck and shoulder
muscles
NURSING INTERVENTIONS
● INTERNAL DERANGEMENT OF THE JOINT - a
1. Cover with chlorhexidine gel and semi permeable
transparent film to prevent CLABS (central line dislocated jaw, a displaced disc, or an injured condyle
associated blood stream infection). In order for the ● DEGENERATIVE JOINT DISEASE - rheumatoid
nurse to check if there is leakage, redness, or rashes, if arthritis or osteoarthritis in the jaw joint
infected, so that is the reason kun kayano transparent CLINICAL MANIFESTATION
film an gingagamit. ● Jaw pain ranging from dull ache to throbbing,
2. Change dressing every 7 days unless damp, bloody,
debilitating pain radiating to ears, teeth, neck
loose or soiled via sterile technique. It can be
contaminated even by the air pollutant kun sige naton muscles and facial sinuses
open ito na dressing ● Restricted jaw motion
● Locking jaw
DISORDERS OF THE ORAL CAVITY ● Clicking, popping and grating sounds when opening
DENTAL PLAQUES AND CARIES mouth
● Difficulty swallowing and chewing
● Tooth Decay - erosive
● Headaches, earaches, dizziness, hearing problems
process that begins with
the action of bacteria on MEDICAL MANAGEMENT
fermentable ● Conservative treatment
carbohydrates in the ● Non invasive: physical therapy, self care, cognitive
mouth, which produces behavioral therapy, exercise, analgesics, muscle
acids that dissolve tooth enamel. relaxants and oral appliance therapy

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RTRMF – BSN LEVEL III BATCH TOPAZ
NCM 116 (MEDICAL-SURGICAL NURSING II) LECTURER: MRS. IVY ROSALES

● Surgical management: jaw reconstruction, plate - Occur in submandibular glands (80-90%)

fixation (mandibular fractures) - for severe cases
NURSING MANAGEMENT
● Liquid or soft diet 4 to 6 weeks
● Mouth care and feeding instructions
● Schedule appointments for fixation appliance
- Formed from calcium phosphate
- Asymptomatic, unless infected
- If obstructs duct, swelling, sudden local, colicky pain,
relieved by gush of saliva
- Lithotripsy - use of shockwaves to dissolve the stones.

DISORDERS OF SALIVARY GLAND

3 salivary glands - Parotid gland, Submandibular gland,

Sublingual gland

PAROTITIS
- Inflammation of the parotid gland
- Due to mumps (viral)
- Staphylococcus aureus (bacterial) - travels from the
mouth through salivary duct
MANIFESTATION
- Onset: fever, chills
- Swelling, tender glands
- Ear pain
- Difficulty swallowing
MEDICAL MANAGEMENT
● Hydration and fluid intake
● Oral hygiene
● Discontinue medication (tranquilizers, diuretic) - this
may cause dehydration
● Antibiotics (bacterial) - S. aureus
● Analgesics - for pain
● Draining of glands, if antibiotic not successful

SIALADENITIS
- Inflammation of salivary glands
- CAUSED BY: dehydration, radiation therapy, stress,
malnutrition, salivary gland calculi, improper oral
hygiene
- S. aureus (common), MRSA (Methicillin-Resistant S.
aureus) if hospitalized
- SYMPTOMS: pain, swelling, purulent discharge
TREATMENT
- Antibiotics
- Massage
- Hydration
- Warm compresses
- Sialagogues
- Surgical drainage or excision - if indicated

SALIVARY CALCULUS (SIALOLUTHIS)

- bagan presence of gallstone ha common bile duct
(Choledocholithiasis) but this time adi man ha salivary
(Sialolithiasis)

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