Bile Duct Stones (Choledocholithiasis) Nursing Care and Management Study Guides

Choledocholithiasis is a gallstone lodged in the common bile duct. Once bile can't drain, the patient gets jaundiced, the pain is severe, and infection can climb the biliary tree fast, so recognize the obstruction early and protect the liver while the stone is cleared.

What is Choledocholithiasis?

Gallbladder and biliary tract disease is common, often painful, frequently surgical, and sometimes life-threatening. Cholelithiasis is stones or calculi (gallstones) in the gallbladder, resulting from changes in bile components. One out of ten patients with gallstones develops choledocholithiasis, gallstones in the common bile duct (sometimes called common duct stones). Gallstones are made of cholesterol, calcium bilirubinate, or a mixture of cholesterol and bilirubin pigment. The prognosis is usually good with treatment unless infection occurs, in which case it depends on severity and response to antibiotics.

Pathophysiology

Abnormal metabolism of cholesterol and bile salts drives gallstone formation. Conditions such as age, obesity, and estrogen balance push the liver to secrete bile that is high in cholesterol and low in bile salts. When the gallbladder concentrates this bile, inflammation can occur; excess water and bile salts are reabsorbed, the bile becomes less soluble, and cholesterol, calcium, and bilirubin precipitate into gallstones. Fat entering the duodenum triggers the mucosa to secrete cholecystokinin, which makes the gallbladder contract and empty. If a stone lodges in the cystic duct, the gallbladder contracts but does not empty, and bile flow into the duodenum is obstructed. Biliary narrowing and swelling around the stone irritate and inflame the bile duct, and that inflammation can progress up the biliary tree to infect any of the bile ducts.

Statistics and Incidences

Choledocholithiasis is common worldwide. Cholelithiasis affects 50% of white women and 30% of white men. Out of every 10 patients with cholelithiasis, one develops choledocholithiasis. Gallstones are uncommon in children and young adults but become more prevalent with age, affecting 30% to 40% of people by age 80 years.

Causes

Gallstones develop more often during pregnancy, when hormonal changes increase stone deposition, and with hormonal contraceptives, which alter gallbladder activity. In diabetes mellitus, high blood glucose makes the gallbladder sluggish. In cirrhosis of the liver, scarring along the common bile duct can trap gallstones within the duct.

Clinical Manifestations

Choledocholithiasis can produce a classic gallbladder attack. Acute abdominal pain in the right upper quadrant may radiate to the back, between the shoulders, or to the front of the chest, and can be severe enough that the patient seeks emergency care. The patient cannot digest fats properly because of the gallbladder dysfunction. Jaundice appears if the stone obstructs the common bile duct, and stools turn clay-colored once bile is obstructed.

Complications

Cholangitis is an infection of the bile duct, commonly tied to choledocholithiasis, and may follow percutaneous transhepatic cholangiography or occlusion of endoscopic stents. Obstructive jaundice follows when too much bilirubin is absorbed into the blood. Pancreatitis develops when stones obstruct the common bile duct. Ultimately, the obstruction damages the liver and can lead to secondary biliary cirrhosis.

Assessment and Diagnostic Findings

Ultrasonography has replaced cholecystography as the diagnostic procedure of choice because it is rapid, accurate, and usable in patients with liver dysfunction and jaundice.

• Abdominal CT scan. May detect stones in the gallbladder.
• Percutaneous transhepatic cholangiography. Done under fluoroscopy, distinguishes gallbladder from bile duct disease and cancer of the pancreatic head in jaundiced patients.
• Endoscopic retrograde cholangiopancreatography (ERCP). Visualizes the biliary tree after the endoscope is passed down the esophagus to the duodenum, the common bile duct and pancreatic ducts are cannulated, and contrast is injected.
• Hepatic biliary iminodiacetic acid (HIDA) scan. Detects obstruction of the cystic duct.
• Magnetic resonance cholangiopancreatography. Detects gallstones, choledocholithiasis, masses, biliary stricture, and dilation.
• Abdominal x-ray. Obtained to exclude other causes of symptoms when gallbladder disease is suspected.
• Cholecystography. Oral cholangiography may detect gallstones and assess the gallbladder's ability to fill, concentrate, contract, and empty.

Medical Management

A low-fat diet is prescribed to prevent attacks. Vitamin K manages the itching, jaundice, and bleeding tendencies caused by vitamin K deficiency. NGT insertion and IV therapy may be needed during acute attacks.

Pharmacologic Therapy

Ursodeoxycholic acid dissolves radiolucent stones over 6 to 12 months and is an alternative for poor surgical risks or patients who refuse surgery. Antibiotics are given during acute attacks.

Surgical Management

Surgery, usually elective, is the treatment of choice for gallbladder and bile duct disease. Laparoscopic cholecystectomy visualizes the gallbladder to remove stones lodged in the common bile duct. Cholecystectomy with operative cholangiography removes stones from the common bile duct and is among the most frequently performed surgeries. ERCP with sphincterotomy is the treatment of choice for choledocholithiasis with obstruction or cholangitis from obstruction.

Nursing Management

The surgical patient is often admitted to the hospital or same-day surgery unit on the morning of surgery.

Nursing Assessment

Focus on respiratory status. Note a history of smoking, previous respiratory problems, shallow respirations, a persistent or ineffective cough, and adventitious breath sounds. Evaluate nutrition through a dietary history and general exam at preadmission testing, and review prior labs for baseline status.

Nursing Diagnosis

• Acute pain related to surgical incision.
• Impaired gas exchange related to high abdominal surgical incision.
• Impaired skin integrity related to altered biliary drainage after surgery.
• Imbalanced nutrition, less than body requirements, related to inadequate bile secretion.

Nursing Care Planning & Goals

Goals are relief of pain, adequate ventilation, intact skin and improved biliary drainage, optimal nutrition, and absence of complications.

Nursing Interventions

Before surgery, teach the patient to cough, deep breathe, expectorate, and do leg exercises, and explain what will happen before, during, and after surgery to ease anxiety and gain cooperation. After surgery, monitor vital signs for bleeding, infection, or atelectasis. Evaluate the incision for bleeding; serosanguinous drainage is common for the first 24 to 48 hours if a wound drain is present. After a choledochostomy, a T-tube drain is placed in the duct and attached to a drainage bag; keep the tubing free of kinks, secure the connection to prevent dislodgement, and measure and record T-tube drainage daily, which normally runs 200 to 300 ml. Monitor intake and output. Evaluate the location, duration, and character of pain, and give adequate pain medication, especially before activities that increase pain.

Evaluation

Expected outcomes are relief of pain, adequate ventilation, intact skin and improved biliary drainage, optimal nutrition, and absence of complications.

Discharge and Home Care Guidelines

Instruct the patient about prescribed medications and their actions. Tell the patient and family which symptoms to report, including jaundice, dark urine, pale-colored stools, pruritus, and signs of inflammation or infection such as pain or fever. Teach proper care of the drainage tube and the importance of promptly reporting changes in the amount or character of drainage. Stress keeping followup appointments and taking part in health promotion and recommended screening.

Documentation Guidelines

Document the client's description of and acceptable level of pain; respiratory rate, character of breath sounds, and the frequency, amount, and appearance of secretions; presence of cyanosis; conditions that may interfere with oxygen supply; characteristics of skin damage; impact of the condition on personal image and lifestyle; caloric intake; cultural and religious restrictions and personal preferences; the plan of care; the teaching plan; the client's responses to treatment, teaching, and actions performed; progress toward desired outcomes; and any modifications to the plan.