Panpacific University

San Vicente, Urdaneta City 

 
 
 
RLE REQUIREMENT 
 
                                              CASE ANALYSIS 
ON 

CHOLELITHIASIS 
 
 
 
 
 
 
 
 
SUBMITTED BY: 
Ibrahim, Qossay Bm
 
 
 
 
TO: 
Sir Almer Cabida, RN
CLINICAL INSTRUCTOR 

 
 
  
OBJECTIVE OF CASE ANALYSIS 
1. To gain indebt knowledge about the disease condition  
2. To gain confidence in handling such cases in the future 
3. To fulfil the partial course objective of R.N curriculum 
4. To share experience and knowledge with colleagues. 
PATIENT’S PROFILE AND HISTORY 
  
Biograpic Data: 
Name of Patient:  Mrs. E.C 
Age:  50 y/o 
Sex:  Female 
Address:     San Blas Vitlans, Pangasinan  
Birthplace:  San Blas Vitlans, Pangasinan  
Birthdate:    April 18, 1970 
Nationality: Filipino 
Religion:       Catholic  
Civil Status:  Trader 
Name of  husband: Robert Calamiong 
           # of Children : 1 
Admission Date:   March 07, 2020 
Admission Diagnosis: CHOLELITHIASIS 
Condition on Admission  
Vital Signs:  
BP: 110/70 mmgh 
T:        36.0 ˚C 
PR:  68 bpm 
RR:  18bpm 
O2Sat:   99% 
Chief Complaint:  
 Past History:  Severe pain in your upper right side ,Twhen it's
touched, Nausea, Vomiting, Fever, diarrhea, indigestion 
Family History 
No history of hypertension, diabetes, TB, or asthma 
Socio economic history 
 Middle class family 
Present Illness: 
Two weeks prior to admission, patient had fever, indigestion, diarrhea, and
pain on the right side was from about 2 months but pain was dull. Then she used to take
pain killer from medical hall. Pain gradually increased. She came to hospital when there
was fever, vomiting and diarrhea. She took the medical treatment from OPD of medical
ward. She was advised to admitted for surgery. 
PAST HEALTH HISTORY 
 No history of any childhood illness 
 No history of hospitalization 
 No history of psychiatric problem 
  No history of past illness of any kind of injuries and accidents. 
Allergies: no allergies to any food, drugs and others 
Medication taken at Home: she used to take medicine from medical hall in minor
cases. 
Traditional Healer’s Prescription: she believes on traditional healer and obeys
them but give emphasis to hospital also 
Medical Practioner’s prescription: if they get health problem they use to cone to
hospital and take prescribed medicine. 
Self prescription: she used to take certain drugs like cetamol when suffering
from fever 
PSYCHOLOGICAL HISTORY 
 Client’s  Reaction to illness: she was worried about the pain that occur during
surgery. 
 Client’s Coping Pattern: she copes by expressing her feelings to her husband 
 Client’s Value to Health: she thinks health is important 
 Client’s perception of the care Giver: she thinks that nurses are caring and
giving health education effectively 
SOCIOLOGICAL HISTORY 
Family Relationship: 
 Client’s Position in the family: she use to help in the family. She is not head of
the family. 
 Person Living with Client(Support System): her husband was caring to her in
hospital. 
 Recent Family Crisis or Changes: there is family crisis, she is unable to care
for her son who is 5years, and her child is with his grandmother. 
Menstrual History 
        Regular menstrual period 
Obstetric history 
 Antenatal checkup: done in the hospital 
 Postnatal checkup: post in the hospital 
 Place of Delivery: hospital 
 Type of Delivery: Spontaneous Vaginal delivery  
 Any Complication: no 
      PERSONAL HISTORY 
 Smoking:     No 
 Alcohol:       No 
 Food habit: 3times a day 
 Food allergy: none 
 Drug allergy: none 
 Bowel and bladder: regular 
 Sleeping pattern: 6-8hrs daily 
       ENVIRONMENTAL HISTORY 
 Type of family:            joint family 
 No of family:               5members 
 Type of house:            cement 
  No of rooms:               4 
 Kitchen:                        separated 
 Fuel used:                     firewood, gas 
 Drinking water:            tap water 
 Toilet:                             pit latrine 
 Drainage System:         open 
PHYSICAL EXAMINATION: 
 General Inspection: 
 Gait:                                  normal 
 Body build:                      fat 
 Consciousness:               conscious and alert 
 Facial expression:          looking anxious 
VITAL SIGNS 
 Temperature:                  36.0C 
 Pulse:                                68bpm and regular 
 Respiration:                    18bpm 
 Blood pressure:              110/70mmHg 
 Height:                            5’3 
 Weight:                           67kg 
       RESPIRATORY EXAMINATION 
 Inspection: symmetrical shape, sternum is located at the midline, expansion of
chest, lateral diameter wider than anteriposterior diameter  
 Palpation: no tenderness, no lump, or depression along the ribs, expansion of
the chest on both sides 
 Percussion: deep resonant sound over the lungs 
 Auscultation:  breath sounds are heard in all areas of lungs,
no rales ronchi wheezing sounds 
CARDIOVASCULAR SYSTEM 
 Inspection: no enlargement of neck vein 
 Palpation:  non tender, no thrill 
 Auscultation: clear and regular heart rate between 60-80bpm. No murmur
sound present. 
CNS EXAMINATION 
 Higher mental functional normal 
 Motor examination e.g position of limbs normal, no atrophy 
 No abnormal movement 
 Normal muscle tone 
 Normal power in all limbs. 
 Deep tendon jerk( bicep triceps, knee and ankle)  
       GASTROINTESTINAL 
  Localized pain in the right upper quadrant, usually with rebound 
 Comfort sleep, rest, slightly anxious about the operation. 
DEVELOPMENT TASK OF YOUNG ADULTHOOD 
IN BOOKS  IN PATIENT 
Selecting a mate  She had selected mate for
marital relationship 
Learning to live with a married She is married since 9yrs, and
partner  lives happy with her Husband 
Starting a family  She has a child 
Rearing children  She’s a house wife, and rears
kids well but unable to do that
now due to illness. 
 
INTRODUCTION OF CHOLELITHIASIS 
Gallstones are hardened deposits of digestive fluid that can form in your
gallbladder. Gallstones range in size from as small as a grain of sand to as large as a
golf ball. Some people develop just one gallstone, while others develop many gallstones
at the same time. 
People who experience symptoms from their gallstones usually require gallbladder
removal surgery. Gallstones that don't cause any signs and symptoms typically don't
need treatment. 
ANATOMY AND PHYSIOLOGY OF CHOLELITHIASIS 
 
 
The gallbladder stores bile produced by the liver 
The gallbladder is a pear-shaped organ that stores about 50 ml of the bile produced by
the liver until the body needs it for digestion. It is about 7–10cm long in humans and is
dark green in color. 
The gallbladder has a muscular wall that contracts in response to cholecystokinin, a
peptide hormone that is synthesized by the small intestine. 
Bile and the Gallbladder 
When food containing fat enters the digestive tract, the secretion of cholecystokinin
(CCK) is stimulated, and the gallbladder releases the bile into the small intestine. The
bile emulsifies fats and neutralizes acids in partly digested food. After being stored in
the gallbladder, the bile becomes more concentrated to increase its potency and
intensify its effect in fats. 
Anatomy of the Gallbladder 
The gallbladder, a hollow organ that stores bile, is located under the liver. Anatomy of
the Gallbladder 
The gallbladder is a hollow organ that sits beneath the liver and stores bile made in the
liver. In adults, the gallbladder measures approximately eight centimeters (3.1 in) in
length and four centimeters (1.6 in) in diameter when fully distended. 
 
The gallbladder, labeled: An illustration of the gallbladder from Gray’s Anatomy with
each section labeled. 
The gallbladder is divided into three sections: 
1. The fundus. 
2. The body. 
3. The neck. 
The neck tapers and connects to the biliary tree via the cystic duct, which then joins the
common hepatic duct to become the common bile duct. At the neck of the gallbladder is
a mucosal fold where gallstones commonly get stuck. 
Layers of the Gallbladder 
There are several different layers of the gallbladder: the mucosa ( epithelium and
lamina propria), the muscularis, the perimuscular, and the serosa. 
 The epithelium is a thin sheet of cells that is closest to the inside of the
gallbladder. 
 The lamina propria is a thin layer of loose connective tissue, which together with
the epithelium, forms the mucosa. 
 The muscularis is a layer of smooth muscular tissue that helps the gallbladder
contract and squirt its bile into the bile duct. 
 The perimuscular (meaning around the muscle) is a fibrous connective tissue
layer that surrounds the muscularis. 
 The serosa is a smooth membrane that is the outer covering of the gallbladder. 
 
Causes 
It's not clear what causes gallstones to form. Doctors think gallstones may result when: 
 Your bile contains too much cholesterol. Normally, your bile contains enough
chemicals to dissolve the cholesterol excreted by your liver. But if your liver excretes
more cholesterol than your bile can dissolve, the excess cholesterol may form into
crystals and eventually into stones. 
 Your bile contains too much bilirubin. Bilirubin is a chemical that's produced
when your body breaks down red blood cells. Certain conditions cause your liver to
make too much bilirubin, including liver cirrhosis, biliary tract infections and certain
blood disorders. The excess bilirubin contributes to gallstone formation. 
 Your gallbladder doesn't empty correctly. If your gallbladder doesn't empty
completely or often enough, bile may become very concentrated, contributing to the
formation of gallstones. 
Types of gallstones 
Types of gallstones that can form in the gallbladder include: 
 Cholesterol gallstones. The most common type of gallstone, called a
cholesterol gallstone, often appears yellow in color. These gallstones are composed
mainly of undissolved cholesterol, but may contain other components. 
 Pigment gallstones. These dark brown or black stones form when your bile
contains too much bilirubin. 
Pathophysiology 
Gallstones are hard, pebble-like structures that obstruct the cystic duct. The formation
of gallstones is often preceded by the presence of biliary sludge, a viscous mixture of
glycoproteins, calcium deposits, and cholesterol crystals in the gallbladder or biliary
ducts.5 In the U.S., most gallstones consist largely of bile supersaturated with
cholesterol.1,2 This hypersaturation, which results from the cholesterol concentration
being greater than its solubility percentage, is caused primarily by hypersecretion of
cholesterol due to altered hepatic cholesterol metabolism.1,3 A distorted balance
between pronucleating (crystallization-promoting) and antinucleating (crystallization-
inhibiting) proteins in the bile also can accelerate crystallization of cholesterol in the
bile.1-3,5 Mucin, a glycoprotein mixture secreted by biliary epithelial cells, has been
documented as a pronucleating protein. It is the decreased degradation of mucin by
lysosomal enzymes that is believed to promote the formation of cholesterol crystals.3 
Loss of gallbladder muscular-wall motility and excessive sphincteric contraction also are
involved in gallstone formation.1 This hypomotility leads to prolonged bile stasis (delayed
gallbladder emptying), along with decreased reservoir function.3,5 The lack of bile flow
causes an accumulation of bile and an increased predisposition for stone formation.
Ineffective filling and a higher proportion of hepatic bile diverted from the gallbladder to
the small bile duct can occur as a result of hypomotility.1,5 
Occasionally, gallstones are composed of bilirubin, a chemical that is produced as a
result of the standard breakdown of RBCs. Infection of the biliary tract and
increased enterohepatic cycling of bilirubin are the suggested causes of bilirubin stone
formation. Bilirubin stones, often referred to as pigment stones, are seen primarily in
patients with infections of the biliary tract or chronic hemolytic diseases (or damaged
RBCs).1,3,6 Pigment stones are more frequent in Asia and Africa.3,6 
The pathogenesis of cholecystitis most commonly involves the impaction of gallstones
in the bladder neck, Hartmann’s pouch, or the cystic duct; gallstones are not always
present in cholecystitis, however.5 Pressure on the gallbladder increases, the organ
becomes enlarged, the walls thicken, the blood supply decreases, and an exudate may
form.2,5 Cholecystitis can be either acute or chronic, with repeated episodes of acute
inflammation potentially leading to chronic cholecystitis. The gallbladder can become
infected by various microorganisms, including those that are gas forming. An inflamed
gallbladder can undergo necrosis and gangrene and, if left untreated, may progress to
symptomatic sepsis.1,2,5 Failure to properly treat cholecystitis may result in perforation of
the gallbladder, a rare but life-threatening phenomenon.2,5,7 Cholecystitis also can lead to
gallstone pancreatitis if stones dislodge down to the sphincter of Oddi and are not
cleared, thus blocking the pancreatic duct. 
ETIOLOGY 
 Gallstone formation is multi factorial, and the factors involved are related to the
type of gallstone. 
RISK FACTOR 
 Women especially those who have had multiple pregnancies 
 Frequent changes in weight 
 Rapid weight loss 
 Treatment with dose estrogen 
 Low-dose estrogen therapy 
 Cystic fibrosis 
 Diabetes mellitus 
 Being female 
 Being age 40 or older 
 Being a Native American 
 Being a Mexican American 
 Being overweight or obese 
 Being sedentary 
 Being pregnant 
  Eating a high-fat diet 
 Eating a high-cholesterol diet 
 Eating a low-fiber diet 
 Having a family history of gallstones 
 Having certain blood disorders, such as sickle cell anemia or leukemia 
 Losing weight very quickly 
 Taking medications that contain estrogen, such as oral contraceptives or
hormone therapy drugs 
 Having liver disease 
DIAGNOSTIC TEST: 
Imaging is used to provide your doctor with valuable information about gallstones, such
as location, size and effect on organ function. Some types of imaging that your doctor
may order include: 
 Abdominal ultrasound: Ultrasound produces pictures of the gallbladder and bile
ducts. It shows signs of inflammation or indications that there is blockage of bile flow.
Ultrasound is the most common test performed to evaluate gallbladder abnormalities. 
 Abdominal CT: CT rapidly produces detailed pictures of the gallbladder and bile
ducts to look for signs of inflammation or indications that there is blockage of bile
flow. 
 Magnetic resonance cholangiopancreatography (MRCP): MRCP is an MRI exam
that produces detailed images of the liver, gallbladder, bile ducts, pancreas and
pancreatic duct. It identifies gallstones and can show gallbladder or bile duct
inflammation or blockage. 
Differential Diagnoses 
Sometimes symptoms of gallstones can overlap with other conditions. Because of this,
your doctor will need to rule these other disorders out before diagnosing you with
gallstones. The lab and imaging tests discussed above can help distinguish these
conditions from one another.  
Some of the disorders that have similar upper abdominal symptoms and must be
considered along with gallstones include: 
 Hepatitis 
 Chronic pancreatitis 
 Irritable bowel syndrome4 
 Ischemic heart disease 
 Gastroesophageal reflux disease4 
 Peptic ulcer disease 
 Kidney infection 
 Ureteral stones (stones in your ureter) 
 Functional gallbladder disorder, which is when you have pain in your gallbladder
but no gallstones 
 Sphincter of Oddi dysfunction 
Gallstone Treatment 
You don’t need treatment if you don’t have any symptoms. Some small gallstones can
pass through your body on their own. 
Most people with gallstones have their gallbladders taken out. You can still digest food
without it. Your doctor will use one of two procedures. 
Laparoscopic cholecystectomy. This is the most common surgery for gallstones. Your
doctor passes a narrow tube called a laparoscope into your belly through a small cut. It
holds instruments, a light, and a camera. They take out your gallbladder through
another small cut. You’ll usually go home the same day. 
Open cholecystectomy. Your doctor makes bigger cuts in your belly to remove your
gallbladder.  
Complications of Gallstones 
Gallstones can cause serious problems, including: 
 Gallbladder inflammation (acute cholecystitis). This happens when a stone
blocks your gallbladder so it can’t empty. It causes constant pain and fever. Your
gallbladder might burst, or rupture, if you don’t get treatment right away. 
 Blocked bile ducts. This can cause fever, chills, and yellowing of your skin
and eyes (jaundice). If a stone blocks the duct to your pancreas, that organ may
become inflamed (pancreatitis). 
 Infected bile ducts (acute cholangitis). A blocked duct is more likely to get
infected. If the bacteria spread to your bloodstream, they can cause a dangerous
condition called sepsis. 
 Gallbladder cancer. It’s rare, but gallstones raise your risk of this kind of cancer. 
Preventing Gallstones 
Some lifestyle changes might lower your risk of gallstones. 
 Eat a healthy diet that's high in fiber and good fats, like fish oil and olive oil. Avoid
refined carbs, sugar, and unhealthy fats. 
 Get regular exercise. Aim for at least 30 minutes, 5 days a week. 
 Avoid diets that make you lose a lot of weight in a short time. 
 If you’re a woman at high risk of gallstones (for example, because of your family
history or another health condition), talk to your doctor about whether you should
avoid the use of hormonal birth control. 
MEDICAL MANAGEMENT 
 Laparoscopic Cholecytectomy 
 Medication; 
 Inj Cifran 200mg IV BD 
 Inj Aciloc 50mg IV BD 
 Inj Tramadol 50mg IM SOS 
 TAB Becto 500mg O BD 
 TAB Rloc 150mg O BD 
 TAB Nise 100mg O BD 
PROGNOSIS 
 The mortality rate for an elective cholecystectomy is 0.5% with less than 10%
morbidity. 
 The mortality rate for an emergent cholecystectomy is 3-5% with 30-50%
morbidity. 
 Following cholecystectomy, stones may reoccur in the bile duct.