Introduction
Gallbladder disease, especially cholelithiasis (gallstones) affects over 20 million Americans every year. The condition often goes undiagnosed because cholelithiasis rarely presents symptoms. Abdominal discomfort, nausea, jaundice and biliary colic are some symptoms of the condition. Imaging techniques are the most accurate diagnosis tools for gallbladder diseases. However, laboratory values such as CBC, serum amylase, liver-function testing and lipase can help differentiate the type of gallbladder disease/or identify related issues. Surgery is the most effective treatment for gallbladder disease patients. Exercise, diet, and nutrition affect gallbladder disease. It is important for patients to integrate the healthy habits into their lifestyle to lower the risk of developing gallbladder disorders (Jugenheimer, et al., 2008).

Cholelithiasis (gallstones) is the most common type of gallbladder disease. It affects over 20 million Americans every year, translating to over $6.3 billion in direct costs. Generally, gallstones are asymptomatic. The stones are usually identified during autopsy or a surgical procedure of an unrelated condition. The condition is the most common inpatient diagnosis among liver and gastrointestinal diseases in the United States. Although the disease is asymptomatic, patients can progress into symptomatic condition of the disease. Cholecystitis (gallbladder inflammation) is the main clinical manifestation and effect of cholelithiasis. Severe cases of the disease may develop gallbladder perforation, gallstone pancreatitis or any other gallbladder disease (In Cox et al., 2018).

Cholecystectomy is a surgical procedure aimed at gallbladder removal. The organ lies below the liver on the top right side of the abdomen. It is responsible for bile collection and storage. Bile is a digestive fluid secreted in the liver. The surgery has a small risk of complications, with the possibility of same-day discharge after the surgery. A tiny video camera and other special surgical tools are inserted into the abdomen via four small incisions for gallbladder observation and removal. The process is known as laparoscopic cholecystectomy. On the other hand, open cholecystectomy involves the use of one large incision during surgery. The surgery minimizes trauma that may be experienced during the interventional process while facilitating satisfactory therapeutic outcomes (Jugenheimer, et al., 2008).

The surgery promotes faster recovery and hastens return to normal life, shortens hospital stay, and reduces postoperative pain and pulmonary complications, explaining its preference as the mode of treatment for cholecystitis. It also reduced stress response, postoperative wound infection rate, respiratory function impairment, intraoperative bleeding and cosmetic appearance. Although it shortens hospital stay, it has no general effect on postoperative mortality. Clinical findings, patient characteristics, and the experience of a surgeon determine the patient’s risk factors for perioperative complications. The benefits of the procedure must outweigh the effects of carbon dioxide used during surgery (In Cox et al., 2018).

The patient’s name is Marie Peter, born on 19/09/38. The female patient’s URL is 012345. She was rushed to St. Thomas hospital emergency department at 1730. The patient was admitted after being diagnosed with post-cholecystectomy- TF ongoing abdominal pain. She was accompanied to the hospital by her husband and daughter. She requires ongoing care forward: D/C still drain Insitu. The paper looks into her case from the pathophysiology of cholecystectomy and pharmacokinetics of her medication, including GORD and T2DM (Jugenheimer, et al., 2008).

Pathophysiology of Cholecystectomy

Cholecystectomy has respiratory and cardiovascular effects, including other body systems. Gallstones are hard, stone-like masses that block the cystic duct. The presence of biliary sludge, calcium deposits, a viscous mixture of glycoproteins, and cholesterol crystals in biliary ducts or the gallbladder lead to the development of gallstones (Borzellino & Cordiano, 2008). Gallstones among patients in the U.S mainly comprise of bile with high saturation of cholesterol. The super saturation (cholesterol is higher in concentration than its solubility percentage) results due to hyper secretion of cholesterol resulting from hepatic cholesterol metabolism alteration. A change in balance between antinucleating (crystallization-inhibiting) and pronucleating (crystallization-promoting) proteins in the bile can speed up cholesterol crystallization in the bile. Biliary epithelial cells secrete mucin, a glycoprotein mixture and a pronucleating protein. Decreased mucin degradation by lysosomal enzymes facilitates the development of cholesterol crystals (Borzellino & Cordiano, 2008).

Gallstone development also results from excessive sphincteric contraction and gallbladder muscular-wall motility loss. The hypomotility results in prolonged bile stasis (delayed emptying on the gallbladder), and reduction function of the reservoir (Jugenheimer, et al., 2008). Increased predisposition for stone development and bile accumulation results from failure of bile to flow. Increased hepatic bile proportion being diverted to the small bile duct from the gallbladder and ineffective filling can result due to hypomotility. Sometimes, gallstones comprise of a chemical produced from RBCs standard breakdown known as bilirubin. Bilirubin stone development results from increased enterohepatic bilirubin cycling and biliary tract infection. Bilirubin stones, also known as pigment stones, manifest in patients with biliary tract infections or chronic hemolytic diseases (or damaged RBCs). Pigment stones are more prevalent in Africa and Asia (Jugenheimer, et al., 2008).

Cholecystitis pathogenesis includes Hartmann’s pouch, effect of gallstones in the neck of the bladder, or the cystic duct; however, cholecystitis does not always present gallstones. Enlargement of the organ, increase in gallbladder pressure, decrease in blood supply, thickening walls, and formation of an exudate can also occur. Cholecystitis is either chronic or acute, with a cycle of acute inflammation. The inflammation may lead to the condition becoming chronic. Various microorganism such as the gas-forming types can infect the gallbladder. Gangrene and necrosis can occur in an inflamed gallbladder, progressing into symptomatic sepsis if not treated. Lack of proper cholecystitis treatment may lead to gallbladder perforation, a phenomenon that is rare, but life-threatening. If stones dislodge in the gallbladder down to the Oddi Sphincter, gallstone pancreatitis develops if clearance of the stone traces does not take place. The result is the pancreatic duct getting blocked (Borzellino & Cordiano, 2008).

Pharmacokinetics Related to Her Medication

Variations in patient positioning and intra-abdominal CO2 insufflation’s physiological effects can heavily impact the cardiorespiratory function. Moreover, anesthesia’s resulting effects produce a distinct hemodynamic response. Proper understanding of the physiological changes is key to maximum anesthetic care. Inhalation agents, intravenous drugs and muscle relaxants...…and make work over two years to clear the stones. Ursodiol is the most popular oral bile acid due to its safe side effects in comparison to chenodiol. The latter is associated with diarrhea dependent on the dose. Other effects include hepatotoxicity, leukopenia, and hypercholesterolemia, limiting its application (In Agresta et al., 2014).

Changes in lifestyle and nutrition can prevent and treat cholelithiasis. Increased risk of the gallbladder disease is associated with obesity, making weight loss essential to prevention of gallstone development. However, rapid weight loss may facilitate the development of gallstones. Monounsaturated fats, polyunsaturated fats, caffeine and fiber can help prevent the formation of gallstones. Moderate alcohol and fish oil consumption has been proven to reduce triglycerides, increase HDL, and reduce saturation of bile cholesterol, making them good additions to patient diets. Hospitalization is necessary for patients diagnosed with acute cholecystitis for parenteral fluids and nutrition, total bed rest, and IV antibiotics to be provided (In Agresta et al., 2014).

The recommendations for physiotherapy include wearing incontinent pad, X1 mobility to walk to toilet with 4 wheel walker, assessment for fall risk, behavior/cognition, skin integrity, monitoring of surgical drainage site and ongoing management care, hygiene and X1 assist. The dietitian’s reason for referral is poor diet intake. Ward diet intake is recommended. Estimated nutrition intake intervention include energy (EER): 8500-10625KJ, protein (EPR): 68-85g, fluid (EFR): 2.1-2.9L. All medication, except insulin, are taken orally and includes Betamethasone depressant, Calcium, Movicol, Flexwell, Norspan patch, paracetamol (SR) tab 1300mg TDS, Panadol Osteo 665mg, esomeprazole tab (EC) 20mg daily, irbesartan tabs 300mg daily, escitalopram tab 20mg daily, diltiazem cap (CD) 240mg daily, metformin tab (ext. release) 1g mane, clopidogrel tab 25mg/75mg mane, and apixaban tabs 5mg/5mg BD (Jugenheimer et al., 2008).

Reflection

According to the clinical facilitator and based on nurse assessment, the patient needs pain management for faster postoperative care. She also needs close monitoring. The patient did not experience a reduction in pain, but it became consistent around the surgical wounds. It seems the patient developed complications during the surgical procedure. Antibiotics should help with any infections and Paracetamol and Panadol minimize pain on the affected sites.

Conclusion

Gallbladder diseases are often secondary to cholelithiasis. Some cases are asymptomatic, but others can progress to become symptomatic. Family history, ethnicity, gender, diet and nutrition, and medical history can increase the susceptibility or risk of developing gallbladder disease. Imaging techniques are used to diagnose gallbladder disease. The techniques have varying pros and cons, and rate of accuracy. The presenting symptoms and type of gallbladder disease determine the right imaging technique to use. Whereas surgical treatment is the most preferred for symptomatic patients, asymptomatic patients do not need treatment. Non-invasive treatment options are available for patients who are either unwilling or unable to undergo a surgical procedure. Creating awareness about the risk factors for gallbladder disease, especially cholelithiasis, and how to minimize the risk through exercise, and proper nutrition and diet, can help reduce cases of gallbladder disease and support provision of proper treatment.