case presentation cholelithiasis

Cholelithiasis

• Pathophysiology |
• Symptoms and Signs |
• Diagnosis |
• Treatment |
• Prognosis |
• Key Points |

Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. Gallstones tend to be asymptomatic. The most common symptom is biliary colic; gallstones do not cause dyspepsia or fatty food intolerance. More serious complications include cholecystitis; biliary tract obstruction (by stones in the bile ducts [choledocholithiasis]), sometimes with infection (cholangitis); and gallstone pancreatitis. Diagnosis is usually by ultrasonography. If cholelithiasis causes symptoms or complications, cholecystectomy is necessary.

(See also Overview of Biliary Function .)

Risk factors for gallstones include female sex, obesity, increased age, American Indian ethnicity, a Western diet, rapid weight loss, and a family history. In the United States, gallstones are present in over 15% of those aged 60 to 75 ( 1 ). Most disorders of the biliary tract result from gallstones.

General reference

1. Everhart JE, Khare M, Hill M, et al : Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 117(3):632-639, 1999. doi: 10.1016/s0016-5085(99)70456-7

Pathophysiology of Cholelithiasis

Biliary sludge is often a precursor of gallstones. It consists of calcium bilirubinate (a polymer of bilirubin), cholesterol microcrystals, and mucin. Sludge develops during gallbladder stasis, as occurs during pregnancy or use of total parenteral nutrition. Most sludge is asymptomatic and disappears when the primary condition resolves. Alternatively, sludge can evolve into gallstones or migrate into the biliary tract, obstructing the ducts and leading to biliary colic, cholangitis , or pancreatitis .

There are several types of gallstones.

Cholesterol stones account for > 85% of gallstones in the Western world ( 1 ). For cholesterol gallstones to form, the following is required:

Bile must be supersaturated with cholesterol. Normally, water-insoluble cholesterol is made water soluble by combining with bile salts and lecithin to form mixed micelles. Supersaturation of bile with cholesterol most commonly results from excessive cholesterol secretion (as occurs in obesity or diabetes ) but may result from a decrease in bile salt secretion (eg, in cystic fibrosis because of bile salt malabsorption) or in lecithin secretion (eg, in a rare genetic disorder that causes a form of progressive intrahepatic familial cholestasis).

The excess cholesterol must precipitate from solution as solid microcrystals. Such precipitation in the gallbladder is accelerated by mucin, a glycoprotein, or other proteins in bile.

The microcrystals must aggregate and grow. This process is facilitated by the binding effect of mucin forming a scaffold and by retention of microcrystals in the gallbladder with impaired contractility due to excess cholesterol in bile.

Black pigment stones are small, hard gallstones composed of calcium (Ca) bilirubinate and inorganic Ca salts (eg, Ca carbonate, Ca phosphate). Factors that accelerate stone development include alcohol-related liver disease , chronic hemolysis, and older age.

Brown pigment stones are soft and greasy, consisting of bilirubinate and fatty acids (Ca palmitate or stearate). They form during infection, inflammation, and parasitic infestation (eg, liver flukes in Asia).

Gallstones grow at about 1 to 2 mm/year, taking 5 to 20 years before becoming large enough to cause problems. Most gallstones form within the gallbladder, but brown pigment stones form in the ducts. Gallstones may migrate to the bile duct after cholecystectomy or, particularly in the case of brown pigment stones, develop behind strictures as a result of stasis and infection.

Pathophysiology reference

1. European Association for the Study of the Liver (EASL) : EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol 65(1):146-181, 2016. doi: 10.1016/j.jhep.2016.03.005

Symptoms and Signs of Cholelithiasis

About 80% of people with gallstones are asymptomatic. The remainder have symptoms ranging from a characteristic type of pain (biliary colic) to cholecystitis to life-threatening cholangitis. Biliary colic is the most common symptom.

Stones occasionally traverse the cystic duct without causing symptoms. However, most gallstone migration leads to cystic duct obstruction, which, even if transient, causes biliary colic. Biliary colic characteristically begins in the right upper quadrant but may occur elsewhere in the abdomen. It is often poorly localized, particularly in diabetics and older patients. The pain may radiate into the back or down the arm.

Episodes begin suddenly, become intense within 15 minutes to 1 hour, remain at a steady intensity (not colicky) for up to 12 hours (usually < 6 hours), and then gradually disappear over 30 to 90 minutes, leaving a dull ache. The pain is usually severe enough to send patients to the emergency department for relief. Nausea and some vomiting are common, but fever and chills do not occur unless cholecystitis has developed. Mild right upper quadrant or epigastric tenderness may be present; peritoneal findings are absent. Between episodes, patients feel well.

Although biliary colic can follow a heavy meal, fatty food is not a specific precipitating factor. Nonspecific gastrointestinal symptoms, such as gas, bloating, and nausea, have been inaccurately ascribed to gallbladder disease. These symptoms are common, having about equal prevalence in cholelithiasis, peptic ulcer disease , and functional gastrointestinal disorders.

Pearls & Pitfalls

Little correlation exists between the severity and frequency of biliary colic and pathologic changes in the gallbladder. Biliary colic can occur in the absence of cholecystitis. If colic lasts > 12 hours, particularly if it is accompanied by vomiting or fever, acute cholecystitis or pancreatitis is likely.

Diagnosis of Cholelithiasis

Ultrasonography

Gallstones are suspected in patients with biliary colic. Abdominal ultrasonography is the imaging test of choice for detecting gallbladder stones; sensitivity and specificity are 95%. Ultrasonography also accurately detects sludge. CT and MRI are alternatives. Endoscopic ultrasonography accurately detects small gallstones ( < 3 mm) and may be needed if other tests are equivocal.

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Laboratory tests usually are not helpful; typically, results are normal unless complications develop.

Asymptomatic gallstones and biliary sludge are often detected incidentally when imaging, usually ultrasonography, is done for other reasons. About 10 to 15% of gallstones are calcified and visible on plain x-rays.

Treatment of Cholelithiasis

For asymptomatic stones: Expectant management

Most asymptomatic patients decide that the discomfort, expense, and risk of elective surgery are not worth removing an organ that may never cause clinical illness. However, if symptoms occur, gallbladder removal (cholecystectomy) is indicated because pain is likely to recur and serious complications can develop.

Surgery can be done with an open or a laparoscopic technique.

Open cholecystectomy, which involves a large abdominal incision and direct exploration, is safe and effective. Its overall mortality rate is about 0.1% when done electively during a period free of complications.

Laparoscopic cholecystectomy is the treatment of choice. Using video endoscopy and instrumentation through small abdominal incisions, the procedure is less invasive than open cholecystectomy. The result is a much shorter convalescence, decreased postoperative discomfort, improved cosmetic results, yet no increase in morbidity or mortality. Laparoscopic cholecystectomy is converted to an open procedure in 4 to 8% ( 1 ) of patients, usually because biliary anatomy cannot be identified or a complication cannot be managed. Older age typically increases the risks of any type of surgery.

Cholecystectomy effectively prevents future biliary colic but is less effective for preventing atypical symptoms such as dyspepsia. Cholecystectomy does not result in nutritional problems or a need for dietary limitations. Some patients develop diarrhea, often because bile salt malabsorption in the ileum is unmasked. Prophylactic cholecystectomy is warranted in asymptomatic patients with cholelithiasis only if they have large gallstones ( > 3 cm) or a calcified gallbladder (porcelain gallbladder); these conditions increase the risk of gallbladder carcinoma .

Stone dissolution

For patients who decline surgery or who are at high surgical risk (eg, because of concomitant medical disorders or advanced age), gallbladder stones can sometimes be dissolved by ingesting bile acids orally for many months. The best candidates for this treatment are those with small, radiolucent stones (more likely to be composed of cholesterol) in a functioning nonobstructed gallbladder (indicated by normal filling detected during cholescintigraphy or by absence of stones in the gallbladder neck).

< 0.5 cm in diameter within 6 months ( 2

Stone fragmentation (extracorporeal shock wave lithotripsy) to assist stone dissolution and clearance is rarely done.

Treatment references

2. Portincasa P, Di Ciaula A, Bonfrate L, et al : Therapy of gallstone disease: What it was, what it is, what it will be. World J Gastrointest Pharmacol Ther 3(2):7-20, 2012. doi: 10.4292/wjgpt.v3.i2.7

Prognosis for Cholelithiasis

Patients with asymptomatic gallstones become symptomatic at a rate of about 2% per year ( 1 ). The symptom that develops most commonly is biliary colic rather than a major biliary complication. Once biliary symptoms begin, they are likely to recur; pain returns in 20 to 40% of patients per year, and about 1 to 2% of patients per year develop complications such as cholecystitis , choledocholithiasis , cholangitis , and gallstone pancreatitis ( 2 ).

Prognosis references

2. Friedman GD, Raviola CA, Fireman B : Prognosis of gallstones with mild or no symptoms: 25 years of follow-up in a health maintenance organization. J Clin Epidemiol 1989;42(2):127-36. doi: 10.1016/0895-4356(89)90086-3

Gallstones are common, but 80% are asymptomatic.

Abdominal ultrasonography is 95% sensitive and specific for detecting gallbladder stones.

Once symptoms develop (usually biliary colic), pain returns in 20 to 40% of patients/year.

Treat most patients who have symptomatic gallstones with laparoscopic cholecystectomy.

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Cholelithiasis: Presentation and Management

Affiliations.

• 1 Frontier Nursing University, Versailles, KY.
• 2 University of Louisiana at Lafayette, Lafayette, LA.
• PMID: 30908805
• DOI: 10.1111/jmwh.12959

Cholelithiasis affects approximately 15% of the US population. Rising trends in obesity and metabolic syndrome have contributed to an increase in diagnosis of cholelithiasis. There are several risk factors for cholelithiasis, both modifiable and nonmodifiable. Women are more likely to experience cholelithiasis than are men. Pregnancy, increasing parity, and obesity during pregnancy further increase the risk that a woman will develop cholelithiasis. The classic presentation of persons experiencing cholelithiasis, specifically when gallstones obstruct the common bile duct, is right upper quadrant pain of the abdomen that is often elicited upon palpation during physical examination and documented as a positive Murphy's sign. Referred pain to the right supraclavicular region and/or shoulder, nausea, and vomiting are also frequently reported by persons with cholelithiasis. Cholelithiasis can result in complications, including cholecystitis (inflammation of the gallbladder) and cholangitis (inflammation of the bile duct). Lack of physical examination findings does not rule out a diagnosis of cholelithiasis. Laboratory tests such as white blood cell count, liver enzymes, amylase, and lipase may assist the clinician in diagnosing cholelithiasis; however, ultrasonography is the gold standard for diagnosis. Management is dependent on severity and frequency of symptoms. Lifestyle and dietary modifications combined with medication management, such as use of gallstone dissolution agents, may be recommended for persons who have a single symptomatic episode. If symptoms become severe and/or are recurrent, laparoscopic cholecystectomy is recommended. It is recommended that individuals with an established diagnosis of cholelithiasis be referred to a surgeon and/or gastroenterologist within 2 weeks of initial presentation regardless of severity or frequency of symptoms.

Keywords: cholecystectomy; cholelithiasis; gallstones.

© 2019 by the American College of Nurse-Midwives.

Publication types

• Cholangiopancreatography, Endoscopic Retrograde
• Cholecystectomy, Laparoscopic
• Cholelithiasis / diagnosis*
• Cholelithiasis / physiopathology
• Cholelithiasis / therapy*
• Pregnancy Complications / diagnosis*
• Pregnancy Complications / physiopathology
• Pregnancy Complications / therapy*
• Pregnant Women
• Risk Factors
• Ultrasonography

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Patient Case Presentation

Mrs. G.B. is a 38 year old female who presents to the emergency department with complaints of severe abdominal pain. G.B reports that she has had similar pain intermittently over the past week, however, tonight her pain has become constant and unbearable. She reports that the pain usually starts on the right side of her abdomen and radiates to her back. The pain makes it hard to take deep breaths and often occurs at night after eating dinner. G.B’s pain prevents her from sleeping and usually lasts several hours. She reports nausea but no vomiting with her pain tonight, and explains that she has taken ibuprofen and antacids but neither have helped her symptoms.

Physical Exam

Upon exam, G.B.’s vitals are found to be as follows: 

Temp: 38.1 c (100.6 F)

G.B. appears uncomfortable and is sweating. G.B. reports it feels better for her to lie in bed and not move. When G.B. is assessed, the right side of her abdomen below her rib cage is palpated during inspiration. She reports increased pain to the point that she gently pushes the examiner’s hands away.

Pertinent Laboratory Tests

Abnormal Laboratory Values

• WBC – 15.4
• CRP – 18.3

Normal Laboratory Values

• Hgb, Hct, Platelets
• AST, ALT, ALP, GGT
• Amylase, Lipase
• serum HCG – not present

Past Medical History

• Obesity, patient with a BMI of 31
• Mother of 2 children, ages 3 and 5 years
• Gestational diabetes with both pregnancies
• Hypertension, diagnosed 1 year ago, mild and not treated with medication at this time
• Cesarean section, age 35 and 33

Pertinent Family History

• Father alive and healthy age 71
• Mother with a history of obesity, hypertension, and gallstones, alive age 70
• Brother with a history of obesity, alive age 41
• Sister alive and healthy age 36

Pertinent Social History

• Patient works for a local hospital doing IT assistance, has worked there for 10 years
• Patient’s hobbies include reading, knitting, and baking
• Patient reports difficulty with attempts at weight loss, prefers to not go to the gym or be seen working out in public environment 

Images used in “Cholecystitis Patient Presentation” video:

Figure 1. Abdominal Pain. (Johns, C., 2018)

Figure 2 . Examination of Abdomen. (Kappan, S., 2018)

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Gallstones Clinical Case

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CASE PRESENTATION ON CHOLELITHIASIS

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CASE PRESENTATION ON CHOLELITHIASIS

Sep 03, 2014

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CASE PRESENTATION ON CHOLELITHIASIS. PREPARED BY MANJU SUNNY OR DEPARTMENT. DEMOGRAPHIC DATA NAME : Mr. PQRS AGE/SEX : 30YRS/ FEMALE DATE OF ADMISSION : 20/05/13

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• gall stones
• hepatic duct
• bile duct formed
• patient underwent laproscopic cholecystectomy

Presentation Transcript

CASE PRESENTATION ON CHOLELITHIASIS PREPARED BY MANJU SUNNY OR DEPARTMENT

DEMOGRAPHIC DATA NAME : Mr. PQRS AGE/SEX : 30YRS/ FEMALE DATE OF ADMISSION : 20/05/13 DIAGNOSIS : CHOLELITHIASIS SURGERY : CHOLECYSTECTOMY SURGERY ON : 20/05/13 DATE OF DISCHARGE : 21/05/13

Physical assesment 1 .GENERAL APPEARANCE • Patient is 30yrs old female • look anxious • conscious and oriented with following vital signs • B.P : 110/70mmHg • PULSE : 88b/m • RESPIRATION : 20b/m • TEMPREATURE : 36.6 c • SpO2 : 99%

2. SKIN • Fair complexion. • Skin is warm. • 3. HEAD • Hair is equally distributed. • Absence of dandruff & alopecia. • EYES • Both eyes are normal , able to move both eyes. • No discharges . • 5. EARS • Patient pinna is same colour as fascial. • Able to hear sounds clearly. • No discharges.

6. NOSE • Pink nasal mucosa.No nasal discharge • MOUTH • Pink and dry oral mucosa. • Tongue and uvula in midline position. • Teeth is properly aligned with no dentures. • 8. NECK AND THROAT • No tenderness nodes. • No palpable mass and lesions

9. CHEST & LUNGS • Thorax is symmetric on inspection. • Dry cough present. • Clear breath sounds. • 10. CARDIO VASCULAR SYSTEM • ECG is normal. • No cardiomegaly. • Apical pulse is 88 bpm • 11. UPPER &LOWER EXTREMITIES • Normal range of motions. • 12. ABDOMEN • Bowel sounds are normal. • On palpation Abdomen is slightly enlarged .

13 . GENITO URINARY SYSTEM • no discharges • GASTRO INTESTINAL • No bowel obstruction present. • Abdominal pain present. • 15. NEUROLOGIC • Patient is mentally alert and oriented with circumstances. • Able to follow commands. • No neurovascular deficit

PATIENT HISTORY PAST MEDICAL HISTORY No past medical history . PRESENT MEDICAL HISTORY Patient came to OPD on 17.5.2013 with complaints of abdominal pain and vomiting . On examination they suspected cholelithiasis and send her for usg abdomen . After Usg abdomen she was diagnosed as having cholelithiasis . • PAST SURGICAL HISTORY • Patient has no past surgical history. • PRESENT SURGICAL HISTORY • Patient had under gone Laproscopiccholeycystectomy on 20.5.2013.

INVESTIGATIONS DONE FOR THE PATIENT • USG Abdomen • X-ray chest • Blood investigations • CBC • ABORH • PT/INR • APTT • ELECTROLYTES

LAB INVESTIGATIONS

TOPIC PRESENTATION CHOLELITHIASIS

CHOLELITHIASIS Cholelithiasis is the medical term for gallstone disease . Presence of stone in the gall bladder is known as cholelithiasis.It is a crystalline concretion formed with the gall bladder by accretion of bile components.These gall stones are formed in the gall bladder but may distally pass in to other parts of biliary tract such as cystic duct,common bile duct, pancreatic duct or thaeampulla of vater. Choledocholithiasis It refers to the presence of one or more Gallstones in the common bile duct. Usually, this occurs when a gallstone passes from the gallbladder into the common bile duct . A gallstone in the common bile duct may impact distally in the ampulla of Vater, the point where the common bile duct and pancreatic duct join before opening into the duodenum

TYPES OF GALLSTONES Types of gallstones that can form in the gallbladder include: • Cholesterol gall stones • Pigment gall stones • Mixed gall stones

ANATOMY & PHYSIOLOGY

Gallbladder is a pear-shaped sac that lies between the right medial and quadrate lobes of the liver. It is partly attachedand partly free. It is covered anteriorly and posteriorly by peritioneum. It sits in a shallow depression called the gallbladder fossa. The gallbladder is about 7.5–10 cm (3–4 inches) long and about a 2.5 cm (1 inch) wide. • LAYERS OF GALL BLADDER • Muscular layer ( A layer of smooth muscle) • Perimuscular layer (connective tissue that covers the muscular layer. • Mucosa (inner layer of epithelium and connective tissue) • Serosa (outer covering of the gallbladder

For the purpose of description gallbladder is divided in to three; • Fundus of the gallbladder • Body of the gallbladder • Neck of gallbladder

BILE DUCT,HEPATIC DUCT, CYSTIC DUCT ,BILE

BILE It is a yellowish green fluid made by the liver. The gall bladder stores bile produced in the liver.The gall bladder can stores about 40 ml-70 ml of bile. Bile is important in the digestion of lipids. • Bile is mainly made up of: • bile salts • bile pigments (such as bilirubin) • cholesterol • water • COMMON BILE DUCT Bile duct formed by the union of hepatic duct &cystic duct that carries bile from liver &gallbladder to the duodenum.

COMMON HEPATIC DUCT Main excretory duct of liver which joins the cystic duct to form the common bile duct. It drains bile from the liver through the left and right hepatic duct. • CYSTIC DUCT The cystic duct joins the gallbladder to the common bile duct. It usually lies next to cystic artery.The Cystic duct of the gallbladder is 2-4 cm long

ARTERIAL SUPPLY, VENOUS DRAINAGE &LYMPHATIC DRAINAGE

: • FUNCTIONS OF GALL BLADDER • Stores and mobilizes bile. • for digestion. • Promote physical coordination. • Maintain health of connective tissues. • Closed linked with the liver. • Defensive energy against catching infections. Etiology Of Cholelithiasis • Female sex. • European or native american ancestry • Increasing age above 40 yrs • Obesity. • Pregnancy. • Gallbladder stasis. • Drugs. • Heredity.

Factors that may increase risk of gallstones include: • Being female • Being age 60 or older • Being an American Indian • Being a Mexican-American • Being overweight or obese • Being pregnant • Eating a high-fat diet • Eating a high-cholesterol diet • Eating a low-fiber diet • Having a family history of gallstones • Having diabetes • Losing weight very quickly • Taking some cholesterol-lowering medications

Signs and symptoms • pain in the upper right portion of abdomen. • Back pain between shoulder blades • Pain in right shoulder. • Nausea and vomiting. • Jaundice. • Clay coloured stool .

DIAGNOSTIC TESTS • HIDA SCAN • CT SCAN • ERCP • ABDOMINAL ULTRA SOUND • BLOOD TESTS DIAGNOSTIC STUDIES

PATHOPHYSIOLOGY

TREATMENT • MEDICAL MANAGEMENT ORAL BILE SALT THERAPY(URSODEOXYCHOLIC+URSODIOL CONTACT DISSOLUTION EXTRA CORPOREAL SHOCK WAVE LITHOTRIPSY

SURGICAL MANAGEMENT

COMPLICATIONS

COMPLICATIONS OF SURGERY • Infection of an incision. • Internal bleeding. • Injury to the common bile duct . • Injury to the small intestine by one of the instruments used during surgery. • Risk of general anaesthesia . UNCOMMON COMPLICATIONS • Injury to the cystic duct,. • Gallstones that remain in the abdominal cavity. • Bile that leaks into the abdominal cavity. • Injury to abdominal blood vessels, such as the major blood vessel carrying blood from the heart to the liver (hepatic artery).. • A gallstone being pushed into the common bile duct. • The liver being cut.

NURSING INTERVENTION • PRE-OPERATIVE INTERVENTION • The provision of psycho-educational care. • Provision of adequate and appropriate informastionthruogh out the day care experience . • Enhancement of patient self-efficacy via positive encouragement and information provision. • Reduction of the negative impact of the clinical environment and encouraging implicit and explicit messages of safety such as • the hospital performs many operations . • helps to create a warm, friendly and comfortable environment. • POST OP INTERVENTION • Management of pain and post-operative nausea and vomiting. • Initial assistance with mobilization. • Pain management should commence with an assessment of the patient’s pain at regular intervals. • Measures to manage patients’ anxiety should be implemented pre-operatively and continued throughout the post-operative recovery period until discharge

Care of Patient with Cholecystectomy • Preventing respiratory complications • Encouraging activity. • Promoting wound healing. • Maintaining normal body temperature. • Promoting bowel function .. • maintaining gastro intestinal function and resuming nutrition .

PRIORITZATION OF NURSING DIAGNOSIS ACUTE PAIN RELATED TO GALL BLADDER REMOVEL NAUSEA AND VOMITING RELATED TO SURGERY RISK FOR INFECTION RELATED TO SURGICAL INCISION KNOWLEDGE DEFICIT RELATED TO TREATMENT REGIMEN AND POST OP CARE

NURSING CARE PLAN

HEALTH EDUCATION • Health education given on wound care and dressing . • Instructed her the signs of infection and asked him to notify if any signs occurs . • Instructed her to follow the physians order regarding diet and medication. • Educated her the the importance of follow up . • Instructed her she will have no restrictions to physical activities, however the patient should listen to their body in response to certain activities. Gradually increase activities at a comfortable and individual pace. • Advised her to contact if he develops any problems such as prolonged nausea/vomiting, temperature elevations above 101.5 or other difficulties. • Advised her to take the medications accordingly.

CONCLUSION • Presented a case of patient with cholelithiasis. • Patient underwent laproscopiccholecystectomy on 20/05/13. • Presence of stone in the gall bladder is known as cholelithiasis • It is a crystalline concretion formed with the gall bladder by accretion of bile components. • Gallstones may cause no signs or symptoms.Gall stones may be asymptomatic even for years .these stones are called silent stones . If a gallstone lodges in a duct and causes a blockage, signs and symptoms may result. • Laproscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gall stones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection.

BIBLIOGRAPHY • BRUNNER AND SUDDARTH TEXT BOOK OF MEDICAL –SURGICAL NURSING 9 TH EDITION . • LIPPIN COTT WILLIAMS AND WILKINS. • POTTER AND PERRY FUNDAMENTALS OF NURSING 5 TH EDITION • WWW.WIKIPEDIA.ORG.

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Prosecutors at hush money trial say Trump led 'porn star payoff' scheme to 'corrupt' 2016 election

Donald Trump "orchestrated a criminal scheme to corrupt the 2016 presidential election," a prosecutor told jurors Monday during opening statements in the first criminal trial of a former president.

"This case is about a criminal conspiracy and a cover-up,” prosecutor Matthew Colangelo told the 12-person jury and six alternates. Trump, he said, conspired to corrupt the 2016 presidential election by scheming with his lawyer Michael Cohen and David Pecker, who was the publisher of the National Enquirer at the time.

“Then, he covered up that criminal conspiracy by lying in his New York business records over and over and over again,” Colangelo said.

Pecker was called as the prosecution's first witness following opening statements from both sides. Trump's lawyer Todd Blanche told the jury his client was not guilty because no crime was committed.

Trump, who had his eyes closed for periods during the morning proceedings, seemed much more engaged when his old ally and friend Pecker was taking the stand. Trump craned his neck when Pecker walked in, almost as if to see whether Pecker would meet his eye. Trump also poked at his attorney Emil Bove and whispered something as Pecker, 72, got situated, and he leaned forward attentively when he began testifying.

Pecker did not get to his relationship with Trump by the time the court day ended. The proceedings ended early because a juror had an emergency dental appointment.

Trump told reporters afterward that the case was "unfair" and launched into an attack against Cohen, who's expected to be called as witness.

"When are they going to look at all the lies that Cohen did in the last trial? He got caught lying in the last trial. Pure lying," Trump said, apparently referring to Cohen's statement in the civil fraud case against Trump that he lied under oath during part of his 2018 guilty plea. "When are they going to look at that?” Trump said.

The comments are likely to come up at a hearing Tuesday morning, when Manhattan District Attorney Alvin Bragg's office is scheduled to argue that Trump has repeatedly violated a partial gag order barring him from making "public statements about known or reasonably foreseeable witnesses concerning their potential participation in the investigation or in this criminal proceeding."

Prosecutors have said Cohen and Pecker, the longtime former publisher of the Enquirer, are central figures in the alleged scheme to bury claims from women who said they had had affairs with Trump.

Colangelo told the jurors they will hear about a 2015 meeting at Trump Tower with Trump, Cohen and Pecker. Both Cohen and Pecker had specific roles to play in the scheme, Colangelo said. “Cohen’s job really was to take care of problems for the defendant,” he said. “He was Trump’s fixer.” Pecker, meanwhile, would act as “the eyes and ears” for Trump and would let him and Cohen know about any allegations that could hurt his campaign.

The DA alleges the three conspired to hide “damaging information from the voting public.” That included allegations from a former Playboy model named Karen McDougal who said she had a 10-month sexual relationship with Trump that ended in April 2007. Pecker’s AMI agreed to pay her $150,000 in a deal to essentially buy her silence — a practice that was referred to as “catch and kill.” Trump has denied McDougal's claims.

The situation took on a greater sense of urgency for Trump in October 2016. That's when The Washington Post published the " Access Hollywood " tape, which caught Trump on a hot mic saying he could grope women without their consent because "when you're a star, they let you do it."

Judge Juan Merchan barred the DA from playing the tape for the jury for fear it would be too prejudicial, but he did allow prosecutors to use a transcript of Trump's remarks.

Colangelo said the impact of the tape was “immediate and explosive.”

“The defendant and his campaign were concerned that it would irrevocably damage him with female voters,” he said, and "the campaign went into immediate damage control mode."

It was around that time that the Enquirer heard that adult film actress Stormy Daniels was interested in coming forward with a claim that she had a sexual encounter with Trump in 2006. Trump was "adamant" he didn't want that claim, which he denies, to become public for fear it would be "devastating" to his campaign, Colangelo said.

Cohen then struck a deal to buy Daniels' silence for $130,000, Colangelo said.

"It was election fraud, pure and simple," Colangelo said, adding “We’ll never know, and it doesn’t matter, if this conspiracy was a difference maker in the close election.”

Colangelo said the Trump Organization, Trump’s company, couldn’t cut Cohen a check with the memo “reimbursement for porn star payoff” so "they agreed to cook the books" and make it look like the reimbursement was income.

"The defendant said in his business records that he was paying Cohen for legal services pursuant to a retainer agreement. But, those were lies. There was no retainer agreement," Colangelo said.

“It was instead what they thought was a clever way to pay Cohen back without being too obvious about it,” he said. But what they did was a crime, Colangelo said. “Donald Trump is guilty of 34 counts of falsifying business records in the first degree,” he concluded.

Trump's attorney Blanche countered in his opening statement that his client hasn’t committed any crimes. “The story you just heard, you will learn, is not true,” he said. "President Trump is innocent. President Trump did not commit any crimes."

He said the only thing Trump did was sign checks for legal services rendered by his lawyer.

“The invoice is processed, somebody at Trump Tower generated a check, the check was ultimately signed, and there was a record in the ledger,” Blanche said. “He’s the only signatory on his personal checking account, which is why he signed the check.

"So what on Earth is a crime? What’s a crime, of what I just described?” Blanche said. "None of this is a crime," he said, adding that nondisclosure agreements like the one Daniels signed are legal.

As for the election interference argument, Blanche said, “I have a spoiler alert: There’s nothing wrong with trying to influence an election. It’s called democracy.”

In a preview of his trial strategy, Blanche also attacked Daniels' and Cohen's character and credibility. He accused Daniels, whom he described as "extremely biased," of trying to "extort" Trump, a word that the judge ordered stricken from the record. Blanche then said what Daniels had been threatening to do by going public with her allegation was "sinister" and "damaging to [Trump] and damaging to his family.”

Blanche also said Daniels' testimony, while salacious, doesn't matter because she doesn't know anything about how Cohen was repaid.

The bulk of Blanche's attacks were reserved for Cohen, who pleaded guilty in 2018 to numerous crimes, including some that he said he carried out on Trump's behalf.

“Michael Cohen was obsessed with President Trump. He’s obsessed with President Trump, even to this day,” Blanche said, calling him a "convicted felon" and a "convicted liar."

“He has talked extensively about his desire to see President Trump go to prison,” Blanche said, including in public on Sunday.

He told the jurors that if they listen to the evidence, they'll return "a very swift not guilty verdict."

Cohen said in a statement afterward, “The facts will come out at the time of trial that contradicts Todd Blanche’s mischaracterizations of me.”

Trump faces 34 counts of falsifying business records related to the hush money payment to Daniels. Trump, who has pleaded not guilty , could face up to four years in prison if he is convicted.

On his way into the courtroom Monday morning, he told reporters: “It’s a very, very sad day in America. I can tell you that.”

The day got off to a rough start for Trump, with Merchan, the judge, ruling that if he winds up taking the stand in his own defense, prosecutors can cross-examine him about another New York judge's finding that he and his business committed "persistent" fraud and violated a gag order, juries' finding him civilly responsible for sexual abuse and defamation in the E. Jean Carroll cases and a settlement in a case that found he used his now- shuttered foundation to improperly further his campaign in the 2016 election. Trump's attorneys had argued that all of those topics should be out of bounds.

Trump didn't show concern — he sat with his eyes closed through much of Merchan's ruling. He briefly opened his eyes when the jury was brought in for the judge's instructions and then closed them again.

Bragg was sitting in the front row of the courtroom ahead of opening statements.

Cohen, Daniels and McDougal are also expected to testify during the trial, which is estimated to take six weeks.

The jury consists of seven men and five women. The final day of jury selection, Friday, was particularly intense , as some potential jurors broke down in tears and said they were too anxious to be seated. They were excused. A man also set himself on fire outside the courthouse.

Trial proceedings Tuesday will be abbreviated, ending at 2 p.m. ET because of the Passover holiday.

Adam Reiss is a reporter and producer for NBC and MSNBC.

Dareh Gregorian is a politics reporter for NBC News.

Jonathan Allen is a senior national politics reporter for NBC News, based in Washington.

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• v.14(2); 2022 Feb

Choledocholithiasis in Pregnancy: A Case Report

Fidel s rampersad.

1 Department of Radiology, The University of the West Indies, St. Augustine, TTO

Adrian Chan

Shirvanie persaud.

2 Department of Surgery, Eric Williams Medical Sciences Complex (EWMSC), San Juan, TTO

Paramanand Maharaj

Ravi maharaj.

3 Department of Surgical Sciences, The University of the West Indies, St. Augustine, TTO

Cholelithiasis during pregnancy and the postpartum period has an incidence of 12%, with pregnancy being an important risk factor for gallstones. Patients with choledocholithiasis can experience complications, such as obstructive jaundice, cholangitis, and pancreatitis, which may be detrimental to both mother and fetus.

A case of cholelithiasis in a second-trimester pregnancy was complicated by choledocholithiasis and obstructive jaundice. Ultrasonography (US), magnetic resonance cholangiopancreatography (MRCP), along with serial blood tests, confirmed the diagnosis. Treatment was safely achieved using endoscopic retrograde cholangiopancreatography (ERCP).

In pregnancy, complicated cholelithiasis is investigated using blood tests, ultrasonography, and cholangiography. Evidence supports the use of intraoperative or endoscopic cholangiography for the management of such complicated gallstone disease in pregnancy.

Introduction

Choledocholithiasis in pregnancy is uncommon and seen in approximately one in 1200 deliveries [ 1 ]. One study showed new onset of gallbladder sludge/stone in 7.1%, 7.9%, and 10.2% of patients by the second trimester, third trimester, or postpartum period, respectively [ 2 ]. However, only 1.2% of patients with biliary sludge or stone developed symptoms attributable to gallstone disease [ 2 ]. Pregnancy is regarded as an important risk factor for gallstone disease, with data suggesting that hyperestrogenemia contributes to the saturation of bile and increasing gallbladder volume resulting in increased biliary sludge and gallstones [ 3 - 4 ].

Choledocholithiasis refers to the presence of gallstones in the common bile duct (CBD). Choledocholithiasis can result in complications such as obstructive jaundice, cholangitis, or pancreatitis, which can be harmful to both mother and fetus [ 3 ]. Patients with symptomatic cholelithiasis routinely have abnormal liver function tests. Radiological imaging in pregnant patients is similar to that in non-pregnant patients, with ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) being the main forms of imaging [ 4 ]. MR imaging, apart from evaluating the biliary system, can assess for evidence of gallstone pancreatitis, edema, and peripancreatic inflammatory changes. Complicated choledocholithiasis is managed definitively, with endoscopic sphincterotomy and stone extraction, along with index or scheduled cholecystectomy.

We report a case of symptomatic choledocholithiasis in a pregnant patient who underwent imaging with US and MRCP and then had a therapeutic endoscopic retrograde cholangiopancreatography (ERCP).

Case presentation

A 22-year-old female presented to the accident and emergency department with a history of abdominal pain in the right upper quadrant (RUQ), worsening over the preceding 48 hours. She was in her seventeenth week of gestation, and this was her fourth pregnancy; with the prior three being uncomplicated. Her period of gestation was calculated using her last menstrual period, and she had not yet received any antenatal care. The patient reported intermittent and colicky right upper quadrant abdominal pain since the beginning of the current pregnancy, usually following fatty meals and resolving spontaneously. However, over the preceding two days, her pain was constant, more severe, and of longer duration. She had associated episodes of vomiting food contents. She denied any fever, chills, diaphoresis, and any changes in her stool or urine color.

On initial assessment, she was in distress from the pain. Her mucus membranes were pink, anicteric, and dry. Her vital signs remained normal and she was afebrile, with a normal respiratory rate. Abdominal examination revealed tenderness in the RUQ. She was positive for Murphy’s sign on examination but had no signs of peritonitis. A fundal height was palpated mid-way between the pubic symphysis and umbilicus.

The urinalysis had no abnormality. Her complete blood count had a normal leukocyte count. However, there was microcytic anemia. Her renal and liver function blood tests remained normal, including a normal partial thromboplastin time and prothrombin time. However, amylase was 673 u/L and lipase was 4163 u/L, establishing the diagnosis of gallstone pancreatitis. Fluid resuscitation was initiated using crystalloid solutions. Insertion of a Foley catheter was deferred. An abdominal US was initially performed. This revealed cholelithiasis, with no evidence of cholecystitis (Figure  1 ), and showed a common bile duct calculus (Figure  2 ).

There were no sonographic features of cholecystitis.

With the diagnosis of choledocholithiasis and gallstone pancreatitis, this patient was kept nil per os (NPO) and closely monitored for the development of cholangitis as analgesia and fluid hydration continued. The pelvic US confirmed fetal viability. MRCP showed cholelithiasis, choledocholithiasis, and biliary duct dilatation (Figures  3 - ​ -4 4 ).

CBD: common bile duct

The patient and her partner were counseled on the high risk of miscarriage associated with gallstone pancreatitis and choledocholithiasis. They were also counseled on the risks and benefits of ERCP, including the radiation and anesthetic risks. Consent was obtained, with the patient opting for ERCP and if it failed, for surgical CBD exploration.

Conservative management consisted of analgesia and hydration, which was continued for the first three days of admission. The patient’s pain persisted, but she did not develop clinical features of cholangitis and her daily bilirubin checks remained within normal limits. When hyperbilirubinemia was demonstrated on Day 4 with a total bilirubin of 1.7 mg/dL (normal 0.2 to 1.3mg/dL), indirect bilirubin of 0.7mg/dL, and direct bilirubin of 0.3mg/dL; the patient was taken for ERCP. After general anesthesia, she was positioned prone, with pillows to support her hips and chest, and her lower abdomen was wrapped in the lead skirt. A side-viewing scope was passed orally and the duodenal papilla was visualized. In an effort to limit radiation exposure, the smallest possible field of the radiograph beam was utilized. The fluoroscopic screening was kept to a minimum. A 1.2 mm sphincterotomy was performed, with the passage of sludge and debris from the ampulla. A single common bile duct stone was subsequently removed (Figure  5 ). Post-extraction cholangiogram confirmed clearance of the biliary ducts (Figure  6 ).

ERCP: endoscopic retrograde cholangiopancreatography

The patient reported a significant decrease in pain after awakening from the ERCP, with the resolution of abdominal pain and the return of serum bilirubin to normal. On the next day, a normal diet was initiated. The patient was allowed home with the plan to continue antenatal care with the obstetric team that reviewed her during admission. She continued with iron supplements and prenatal vitamins. She was counseled on the risk of recurrence of complications of her cholelithiasis and possible symptoms. She will be reviewed in the surgical outpatient clinic and was scheduled for an elective laparoscopic cholecystectomy after completion of the pregnancy.

Choledocholithiasis in pregnancy is uncommon and seen in approximately one in 1200 deliveries [ 1 ]. In one of the largest prospective studies, with more than 3200 pregnant patients who did not have gallstones on initial US examination, new sludge/stone was noted in 7.1%, 7.9%, and 10.2% of patients by the second trimester, third trimester, or four to six-week postpartum US, respectively [ 2 ]. Pregnancy and its resultant physiologic changes cause the gallbladder volume to double, the emptying rate to slow, and motility impairment resulting in saturation of cholesterol which contributes to the ideal environment for gallstone formation [ 3 ]. One prospective study showed that only 1.2% of patients with biliary sludge or stones developed symptoms due to their disease [ 2 ]. Choledocholithiasis is defined as the presence of gallstones in the common bile duct. Its true incidence is unknown because it is most commonly asymptomatic. When symptomatic, choledocholithiasis may present as right upper quadrant pain that is more prolonged than typical episodes of biliary colic; as symptoms of obstructive jaundice such as dark urine, scleral icterus, and acholic stools; or as ascending cholangitis with Charcot’s triad of fever, right upper quadrant pain, and jaundice [ 3 ]. Progression to hypotension and mental status changes, i.e., Reynold’s pentad indicates shock from a biliary source [ 5 ]. Knowledge of the presentation of cholelithiasis and choledocholithiasis is important, as this can modulate its impact on maternal and fetal mortalities. In this case, the patient presented with right upper quadrant pain and developed obstructive jaundice.

The aim of imaging in the pregnant patient is to differentiate choledocholithiasis from intrahepatic cholestasis of pregnancy, as both clinical and biochemical presentations are similar. Ultrasonography and MRCP are the two main modalities of imaging of suspected choledocholithiasis in pregnancy [ 4 - 5 ]. Ultrasonography is regarded as the initial modality of choice to evaluate the hepatobiliary system in pregnancy, as it is safe, low cost, reliable, and readily available. However, limitations include shadowing due to overlying bowel gas, poor beam penetration due to body habitus, and the fact that it is operator-dependent [ 4 ]. In this case, the US was proven useful in the initial evaluation, with the identification of gallstones within the gallbladder and CBD. Ultrasonography and MRI are excellent to use in pregnancy, as they can provide multiplanar imaging in the absence of ionizing radiation. In contrast, MRI offers increased sensitivity in detecting diffuse liver disease, improved spatial resolution, and an increase in soft-tissue contrast, allowing for its large fields of view (FOVs). Relevant to this case, MRCP has a specificity of 93% and sensitivity of 88% with detailed evaluation of the biliary tree; it allows further evaluation of the pancreas with detection of edema, obstruction of the pancreatic duct in gallstone pancreatitis, and surrounding inflammatory changes [ 6 - 8 ].

Supportive care is an important aspect of the management of choledocholithiasis [ 9 ]. Analgesia, antibiotics, and intravenous fluids are prescribed. Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are done as prophylaxis against deep venous thrombosis in the pregnant patient.

Choledocholithiasis in pregnancy can be managed safely with ERCP and sphincterotomy followed by laparoscopic cholecystectomy [ 10 - 12 ]. Laparoscopic or open CBD exploration and index cholecystectomy are also acceptable. Contemporary literature supports that laparoscopic surgery performed during any trimester is safe for the mother and fetus however laparoscopic surgery was not readily available in our facility due to lack of the equipment needed to safely perform laparoscopic surgery in the current coronavirus disease 2019 (COVID-19) pandemic [ 13 ]. The endoscopic methods for bile duct clearance include sphincterotomy, balloon dilation of the ampulla, and basket or balloon extraction. Sphincterotomy involves severing the deep muscle layers of the sphincter of Oddi with electrocautery. It should be performed by high-volume practitioners to improve success rates and to minimize procedure duration and radiation exposure [ 14 ]. The usual complications of ERCP, including post-sphincterotomy bleeding, pancreatitis, and perforation, can have greater consequences in a pregnant woman. A meta-analysis of 27 studies assessed the safety of ERCP in pregnancy included 1,307 patients. The overall adverse event rate was 15.9 % [ 15 ].

Cumulative radiation dosage should be limited to 50-100 milliGray (mGy) during pregnancy to decrease the risk of teratogenesis and childhood leukemia [ 16 - 17 ]. Radiation exposure during intra-operative cholangiography is estimated to be 20-50 mGy. The radiation exposure during ERCP averages 20-120 mGy [ 18 ]. Efforts should be made to shield the fetus from radiation exposure without compromising the field of view. The lead apron shield must be placed underneath the patient and not simply draped over the abdomen since the radiation source is underneath the patient when using the standard fluoroscopy C-arm. Endoscopic ultrasound (EUS) provides an alternative (non-ionizing) means of imaging the CBD. Transabdominal US-guided non-radiation ERCP procedures for the removal of CBD stones during pregnancy have been demonstrated [ 19 ]. More studies are needed to assess its safety and efficacy.

Non-radiation ERCP is a sophisticated procedure that requires a high level of expertise [ 14 ]. Successful bile-duct cannulation with sphincterotomy and clearance of biliary stones or sludge was performed without fluoroscopy in a series of 21 pregnant women. One case of mild post-ERCP pancreatitis was the only reported adverse event. Choledochoscopy confirmed ductal clearance in five cases [ 20 ]. Noteworthy, there was no significant difference between the subgroups of radiation-ERCP and non-radiation ERCP in terms of fetal outcomes (5.2 % versus 6.2 %). Unexpectedly, maternal non-pregnancy-related complications occurred half as often in the non-radiation group than conventional radiation ERCP (7.6 % versus 14.9 %). This may have been due to extensive pre-procedure workup, along with the need for expert endoscopists to perform non-radiation ERCP [ 15 ].

Another concern is with anesthesia during endoscopy. The medications used for sedation are poorly studied in pregnancy but the current recommendation is to use the lowest effective dose of category B drugs [ 14 ]. Monitoring is done with continuous electrocardiography, pulse oximetry, and intermittent sphygmomanometry [ 21 ]. In patient positioning, care must be taken to avoid the physiological changes of uterine compression of the inferior vena cava. The index patient was positioned prone. However, acceptable positioning also includes left pelvic tilt or left lateral position [ 14 ].

If ERCP is not possible, percutaneous transhepatic biliary drainage (PTBD) serves as an option for biliary decompression. Additionally, CBD exploration via choledochotomy with stone removal with or without T-tube placement allows biliary decompression.

If cholelithiasis is present, an index cholecystectomy can be performed in a stable patient. Scheduling cholecystectomy until after delivery is associated with high rates of recurrent symptoms, emergency department visits, and recurrent hospitalizations [ 22 ]. As seen in this case, ERCP and sphincterotomy may be sufficient to prevent recurrence during pregnancy [ 23 ]. Complicated gallstone disease results in preterm labor and fetal loss. Optimal management is, therefore, necessary for fetal and maternal well-being.

Conclusions

Imaging of suspected choledocholithiasis in pregnancy can be safely performed with ultrasound and MRCP, the latter being better-suited to evaluate the CBD and provide information regarding the size, number, and position of gallstones within the CBD. Choledocholithiasis in pregnancy can be safely managed with ERCP and sphincterotomy. This can be followed by an index laparoscopic cholecystectomy; otherwise, the risk of recurrent complications remains high. Cholangiography (intraoperative or endoscopic) can be used selectively during pregnancy because of its adequately low radiation exposure to the mother and fetus, especially when the lower abdomen is shielded.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study