I. INTRODUCTION 1.

Description of the Disease

Obstructive jaundice is a result from the obstruction of the flow of bile from the liver to the duodenum. It is cause by several factors such as tumors of the liver, pancreas or bile duct and Cancer of the pancreas or liver, but the most common cause of obstructive jaundice is Choledocholithiasis a disease of the gallbladder wherein there is an obstruction of the bile ducts by gallstones which may consist of bile pigments or calcium and cholesterol salts that become hardened due to some factors causing obstructive jaundice. The most common sign and symptoms of gallstones that may occur include Abdominal pain in the right upper or middle upper abdomen that may come and go, and defined as a sharp, cramping, or dull pain that spread to the back or below the right shoulder blade and get worse after eating fatty or greasy foods. Other symptoms include fever, loss of appetite, jaundice (yellowing of skin and whites of eyes), nausea, and vomiting. The secondary effects of obstructive jaundice include clay-colored stool, tea-colored urine, jaundice, nausea/vomiting, and pruritus. Gallstones are a common health problem worldwide. Gallstones can occur anywhere within the biliary tree, including the gallbladder and the common bile duct. On the basis of their composition, gallstones can be divided into the following types: Cholesterol stones vary in color from light yellow to dark green or brown. Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile. Mixed stones typically contain 20% cholesterol and some constituents like calcium carbonate, palmitate phosphate, bilirubin, and other bile pigments. The incidence of choledocholithiasis varies from person to person. Women are twice as likely as men to develop gallstones; the higher prevalence of gallstones in women is thought to be caused by multiple pregnancies, obesity, and rapid weight loss. It is also said to be common to patients with higher intake or consumption to saturated fatty

acids and prolonged estrogen exposure. It is also prevalence in Hispanic population and can be inherited by familial tendency. A study called Gallstone Disease is Associated with Increased Mortality in the United States, they analyzed data from 14,228 participants in the third U.S. National Health and Nutrition Examination Survey (20-74 years old) who underwent gallbladder ultrasonography from 1988 to 1994. Gallstone disease was defined as ultrasounddocumented gallstones or evidence of cholecystectomy. The underlying cause of death was identified from death certificates collected through 2006 (mean follow up=14.3 years). Mortality hazard ratios (HR) were calculated using Cox proportional hazards regression analysis, to adjust for multiple demographic and cardiovascular-disease risk factors. The results indicates that the prevalence of gallstones was 7.1% and of cholecystectomy was 5.3%. During a follow-up period of 18 years or more, the cumulative mortality was 16.5% from all causes (2,389 deaths), 6.7% from cardiovascular disease (886 deaths), and 4.9% from cancer (651 deaths). Gallstones are the most common and costly digestive disease in the United States, causing more than 800,000 hospitalizations annually at estimated cost of over five billion dollars. More than 20 million Americans have gallstones and approximately one million new cases are diagnosed each year. In the Philippines, the prevalence of gallstones is quite high as according to a study of the US Census Bureau, Population Estimates, 2004, the no. of cases in the Philippines each year estimates 5,073,040 million and most of them were women. The nursing students (Group 3b) were tasked to find a case for their comprehensive case study. They gathered first all the cases available in the orthopedic and surgical ward and reported it to their clinical instructor to choose which case is interesting and new to us. Their clinical instructor chose Obstructive jaundice secondary to Choledocholithiasis. The nursing students agreed to handle the case since its new to them. They were challenged to study the disease because they want to know the reasons and root causes why such condition occurs and how does it affect an individual who experienced such condition. And they hope that this study will be an advantage for their

group in facilitating and scrutinizing the cause of the problem. Eventually, it will give them a better understanding of the disease and know the importance of being a competent student nurses as how they provide health teachings and perform independent nursing functions by rendering care and support to their patient. This study will be a future reference that may help other researchers/student nurses that take the challenge of finding the root of this condition in doing/completing their requirements. 2. Current Trends Prompt Gallbladder Removal in Elderly Associated With Increased Survival, Lower Costs ScienceDaily (June 2, 2010) New research findings published in the May issue of the Journal of the American College of Surgeons indicate that delaying cholecystectomy, the surgical removal of the gallbladder, in elderly patients with sudden inflammation of the organ often results in increased costs, morbidity and mortality. Typhoid Fever Bacteria Collect on Gallstones to Perpetuate Disease ScienceDaily (Feb. 23, 2010) A new study suggests that the bacteria that cause typhoid fever collect in tiny but persistent communities on gallstones, making the infection particularly hard to fight in so-called "carriers" -- people who have the disease but show no symptoms. Patients With Mild Gallstone Pancreatitis Can Undergo Surgery Sooner, Shortening Hospital Stays ScienceDaily (Feb. 9, 2010) Patients with mild gallstone pancreatitis usually stay in the hospital for several days, waiting for the symptoms to subside, before undergoing surgery to remedy the condition. A new study from researchers at Los Angeles Biomedical Research Institute (LA BioMed) indicates patients may no longer have to wait so long for surgery and could leave the hospital sooner.

3. Objectives After 7 days of making this case study, the students will be able to: Cognitive: Define Choledocholithiasis Be familiar with the modifiable and non-modifiable factors as well as the signs and symptoms of the stated complication, treatment and preventions of Choledocholithiasis Grasp knowledge about the advancement of the complication, their effects and manifestations Analyze and interpret laboratory results and relate them to the pathology of the disease. Be familiar with the treatment modalities available. Formulate nursing diagnoses related and significant to patients condition. Document pertinent data and information about the patient.

Affective: Empathize with the patients current condition. Provide comfort to the client as she copes up with her current situation.

Psychomotor: Demonstrate to the significant other the appropriate interventions to the patient. Educate the significant other regarding the patients condition according to her level of comprehension. Assist the significant other on how to be acquainted with the patients actual condition. Improve patients strength and certainty in dealing and handling ones behavior.

Provide health teachings to the support people by health teachings that would help improve the patients condition. Administer medications appropriately and explain the need and purpose of the treatment to the significant others.

Nursing Care Plan Assessment Subjective: Nursing Dx Scientific Objectives Explanation Impaired tissue After 4 hours integrity is of damage to nursing mucous intervent membrane, ions, the corneal, patient integumentary, will be or subcutaneous able to tissues. There demonst are several rate factors that techniqu could damage es or the tissues such measure as infection, s to surgery and etc. promote In the case of the healing patient, the such as cause of the repositio disruption of ning and tissues is the deep procedure done breathin to her which is g cholecystectomy exercises , wherein they . will make an incision on the RUQ of the Nursing Intervention > assist patient in repositioning. > change the dressing as often as needed. > teach patient deep breathing exercises > encourage patient on proper observance of good hygiene > encourage adequate periods of rest and sleep. > monitor laboratory results such as CBC, creatinine level, Rationale > To promote good circulation and prevent excessive tissue pressure. > Keeps the area of the dressing clean and protect skin from infection. > To promote tissue perfusion and healing > To prevent infection and other complications. > To maximize energy available for healing and meet comfort needs. > To notify if Evaluation

Impaired tissue integrity r/t post Objective: operative cholecystec > Presence of tomy AEB disruptio disruption n of of tissues tissue and skin on and skin the right upper > With quadrant of difficulty the mobilizi abdomen. ng > With facial grimace upon mobilizi ng > Presence of sutured skin > Needs

assistanc e upon mobilizi ng.

abdomen to remove the gallbladder to relieve the symptoms manifested by the patient and to promote comfort.

blood sugar tests. > administer fluids and electrolytes as per doctors order. > administer medications as per doctors order.

there is changes that could be an indicative of healing/infectio n or complications. > To support volume circulating tissue perfusion. > To prevent the spread of infection and other complications, and promote healing and decrease inflammation.

Assessment Subjective:

Nursing Dx Acute pain r/t irritation of

Scientific Explanation Acute pain is described as an

Objectives After 3 hours

Nursing Intervention > Monitor vital signs specifically heart

Rationale > To monitor changes such

Evaluation

Objective: > Facial grimace upon mobilizi ng > Guarding behavior on the area of pain > Restless ness > Diaphore sis > Selffocusing

nerve endings secondary to disruption of tissues and skin from surgery AEB facial grimace upon mobilizing.

unpleasant sensory or emotional experience associated with actual or potential tissue injury. In the case of the patient, the cause of pain is the disruption of tissues due to the operation done to the patient. The pain usually comes after the effect of anesthesia is gone resulting to irritation and pain.

of nursing interven tions, the patient will be able to demons trate behavio rs that minimi zes/cont rol pain such as use of relaxati on techniq ues and diversio nal activitie s.

as increase heart rate that would indicate severity of > Assist patient on pain. repositioning. > To promote good circulation that helps to > Encourage patient to promote faster use soft linens and healing. pillows > To promote > Encourage patient the comfort use of relaxation technique such as > To minimize pain deep breathing and promote exercises. comfort > Encourage patient to have some > To divert the diversional attention of the activities such as patient instead watching tv, of focusing on socializing, and the pain. reading newspapers. > Bed rest will help > Promote bed rest conserve energy and minimize pain > Administer fluids > To support and electrolytes as volume per doctors order. circulating tissue

rate.

> Administer analgesics as per doctors order.

perfusion. > To control the pain.

Prompt Gallbladder Removal in Elderly Associated With Increased Survival, Lower Costs ScienceDaily (June 2, 2010) New research findings published in the May issue of the Journal of the American College of Surgeons indicate that delaying cholecystectomy, the surgical removal of the gallbladder, in elderly patients with sudden inflammation of the organ often results in increased costs, morbidity and mortality. Gallstone disease is the most costly digestive disease in the United States, with approximately 20 million people having the disorder. Annually, gallstone disease leads to more than one million hospitalizations, 700,000 operative procedures, and a cost of $5 billion. Furthermore, the prevalence of gallstones increases with age: 15 percent of men and 24 percent of women will have gallstones by age 70. As well, complications related to gallstones are more common in elderly patients, with the most common being acute cholecystitis, a sudden inflammation of the gallbladder, which can cause abdominal pain, nausea, vomiting, and fever. "This is the first systematic study on how adherence to the recommendations for management of acute cholecystitis affects long-term outcomes and resource use," said Taylor S. Riall, MD, PhD, FACS, associate professor of surgery at the University of Texas Medical Branch in Galveston. "Our study helped identify both patients who are at high risk for not receiving definitive surgical treatment with cholecystectomy and those that are at high risk for being readmitted if they do not have cholecystectomy." Researchers used a five percent sample of national Medicare claims data from 1996 to 2005 to identify a cohort of patients admitted to an acute care hospital with acute cholecystitis. By choosing patients from this period, researchers were able to evaluate comorbidities in the year before initial hospitalization and then follow all patients two years after their initial hospitalization for gallstone complications. Between 1996 and 2005, 29,818 Medicare beneficiaries were admitted to acute care facilities for a first episode of acute cholecystitis. Of these patients, 75 percent (n=22,367) underwent cholecystectomy. The inpatient mortality rate was 2.7 percent in patients who did not undergo cholecystectomy, and 2.1 percent in patients who did (p = 0.001). For the 25 percent of patients (n=7,451) who did not undergo cholecystectomy upon first hospitalization, 38 percent required gallstone related re-admission over the subsequent two years, compared to only four percent in patients who did undergo the surgery (P< 0.0001). Twenty-seven percent of patients who did not undergo definitive therapy (gallbladder removal) required subsequent cholecystectomy, often not performed electively, but associated with acute care re-admission. The gallstone-related readmissions were expensive for Medicare, leading to approximately $14,000 in total charges and greater than $7,000 in Medicare payments per readmission.

Additionally, patients who did not undergo cholecystectomy during initial hospitalization were 56 percent more likely to die two years after hospitalization discharge versus those who received immediate treatment (HR 1.56, 95 percent CI 1.47 to 1.65), even after controlling for patient demographics and comorbidities. Typhoid Fever Bacteria Collect on Gallstones to Perpetuate Disease ScienceDaily (Feb. 23, 2010) A new study suggests that the bacteria that cause typhoid fever collect in tiny but persistent communities on gallstones, making the infection particularly hard to fight in so-called "carriers" -- people who have the disease but show no symptoms. Humans who harbor these bacterial communities in their gallbladders, even without symptoms, are able to infect others with active typhoid fever, especially in developing areas of the world with poor sanitation. The disease is transmitted through fecal-oral contact, such as through poor hand-washing by people who prepare food. Typhoid fever is rare in the United States, but it affects an estimated 22 million people worldwide, causing symptoms that include a high fever, headache, weakness and fatigue, and abdominal pain. It leads to hundreds of thousands of deaths each year. Scientists and physicians have known for decades that these bacteria, Salmonella enterica serovar Typhi, accumulate in the gallbladder. In fact, the most widely accepted treatment of chronic typhoid infection is removal of the gallbladder. "We're trying to get to the heart of why this is. Why does Salmonella sit in a pool of highly concentrated detergent, which is what bile is, but not die?" said John Gunn, professor of molecular virology, immunology and medical genetics at Ohio State University and senior author of the study. "It's got to survive in some way, and a good way to survive is by forming a biofilm." Biofilms -- in this case, the collection of bacteria on gallstones -- typically do not respond well to antibiotics or the human immune response. But now that the biofilms themselves have been discovered in association with asymptomatic typhoid infection, they present a potential treatment alternative to expensive and invasive gallbladder removal, Gunn said. Specifically, targeting a sugar polymer on the bacterial surface that promotes development of the biofilm might be a strategy to prevent biofilm formation in the first place, he said. The research appears in the online early edition of the Proceedings of the National Academy of Sciences. Gunn and colleagues observed this biofilm formation in mice infected with a strain of Salmonella bacteria similar to the strain that causes typhoid fever in humans. The scientists also detected these biofilms on gallstones in about 5 percent of humans in a

Mexican hospital who had their gallbladders removed because of complications from gallstones. Typhoid fever is widespread in Mexico. "The mouse data coupled with the human data suggest strongly that biofilms lay a foundation that allows for establishment and maintenance of chronic typhoid infection," said Gunn, also a vice director of Ohio State's Center for Microbial Interface Biology. And the researchers suspect biofilms are at play in the gallbladder's association with typhoid fever because in most cases, the only way to treat a biofilm-related infection is to remove whatever the biofilm has attached to from the body. For example, infections that form on catheters, implanted joints or artificial heart valves typically result from biofilms, and the only way to clear the infection is to remove those devices. "Information in our lab and in the literature that gallstones were associated with how people became carriers of typhoid bacteria, that organisms were confined to one site, and that antibiotics are ineffective so one has to remove the gallbladder for successful therapy -- it all fit with biofilm-related disease," Gunn said. In the study, the researchers fed mice either normal food or a high-cholesterol diet for eight weeks, intending to induce gallstones in the animals on the fatty diet. The scientists then gave these mice a type of Salmonella bacteria designed to mimic a chronic human typhoid infection without causing actual illness in the mice. A control group of mice received no bacteria. The number of bacteria harbored in the gallbladders of mice with gallstones increased over time, becoming abundant within 21 days, and was significantly higher than bacteria in mice that did not have any stones. No bacteria were detected in mice that weren't given the infection, even if they had gallstones. In the infected mice, the Salmonella bacteria also could be seen in the gallbladder lining and in bile as well as on the surface of the gallstones. The gallstones were the focus of this study because Gunn's lab has determined in previous experiments that Salmonellae are attracted to cholesterol-coated surfaces. There are two common types of gallstones -- cholesterol stones and brown or black stones composed primarily of calcium bilirubinate, which can be found in bile. Gunn's test-tube research to date had suggested that Salmonella Typhi bacteria bind particularly well to cholesterol gallstones to form biofilms, and this current study supported that. Three weeks after infection, biofilms covered about 50 percent of the surfaces of the gallstones removed from the infected mice. "What we think is that having gallstones makes you more susceptible to becoming a carrier because it provides that environment for Salmonella to bind to the surface, form a biofilm and establish infection," Gunn said. "Whether that happens 100 percent of the time, nobody knows."

In a second component of the mouse study, the researchers tested fresh fecal pellets from infected mice to test the association between gallstone biofilms and transmission of a typhoid-like infection via feces, a phenomenon called "shedding." The mice with gallstones shed three times more bacteria than did infected mice without gallstones. "The mice that had gallstones and were infected with bacteria had a much higher rate of shedding, meaning those bacteria were released, probably because they had more bacteria in the gallbladder itself," Gunn said. The mouse data not only supported Gunn's hypothesis that gallstones present at least one surface on which Salmonella biofilms form and maintain the carrier state of typhoid fever. The researchers also realized they had developed a new mouse model for further study of asymptomatic typhoid carriage. Gunn and colleagues also obtained data from humans at a hospital in Mexico whose gallbladders were removed as a treatment for gallstone complications. Though none of the patients had ever shown symptoms for typhoid fever, 5 percent of them ended up being carriers of Salmonella Typhi bacteria biofilms on their gallstones. In the single patient determined to be a typhoid carrier who didn't have biofilm on his gallstones, the stones were dark in color, suggesting they were likely composed of something other than cholesterol, Gunn said. This ability of a single individual to harbor latent bacteria elsewhere in the gallbladder leads Gunn and colleagues to suspect that biofilms can form elsewhere in the gallbladder -- perhaps in its lining or persisting within specific cells of the gallbladder wall. Gunn's lab is exploring those possibilities. This work is supported by the National Institutes of Health and a graduate education fellowship from Ohio State's Public Health Preparedness for Infectious Diseases initiative. Co-authors of the study are Robert Crawford of the Center for Microbial Interface Biology and Department of Molecular Virology, Immunology and Medical Genetics at Ohio State; Roberto Rosales-Reyes and Mara de la Luz Ramrez-Aguilar of the Universidad Nacional Autonoma de Mexico; Oscar Chapa-Azuela of Hospital General de Mexico; and Celia Alpuche-Aranda of the Instituto Nacional de Referencia Epidemiologica in Mexico. Patients With Mild Gallstone Pancreatitis Can Undergo Surgery Sooner, Shortening Hospital Stays ScienceDaily (Feb. 9, 2010) Patients with mild gallstone pancreatitis usually stay in the hospital for several days, waiting for the symptoms to subside, before undergoing surgery to remedy the condition. A new study from researchers at Los Angeles Biomedical Research Institute (LA BioMed) indicates patients may no longer have to wait so long for surgery and could leave the hospital sooner.

The study, slated for publication in the Annals of Surgery in April, found surgeons could safely operate on patients with mild gallstone pancreatitis within 48 hours of admission, rather than waiting for the painful inflammation in the pancreas to subside before performing the surgery. "In the study, patients with mild pancreatitis, who underwent surgery within two days of admission, left the hospital sooner and had similar favorable outcomes as those patients who waited several days before surgery," said Christian de Virgilio, MD, a LA BioMed principal investigator and the corresponding author for the study. "The common practice of delaying surgery on patients with mild gallstone pancreatitis should be abandoned because it results in longer and more costly hospital stays." Mild gallstone pancreatitis is caused by a gallstone or gallstones in the common bile duct triggering a backup in the pancreas of the digestive enzymes and hormones it produces to help the body digest food and convert glucose to energy. The standard treatment is laparoscopic surgery to remove the gall bladder, which produces the gallstones. In the study reported in the Annals of Surgery, surgeons removed the gall bladders of 25 patients with mild gallstone pancreatitis within 48 hours of admission and operated on 24 other patients after lab tests and physical examinations found their enzyme levels had normalized. (One patient was excluded from the study after developing other unrelated medical complications.) The researchers found operating on the patients within 48 hours of admission decreased the overall length of hospital stays from four to three days when compared with the patients who waited for the symptoms to subside before undergoing surgery. "Operating within 48 hours of admission is ideally suited to patients with mild gallstone pancreatitis who don't demonstrate evidence of cholangitis, a bacterial infection, and don't require aggressive fluid resuscitation," said Dr. de Virgilio.

http://www.unboundmedicine.com/medline/ebm/record/21075109/full_citation/Gallstone _Disease_is_Associated_with_Increased_Mortality_in_the_United_States_ http://digestive-disorders.health-cares.net/obstructive-jaundice.php http://www.ihealthdirectory.com/obstructive-jaundice/ http://im.unboundmedicine.com/medicine/ub/view/5-Minute-ClinicalConsult/116128/all/Choledocholithiasis

http://www.sciencedaily.com/releases/2010/06/100602121105.htm http://www.sciencedaily.com/releases/2010/02/100222162004.htm http://www.sciencedaily.com/releases/2010/02/100204144600.htm