It's about cholelithiasis & cholicystitis for BNS (Bachelor in nursing) students

1. 6/29/2022 1

2. Prepared by:
RN Arpana
Bhusal
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3. Content
• Introduction of Cholelithiasis
• Types
• Risk Factors/Etiology
• Pathophysiology
• Clinical features
• Diagnostic Evaluation
• Treatment
• Nursing Management
• Prevention
• Complication
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4. content
• Introduction of Cholicystitis
• Types
• Etiology
• Pathophysiology
• Clinical features
• Diagnostic evaluation
• Management:
 Medical Management
 Surgical Management
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5. Introduction Of Cholelithiasis
It is derived from Greek
word ‘chol’ means bile,
‘lith’ means stone and
‘iasis’ means process.
• Cholelithiasis is defined
as stone formation in gall
bladder.
• Choledocholelithiasis :
Stone in common bile
duct.
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7. Types
There are two types of gallstones:
 Cholesterol stones are the result of bile that is made of
too much cholesterol or bilirubin and not enough bile
salts.
 Cholesterol stones may also form when the gallbladder
fails to empty during the digestive process.
 These are usually seen as yellow-green gallstones (most
common type).
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8. Types contd…
Pigment stone: are dark in color ,made up of
bilirubin and calcium salts. It is of two types as;
- Black pigment stone: occurs in individual
whose hemoglobin breaks down rapidly leading
to increased production of the bile pigment
bilirubin. Eg. Sickle cell anemia, liver cirrhosis.
- Brown pigment stone: formed when
cholesterol stone colonize with bacteria. Both
male and female are at equal risk.
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10. Risk Factor
5 ‘F’
• Female
• Forty
• Fair
• Fat
• Fertile
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11. Etiology
• Gender i.e. women 4 times more likely to develop cholesterol stone
than men.
• Use of estrogen and cholesterol lowering drugs
• Bile and mal absorption with GI disease
• Genetic disposition ( 25% of cases)
• Rapid wt loss
• Pigment stones occurs when free bilirubin combines with calcium
• Diet rich in refined carbohydrate and saturated fat is associated
with a higher risk for
• gallstones.
• Multiparity
• Women of reproductive age group
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12. Pathophysiology
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Hypo activity of gall bladder
Stasis of bile
Excessive absorption of water by gall bladder wall
Cholesterol precipitates the formation of crystals
Bile supersaturated with cholesterol
Formation of cholesterol stone

13. Clinical features:
• May be silent, producing no pain or only mild GI
symptoms
• May be acute or chronic with epigastric distress
(fullness, abdominal distention, and vague upper right
quadrant pain), may follow a meal rich in fried or fatty
food
• Biliary colic: right upper abdominal pain radiating to
back or right shoulder associated with nausea and
vomiting
• Jaundice: clay colored stools, itching skins, dark urine
• Temperature increased 80%
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14. Clinical features contd…
• If the cystic duct is obstructed, the gallbladder
becomes distended, inflamed and eventually
infected; fever and palpable abdominal mass;
nausea and vomiting several hours after heavy
meal, restlessness and constant or colicky pain.
• Deficiencies of vitamin A, D, E and K (fat
soluble vitamins)
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15. Diagnostic Evaluation:
• History taking
• Physical examination
• Blood investigation
• Radiological test
• Abdominal Ultrasound :detect GB stone in 90 %
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16. Diagnostic Evaluation contd…
• CT scan and MRI
• Cholecystography: radioactive agent is given
IV and then biliary tract is scanned
• Percutaneous trans hepatic cholangiography
(PTC)
• Endoscopic Retrograde
Cholangiopancreatography (ERCP)
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17. Endoscopic Retrograde Cholangio
pancreatography (ERCP)
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18. Treatment and Management
• Supportive :rest , IV fliud, NG suction, analgesic and
antibiotics, antiemetics and antacids
• Diets : decreased fat , fried foods cheese, alcohol,
porks etc.
• Pharmacological therapy:
(Chenodeoxycholic acid) CDCA (cholesterol dissolving
agent )
(Urosodeoxycholic acid) UDCA,ursodiol
They are given in pill form to dissolve cholesterol
gallstones. However, they may take 2 years or longer to
work, and the stones may return after treatment end.
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19. Treatment and Management contd…
• Non surgical removal of gallstone:
Extracorporeal shock wave lithotripsy
(ESWL).
• Surgical Intervention: Cholecystectomy
(Surgical Laparoscopic/open) ,
Cholecdochotomy( removal of common bile
duct)
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21. Nursing Management
Assessment
• Obtain history of precipitating factors such as alcohol
abuse, biliary disease.
• Perform abdominal examination, assessing for
ascites.
• Observe for pain, skin integrity bleeding
• Assess daily weight and abdominal girth
measurement.
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22. Nursing Diagnosis
• Activity intorelence related to fatigue and
discomfort
• Acute pain and discomfort related to surgical
incision
• High risk of infection related to operative
procedure.
• Imbalanced nutrition, less than body
requirements, related to inadequate bile
secretion
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23. Nursing Diagnosis contd…
• Impaired skin integrity related to altered
biliary drainage after surgical intervention.
• Deficient knowledge about self-care activities
related to incision care, dietary modifications
(if needed), medications, reportable signs or
symptoms (e.g, fever, bleeding, vomiting
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24. Nursing Intervention
1. Promoting activity intolerance
• Encouraging alternate period of rest and ambulation.
• Maintain some period of best rest with legs elevated
to mobilize edema and ascites.
• Encourage and assist with gradually increasing period
of exercise.
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25. Cont.
2. Relieving pain
• Observe and document location, severity and character of pain
• Splint the affected site and to take shallow breaths to prevent
pain.
• Administer analgesic agent as prescribed
• Helping the patient to turn, cough, breathe deeply and
ambulate as indicated.
• Use of a pillow over the incision.
• Control environment temperature.
• Encourage use of relaxation techniques
• Provide diversional activities
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26. Cont.
3. Improving nutritional status
• Encourages the patient to eat a diet low in fats and high
in carbohydrates and proteins immediately after surgery
• Fat restriction usually is lifted in 4 to 6week. This is in
contrast to before surgery, when fats may not be
digested completely or adequately, and flatulence may
occur
• Suggest small frequent feeding and attractive meals in
an aesthetically pleasing meal setting at mealtime.
• Encourage oral hygiene before meals
• Administer medication for nausea, vomiting, diarrhea
or constipation.
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27. Cont.
4. Improving skin integrity
• Necessitating frequent changes of the outer dressings
and protection of the skin from irritation because bile
is corrosive to the skin
• Every 24 hours, measures the bile collected and
records the amount, color, and character of the
drainage.
• After several days of drainage, the tube may be
clamped for an hour before and after each meal to
deliver bile to the duodenum to aid in digestion
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28. Cont.
• In all patients with biliary drainage, the nurse
observes the stools daily and notes their color.
• Specimens of both urine and stool may be sent to the
laboratory for examination for bile pigments.
• Maintaining a careful record of fluid intake and
output is important.
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29. 5. Patient Education
Managing pain
• Sitting upright in bed or a chair or walking may ease
the discomfort.
• Analgesic medication as needed and as prescribed
• Report to surgeon if pain is unrelieved even with
analgesic use.
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30. 5. Patient Education Cont…
Resuming Activity
• Light exercise (walking) immediately.
• Shower or bath after 1 or 2 days
• Avoid lifting objects exceeding 5 pounds after
surgery, usually for 1 week.
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31. 5. Patient Education Cont...
Caring for the Wound
• Check puncture site daily for signs of infection.
• Wash puncture site with mild soap and water.
• Allow special adhesive strips on the puncture site to fall
off. Do not pull them off
Resuming Eating
• Resume your normal diet.
• If you had fat intolerance before surgery, gradually add fat
back into your diet in small increments.
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32. 5. Patient Education Cont…
Managing Follow-Up Care
• Make an appointment with surgeon for 7 to 10 days
after discharge.
• Report surgeon if experience any signs or symptoms
of infection at or around the puncture site: redness,
tenderness, swelling, heat, or drainage.
• Report surgeon if experience a fever of 37.7°C
(100°F) or more for 2 consecutive days.
• Report surgeon if you develop nausea, vomiting, or
abdominal pain.
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33. Prevention:
• Eat three well balanced meal everyday
• Eat a diet that is high in fibre and calcium
• Avoid saturated fats and refined carbohydrate
in diet
• Drink at least 8-10 glass of water daily
• Maintain healthy body weight
• Exercise for at least 30min for 5 days a week
• Avoid taking high dose of birth control pills.
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34. COMPLICATION:
• Acute cholecystitis in 50% of patient
• Obstruction of cystic or bile ducts
• Cholangitis
• Gallstone illeus
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36. Cholecystitis
• Cholecystitis is a
redness and
swelling
(inflammation) of
the gallbladder.
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37. Types of cholecystitis:
• Acute Cholecystitis :
Calculous:It is the obstructive cholecystitis due to
gall stones having the most common variety in
which around 90% of people having gall stones
suffers.
Acalculous: It is the non obstructive type which is
common in person suffering from major illness like
severe sepsis, burns, DM, dehydration, multiple
injury etc.
• Chronic Cholecystitis (long-term) (repeated
inflammation and infection of gallbladder)
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38. Etiology
I. Calculas acute cholecystitis
• Gall stone
II. Acalculas acute cholecystitis
• Serious trauma or burns
• Prolonged labor
• Orthopedic and other nonbiliary major surgical
operations in the postoperative period.
• Biliary sludge in the cystic duct
• Vasculitis
• Obstructing adenocarcinoma of the gallbladder
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39. Etiology
• Diabetes mellitus
• Torsion of the gallbladder
• Bacterial infections of the gallbladder (e.g., Escherichia
coli, Klebsiella species Streptococcus, Clostridium,
Leptospira, Streptococcus, Salmonella, and Vibrio
cholerae).
• parasitic infestation of the gallbladder
• Acalculous cholecystitis may also be seen with a
variety of other systemic disease processes (sarcoidosis,
cardiovascular disease, tuberculosis, syphilis,
actinomycosis, etc.).
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43. Diagnostic evaluation:
• Complete blood count (CBC). This test
measures your white blood cell count. You
may have a high white blood cell count if you
have an infection.
• Liver function tests. A group of special blood
tests that can tell if your liver is working
properly.
• Ultrasound (also called sonography)
• Belly X-ray
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44. Diagnostic evaluation contd…
• CT scan
• HIDA scan (cholescintigraphy or hepatobiliary
scintigraphy)
• PTC (percutaneous transhepatic
cholangiography)
• ERCP (endoscopic retrograde
cholangiopancreatography
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45. Medical management:
• Goal- to treat symptomatic causes
• To prevent complication
• Taking bacteria-fighting medicines (antibiotics) to
fight the infection
• Taking fluids and pain medicines by IV (through a
vein or intravenously)
• Keeping your stomach empty until your
symptoms ease
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46. Surgical management:
• cholecystectomy
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47. REFERENCES
• Mandal G.N, Textbook of medical surgical nursing (adult
nursing), Dec.2012 published by Makalu publication house,
3rd edition. (Page 283-285)
• Smeltzer.S.G, Bare.B.G. Hinkle.J.G, Cheezer K.H, (2010)
“Brunner & Suddarth’s Textbook of medical- surgical
nursing”, 12 th edition, New Delhi, Wallers Kluwer India
Pvt.Ltd, page no: - 1170-1178,2078/10/11 at 4:00 pm
• Thapa Basanta (2009), Medical Surgical Nursing, 2nd
edition, New Delhi, Jaypee Brothers Medical Publishers (P)
Ltd, page no: 542-544,2078/10/12 at 10:00 am
• https://emedicine.medscape.com2076/02/24 at 11pm
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