Disorder of gallbladder

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  • Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications. 
  • Disorder of gallbladder

    1. 1. Cholecystitis.
    2. 2.  Cholecystitis ; Inflammation of gallbladder or cystic duct  >90% due to calculous cholecystitis.  10% acalculous cholecystitis. It can be  Acute (middle age)  Chronic (elderly people)
    3. 3.  Cholelithiasis ; Obstruction caused by gallstones; gall stone formation.  Cholesterol (most common)  Pigmented occurs later in life, associated with cirrhosis.
    4. 4.  Obesity  High calorie, high cholesterol diet  Middle age  Female gender  American Indian ancestry  Gallbladder, pancreatitis, diabetic mellitus, ileal disease, liver disease, blood disorders.  Hormonal contraceptives, HRT or pregnancy  Use of clofibrate, an antilipemic drug.
    5. 5.  The obstruction in gallbladder distension,  edema of the cells lining the gallbladder.  Ischemia spurs on inflammatory mediators.  Prostaglandins aggravates the inflammation.  The lining wall of the gallbladder may eventually undergo necrosis and gangrene, which is known as gangrenous cholecystitis.
    6. 6.  The inflammation of the gallbladder wall may be bacterial or sterile in some cases.  In bacterial, normally super-infection with gas forming organisms.  formation of gas in the wall or the lumen of the gallbladder leads to a condition known as emphysematous cholecystitis. 
    7. 7.  Enzymatic defect increases cholesterol synthesis  Decreased secretion of bile acids to emulsify fats  Decreased reasorption of bile acids from ileum  Gallbladder smooth muscle hypomotility and stasis  Genetic predisposition  Combination of any or all of the above
    8. 8.  Sharp, cramping, or dull ,steady or intermittent epigastric and right hypochondrium pain, radiating to mid upper back.  worse during a deep breath.  More than 6 hours, particularly after meals.  Heartburn; flatulence, Intolerance to fatty food  Clay-colored stools  Fever  Nausea and vomiting  Yellowing of skin and whites of the eyes (jaundice)
    9. 9.  Medical History, Physical Examination  Blood tests: Amylase and lipase, Bilirubin, CBC; elevated WBC, LFTs Imaging tests  Abdominal ultrasound  Abdominal CT scan  Abdominal x-ray  Oral cholecystogram  Gallbladder radionuclide scan ; intravenous Cholangiography
    10. 10. Uncomplicated ; Nonsurgical treatment  CDCA (Chenodeoxycholic acid) and UDCA (Ursodeoxycholic acid) to dissolve cholesterol gallstones.  Antibiotics to fight infection  Low-fat diet (when food can be tolerated)  Pain medicines, antiemetic etc. Complicated ; a surgical approach.  Percutaneous transhepatic cholecystostomy drainage .Laproscopic cholecytectomy or open cholestectomy.  ERCP for choledocholithiasis
    11. 11.  Patient education to reduce anxiety and depression  Preoperative and post operative care.  Pain management  Fluid and electrolyte balance  Nutritional status: avoid fatty foods and fluids, : Encourage fluid intake. Modified diet provision, balance, and bowel routine.  Prevention of complications.
    12. 12.  Empyema (pus in the gallbladder)  Gangrene (tissue death) of the gallbladder  Injury to the bile ducts draining the liver (an occasional complication of cholecystectomy)  Pancreatitis  Peritonitis (inflammation of the lining of the abdomen) due to Gallbladder perforation.
    13. 13.  In this section I would like to share my experience taking care of a patient, she is my own aunt, even though, I have worked with patients with cholecystitis. I used to work in ER in Nepal. We used to get most of patients with abdominal pain or acute abdomen cases. Patients who were diagnosed cholecystitis or cholelithiasis, usually presents with sudden severe pain to right upper gastric pain with nausea and vomiting, jaundice in some cases. The lab test and ultrasound were main diagnostic tools for those patients, elevated WBC and LFT’s and positive for gall stones or cholecystitis in abdominal ultrasound. During my 7 years work experience back home, I used to get floated to surgical floor sometime, most of surgical cases used to be related to GI. continued
    14. 14. Open cholecystectomy and laparoscopic cholecystectomy were very common and simple surgical operations. Length of stay was also short, only 2-4 days. Common complications was infection of surgical site and I had witnessed death of one patient due to internal bleeding in immediate post operative period. Last year, I went my country for vacation, I got opportunity to take care of my aunt during her treatment of cholecystitis, who was scheduled for elective cholecystectomy after 3 months because she was asymptomatic and stable. One early morning I received call that she was brought to ER due to severe abdominal pain. I went to see her in ER, She was weak and complaining of intermittent pain to epigastric area. My cousin told me that she had vomited several times at home, had mild fever for few days. She was already given antiemetic promethazine and IM diclofenac sodium for pain and also IV fluid was in progress. After physical examination and history taking ,MD ordered stat abdominal ultrasound and x ray of abdomen and chest. continued
    15. 15.  ER physician recommended surgical consult and she got admitted for emergency surgery. Open cholecystectomy was done within an hour. My aunt and her whole family were very anxious, they were not ready for surgery yet ,she was expecting after three month only. But I had to teach her the possible complications for waiting longer .eventually she signed the consent. After surgery, while waiting out side operation theater, surgeon showed us the gall bladder with gall stones with pus. He said she was lucky that we took her to ER on time because the gallbladder was full of pus and about to perforate. She could have peritonitis due to perforation. After two hours of post operative care, she got transferred to surgical floor again. She had penrose drain tube in place to drain pus. continued
    16. 16. She was hospitalized for 7 days, longer than usual due to her condition. She was discharged home with oral antibiotic and pain medication. I provided health education to her and her family regarding  incision care to prevent infection,  activities at home including ambulation to prevent post operative complications,  encouraged to avoid fatty diet, to increase fluid intake,  medication regimen to complete antibiotic course  Follow up with MD on scheduled date.  Nutritional diet to promote healing of incision.
    17. 17.  McCance, K.L., Huether, S.E., Brashers, V.L., & Rote, N.S. (Eds.). (2006). Struture and Function of Digestive System. Pathophysiology: The Biologic Basis for Diseases in Adults and Children (5th ed.). St. Louis, MO: Elsevier Mosby.  Margaret Eckman, Debra Share(Eds.) (2013).Gastrointestinal System. Pathophysiology made Incredibly Easy (5thed.) Wolters Kluwer, Lippincott Williams & Wilkins
    18. 18.  Alan A Bloom, MD; Chief Editor: Julian Katz, MD. Retrieved from http://emedicine.medscape.com/article/171886- overview  Dr. Sumaiya Khan. Retrieved from http://www.buzzle.com/articles/cholecystitis- pathophysiology.html  Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001310/  Retrieved from http://www.webmd.com/digestive- disorders/tc/cholecystitis-overview

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