Liver Disease: Gallstone Disease or Cholelithiasis - Case Study Example

Gallstone Disease Student Name Course Code Institutional Affiliation Gallstone Disease Introduction Gallstone disease, or cholelithiasis, is among the commonest and most costly gastrointestinal diseases. The disease poses a major socioeconomic burden to the health care sector. Various disorders lead to the formation of gallstones by contributing to the impaired cholesterol, bile acids and bilirubin metabolism. The gallstones are mostly asymptomatic. A few asymptomatic patients become symptomatic, presenting with biliary colic. Complications of bacterial infections are also common (Abraham, Rivero, Erlikh, Griffith & Kondamudi, 2014). It is essential for health care providers to have a thorough understanding of the various aspects of the disease to ensure that appropriate measures are taken in managing the patients and reducing the socioeconomic burden. To demonstrate appropriate practice skills, this paper will discuss the pathophysiology, management, cholangiopancreatography, and the necessary nursing interventions such as preoperative preparation, patient education and home visits in relation to Mrs. Fiona James, who is a patient with gallstones. Pathophysiology Gallstones form when some bile substances approach solubility levels. Bile becomes concentrated and supersaturated to precipitate and form microscopic crystals. Gallbladder sludge forms when gallbladder mucus traps the crystals. Macroscopic stones form after the growth, fusion and aggregation of the crystals. These microscopic stones and sludge occlude the bile ducts to produce gallstone complications (Heuman, 2015). Gallstones can be made up of calcium, bilirubin and pigments stones, cholesterol or a mixture of the substances. Most gallstones are made up of supersaturated cholesterol, which results from the greater concentration of cholesterol in relation to its percentage of solubility. An imbalance between the antinucleating and pronucleating proteins accelerate cholesterol crystallization in bile (Afamefuna & Allen, 2013). Liver cells can secrete bilirubin or cholesterol into the bile ducts to form either bilirubin or cholesterol gallstones respectively. Liver cells also secrete lecithin as unilamellar vesicles and bile salts to aid fat absorption and digestion. Mixed micelles are the soluble aggregates that form when the bile salts have dissolved the vesicles. Cholesterol gallstones arise when there is a relatively higher cholesterol proportion in bile in relation to the residual vesicles and micelles. Bilirubin gallstones arise when unconjugated bilirubin forms precipitates with calcium like other anions. In chronic cirrhosis and hemolysis, and in other situations of when the turnover of heme is high, the concentration of bilirubin is higher than normal. Eventually, the high concentration leads to the crystallization of the calcium bilirubinate. The bilirubin precipitates oxidize over time to form black pigment stones (Heuman, 2015). Brown pigment stones are composed of varying protein and cholesterol levels, and unconjugated bilirubin. Chronic bacterial and parasitic bile duct infections facilitate the development of the brown pigment stones. The stones form when bacteria produces factors that forms insoluble compounds after reacting with calcium. Bile duct parasites enhance calcium bilirubinate precipitation through the calcified overcoat of their eggs (Erpecum, 2011). The gall bladder enlarges as pressure increases. It may be further complicated by bacterial infections in the form of acute or chronic cholecystitis. The bacteria, especially those that are gas forming, initiate inflammation, which can lead to necrosis and gangrene. Though rare, the perforation associated with exudates is life threatening. If the gallstones dislodge onto the sphincter of Oddi, gallstone pancreatitis may ensue (Afamefuna & Allen, 2013). Management The treatment of gallstones primarily involves the removing of the stones and is symptomatic. This is usually followed by treating the underlying cause of the gallstones if known. Surgery has been used exclusively in the treatment of gallstones but with the advances in bile biochemistry and molecular biology, medical treatments are used as well. The specific basic treatments for gallstones include cavitary endoscopic cholecystectomy, shock wave extracorporeal lithotripsy, litholytic therapy (LT), a combination of litholytic therapy and shock wave extracorporeal lithotripsy, and percutaneous transhepatic LT (Reshetnyak, 2012). It is also usually essential to manage gallstone related diseases. Biliary colic is managed through reassurance, education and laparoscopic cholecystectomy that is not urgent. Acute cholecystitis is managed with intravenous antibiotics and laparoscopic cholecystectomy. The management of choledocholithiasis involves treating cholangitis when present and cholecystectomy. High risk patients with choledocholithiasis are admitted and referred for endoscopic retrograde cholangiopancreatography (ERCP). Patients with cholangitis are initiated on intravenous antibiotics and ERCP is indicated if it is moderate to severe. Finally, gallstone pancreatitis is managed by treating cholangitis when present, and laparoscopic cholecystectomy or ERCP. In severe gallstone pancreatitis, cholecystectomy is delayed for the pancreatitis to resolve first (Alam et al., 2014). Preoperative Preparation It is critical to obtain a detailed history to reduce the peri-operative morbidity risk and facilitate operative planning. The most important history to note include that related to reduced cardiopulmonary reserve, occult bleeding diatheses, jaundice and pancreatitis. The critical preoperative investigations necessary include liver function tests or biochemical analysis, and ultrasound scans for the biliary tree and gall bladder to assist the surgeon in decision making. Cholangiography should be carried out selectively to benefit the patients with the highest risk and reduce the complications of the additional surgery associated with choledocholithiasis (Swanstorm & Soper, 2013). Swanstorm and Soper (2013) state that routine antibiotic prophylaxis is not recommended because trials have found no benefit in uncomplicated procedures. In contrast, selective prophylactic antibiotics are recommended for patients with high risk of contamination. This is achieved by administering a second-generation cephalosporin a quarter to half an hour before surgery. Before the surgery, the single stage procedure is given to the patients and they are counseled. The patients are made aware of the possible change to open cholecystectomy and the possible development of the laparoscopic conventional ports. The patients are then intubated with and endotracheal tube medicated for general anesthesia. Compression stockings can be used to prevent blood from pooling in the legs (Prasad, Surapaneni & Dabade, 2012). Other preparation activities include positioning the patient in supine, inserting peripheral intravenous lines and placing blood pressure, pulse oximetry and electrocardiography monitors (Sherwinter, 2015). Patient Education Patient education is of critical importance just like in other procedures. The education facilitates the essential patient cooperation and manages the expectations of the patient. It is also important in evaluating the patient and obtaining the informed consent. Mrs. Fiona James should be informed about the rationale of laparoscopic cholecystectomy. She should also be informed about the other available surgical interventions for gallstone disease along with their risks, and relative advantages and disadvantages. The education sessions should cover the details of the recommended procedure; follow up, outcomes, complications and surgical risks (Swanstorm & Soper, 2013). The education given to Mrs. Jones should especially focus on what she wishes to know, to help her understand better. It is also highly recommended that the patient be given written information to supplement verbal and direct consultations. However, the written information cannot substitute the verbal direct consultations. The risks should be given in the form of numerical estimates because most patients have been found to prefer them. Mrs. Jones can also be supplemented with video information to supplement the knowledge where feasible (Hert et. al., 2011). Significance of Home Visit Findings to Hospital Injuries to the abdominal structures are more common in laparoscopic than open cholecystectomy. The worsening right-side abdominal pain should prompt the hospital to investigate the possibility of injuries. Postoperative bile duct injuries are usually in the form of a complete transection, stricture, leak or total excision and transection of a duct segment. These together with the proximal biliary tree obstruction can lead to bile leak to form peritoneal fluid (Mungai, Berti & Colagrande, 2013). The hospital should also investigate other structure injuries such as bowel injury. Severe abdominal pain in the presence of fever and tachycardia starting 12 – 36 hours after surgery is usually associated with bowel injury. The hospital should perform radiography to determine the presence of persistent postoperative ileus associated with bowel injury (Hindman, Kang & Parikh, 2014). The history of hypertension is important in the management of Mrs. Jones. The home visit findings showed tachycardia and hypotension instead of hypertension or normal blood pressure. Hypovolemia is usually associated with an increase in the heart rate with unchanged arterial pressure. Therefore, reduction is blood pressure and increase in heart rate is an indication of internal blood loss (Pizov et al., 2012). The hospital should investigate the extent and origin of blood loss. The effectiveness of the surgery and management should also be investigated. Mrs. Jones exhibited guarding, tenderness and fever, which are the features of complication with peritonitis. The hospital should carry out a blood count to investigate the presence of leukocytosis arising from peritonitis (Sista et al., 2013). Rationale of Endoscopic Retrograde Cholangiopancreatography (ERCP) ERCP should be used only when it is necessary because it has more severe complications than other procedures of endoscopy. Clinical information should be used in conjunction with imaging modalities to determine when the use of the procedure is appropriate. For Mrs. Jones, ERCP is indicated to diagnose, assess and treat choledocholithiasis. ERCP is also used to treat choledocholithiasis when it is identified during the exploration of the common bile duct and with intraoperative cholangiography. ERCP can as well assess and treat sphincter of Oddi dysfunction, postoperative biliary leaks and postoperative complications (Malas, 2015). ERCP will be valuable for Mrs. Jones when she is referred back to hospital after the home visit. ERCP can evaluate the pancreas and assess any morphological changes. ERCP is preferred in the treatment of pancreatic strictures and common bile duct stones. ERCP can be an alternative to surgery in the treatment of Mrs. Jones because she is a high-risk surgery candidate considering her hypotension and tachycardia. Further, ERCP is commonly used in the management of patients with advanced disease and greater co-morbidities. ERCP may also be used in the assessment and treatment of acute severe gallstone pancreatitis and hilar cholangiocarcinoma (Wanis, Haimanot & Kanthan, 2014). Conclusion This paper has discussed the aspects of gallstone disease that are important for the management of Mrs. Fiona James. In the presence of predisposing factors, bile becomes concentrated and supersaturated to precipitate and form microscopic crystals. The microscopic crystals are trapped in mucus to form gallbladder sludge and others fuse to form macroscopic stones. The stones can be made up of either bilirubin or cholesterol. Biliary bacteria and parasites facilitate the development of gallstones. Gallstones can also be complicated with infections to result in acute or chronic cholecystitis. The treatment of gallstone disease involves removing the stones medically and surgically. The underlying and related diseases are also treated. ERCP is used to treat high-risk patients with choledocholithiasis. Therefore, it is indicated on Mrs. Jones, being a high risk patient. The preoperative preparation involves taking a detailed history and carrying out biochemical tests to help in decision-making. Selective prophylactic medications are recommended for patients at risk of infections. Mrs. Jones should be informed about the rationale of the surgery, its risks and other issues that she may wish to know through direct consultations, written information and videos when feasible. The patient is given the procedure of the surgery and counseled on the possible changes. An informed consent is obtained and the patient is intubated and positioned for surgery. Finally, a home visit to Mrs. James is important in revealing the complications or inadequacies of the surgery such as abdominal structure injury and bile leak for further management and follow up. References Abraham, S., Rivero, H., Erlikh, I., Griffith L. & Kondamudi, V. K., (2014). Surgical and nonsurgical management of gallstones. Am Fam Physician, 89(10), 795-802. Retrieved 5/18/2018 form . Afamefuna, S. & Allen, S., (2013). Gallbladder disease. US Pharmacist, 38(3), 33-41. Retrieved 5/18/2018 from . Alam, H., Demehri, F. R., Chong, T., Kronick, S. L., Repaskey, W. T., Rice, M. D. & Seagull, F. J., (2014). Evaluation and management of gallstone-related diseases in non-pregnant adults. University of Michigan Health System. Retrieved 5/18/2018 from . Erpecum, K. J. V., (2011). Pathogenesis of cholesterol and pigment gallstones: An update. Clinics and Research in Hepatology and Gastroenterology, 35(4), 281-287, doi : 10.1016/j.clinre.2011.01.009. 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Mastery of endoscopic and laparoscopic surgery. Philadelphia. Lippincott Williams & Wilkins. Wanis, K., Haimanot, S. & Kanthan, R., (2014). Endoscopic retrograde cholangiopancreatography: A review of technique and clinical indications. Journal of Gastrointestinal & Digestive System, 4(208). doi: 10.4172/2161-069X.1000208 Read More