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Nursing Guide to Choledocholithiasis: Nursing Diagnosis, Interventions, & Care Plans

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Updated On 7 Minute Read

Choledocholithiasis describes the presence of one or more gallstones lodged within the common bile duct (CBD). These stones can partly or fully block the flow of bile from the liver and gallbladder into the duodenum, resulting in a variety of clinical manifestations ranging from mild biliary colic to life-threatening complications such as cholangitis and acute pancreatitis. The accumulation of bile can lead to pressure build-up, inflammation, and infection, affecting liver function and systemic health. 

This condition often arises as a complication of gallbladder stones (cholelithiasis), which migrate into the bile duct. Timely identification and treatment are crucial to prevent long-term hepatobiliary damage and systemic infection.  

Nurses play a vital role throughout the patient care continuum, from early recognition and symptom assessment to post-procedural monitoring, pain control, patient education, and psychosocial support. 

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Etiology and epidemiology 

Choledocholithiasis most commonly results from gallstones migrating from the gallbladder into the common bile duct. In some cases, stones may form primarily within the duct, particularly in the presence of bile stasis or bacterial infection. These stones are typically composed of cholesterol, bilirubin, or a mixture of both. 

Risk factors 

  • History of gallstones (cholelithiasis) 
  • Female sex and age over 40 years 
  • Obesity, metabolic syndrome, or rapid weight loss 
  • Pregnancy due to hormonal changes affecting bile composition 
  • Racial and ethnic predisposition (Native American or Latinx populations) 
  • Previous biliary surgery or interventions such as cholecystectomy 
  • Chronic hemolytic conditions (due to elevated bilirubin load) 

Epidemiology 

  • Up to 10% to 20% of patients with gallstones will develop choledocholithiasis 
  • More prevalent among individuals over age 60 
  • One of the leading causes of biliary obstruction worldwide 
  • High incidence in females and increases with age and comorbidities such as diabetes or cirrhosis 

ICD-10 code 

  • K80.5 — Calculus of bile duct without cholangitis or cholecystitis 
  • Additional relevant codes: 
    • K80.3 — Calculus of bile duct with cholangitis 
    • K80.4 — Calculus of bile duct with cholecystitis 

Assessment 

Clinical presentation 

  • Sudden onset of right upper quadrant (RUQ) or epigastric abdominal pain, often severe and persistent. 
  • Jaundice (yellowing of skin and sclera), and sweating, fever, and a fast heart rate can also be noted. 
  • Fever, chills, and rigors, particularly in cases complicated by cholangitis. 
  • Nausea and vomiting, sometimes accompanied by anorexia. 
  • Dark-colored urine and pale or clay-colored stools due to impaired bile flow. 

Physical examination 

  • RUQ tenderness to palpation 
  • Positive Murphy’s sign, especially if cholecystitis coexists 
  • Icteric sclerae and generalized jaundice (Pain may occur most severely after eating. Pain may wake a patient from sleep.) 
  • Signs of systemic toxicity (tachycardia, hypotension) in severe infections 

Diagnostic tests 

  • Liver function tests: This is used to detect elevated AST, ALT, alkaline phosphatase (ALP), and total/direct bilirubin. (Female patients may be more likely to have referred pain.) 
  • Abdominal ultrasound: This is an Initial imaging modality that may show biliary duct dilation or gallstones but may miss stones within the CBD. 
  • Magnetic resonance cholangiopancreatography (MRCP): Non-invasive imaging helps to visualize biliary tree and locate stones. 
  • Endoscopic ultrasound (EUS): This is a highly sensitive diagnostic tool for detecting bile duct stones. 
  • Endoscopic retrograde cholangiopancreatography (ERCP): This is the gold standard for both diagnosis and therapeutic removal of stones. 
  • CT scan: This is useful in identifying complications such as pancreatitis or hepatic abscess. 

Management 

The management of choledocholithiasis involves a multifaceted approach that aims to alleviate biliary obstruction, relieve symptoms, and prevent complications such as cholangitis, pancreatitis, or hepatic dysfunction. Early and effective intervention is essential, especially when infection or systemic signs are present. 

Treatment typically includes endoscopic or surgical procedures to remove stones, along with supportive care to stabilize the patient and manage pain, hydration, and infection. Nurses help with monitoring patients throughout the diagnostic and treatment phases, ensuring timely interventions and supporting recovery. 

Medical and procedural treatment 

  • ERCP with sphincterotomy and stone extraction: This is a first-line treatment to relieve obstruction and prevent complications. 
  • Cholecystectomy: This is recommended following ERCP in most cases to prevent recurrence of stones. Laparoscopic cholecystectomy is the standard treatment for symptomatic gallstones. 
  • IV fluid resuscitation and broad-spectrum antibiotics: This is required for cases involving cholangitis or systemic infection. 
  • Analgesics and antiemetics: This is used to manage pain, nausea, and improve patient comfort during acute episodes. 

Supportive care 

  • Enforce NPO (nothing by mouth) status during acute presentation to reduce biliary stimulation. 
  • Administer IV hydration and monitor electrolytes and renal function. 
  • Frequent monitoring of temperature, heart rate, and urine output to detect early signs of sepsis. 
  • Oxygen supplementation and hemodynamic support as needed in unstable patients. 

Nursing care plan 

Nursing care for patients with choledocholithiasis is critical to ensuring safe, effective treatment and recovery. Nurses help with assessing for signs of biliary obstruction, managing pre- and post-procedural care, preventing infection, and supporting patient education.  

Due to the potential for complications, such as sepsis, pancreatitis, and hepatic dysfunction, vigilant nursing observation and multidisciplinary coordination are essential. The care plan should address both acute needs, such as pain management and fluid balance, as well as long-term education about recurrence prevention and recovery support. 

Nursing considerations 

  • Monitor lab values, particularly liver function enzymes and bilirubin, for signs of hepatic involvement. 
  • Assess for progression of jaundice, worsening abdominal pain, and systemic signs of infection. 
  • Provide pre- and post-procedural care for patients undergoing ERCP and laparoscopic cholecystectomy. 
  • Educate on medication compliance, pain control strategies, and post-op mobility and breathing exercises. 

Assessment 

  • Evaluate pain characteristics (location, intensity, duration, aggravating/relieving factors). 
  • Monitor vital signs closely, especially temperature, blood pressure, respiratory rate, and oxygen saturation. 
  • Assess color and output of urine and stools for cholestasis-related changes. 
  • Review lab results daily for changes in liver enzymes, WBC count, and renal function. 

Nursing diagnosis/risk for 

  • Acute pain related to biliary obstruction and inflammation 
  • Risk for infection due to biliary stasis or stone-induced trauma 
  • Risk for fluid volume deficit related to vomiting or sepsis 
  • Deficient knowledge regarding disease process, procedures, and recovery 

Interventions 

  • Administer prescribed analgesics, and monitor for effectiveness and side effects. 
  • Provide IV fluids and maintain accurate intake and output documentation. 
  • Support respiratory status post-surgery using incentive spirometry and early ambulation. 
  • Offer emotional support and provide written instructions to reinforce teaching. 
  • Coordinate interdisciplinary care involving gastroenterology, surgery, and nutrition services. 

Expected outcomes 

  • Pain levels are reduced and effectively managed with both pharmacologic and non-pharmacologic interventions. 
  • Laboratory markers stabilize or normalize following stone removal and infection control. 
  • Patients exhibit stable vital signs and show no signs of biliary sepsis. 
  • Patients and caregivers demonstrate understanding of post-procedure care, dietary guidelines, and signs of recurrence. 

Individual/caregiver education 

  • Reinforce the importance of follow-up appointments after ERCP and/or surgical interventions. 
  • Educate on dietary changes, such as adopting a low-fat diet to minimize biliary stimulation. 
  • Identify warning signs that require prompt medical attention, such as fever, persistent pain, vomiting, jaundice, or signs of infection. 
  • Discuss the role of cholecystectomy in preventing recurrence and the potential need for lifestyle modifications post-procedure. 
  • Encourage gradual return to activity and provide pain management guidance during recovery. 

FAQs

Resources 

References 

Mari Wagner, RN

Mari Wagner, BSN, RN

Mari Wagner, BSN, RN, has been a nurse for 40 years and is an accredited nurse case manager. She has extensive experience in both pediatric and adult care, including work in chronic care and in critical care in both the pediatric ICU and adult burn unit. Wagner also brings a unique perspective as both a nurse and a patient, having been diagnosed with a rare illness — autoimmune encephalitis. She currently serves as the secretary of the International Autoimmune Encephalitis Society.