Cholelithiasis and cholecystitis, sunita kharel

Cholelithiasis & Cholecystitis
Presented By
Ms. Sunita Kharel
Medical Surgical Nursing Batch 2019
Supervised By
Prof. Pushpa Parajuli
Medical Surgical Nursing Department

Content
 Relevant Anatomy
 Physiology of gall
bladder
 Cholelithiasis
o Introduction
o Epidemiology
o Etiological factors
o Pathophysiology
o Types of stones
o Diagnostic
evaluation
o Management
 Cholecystitis
o Introduction
o Epidemiology
o Etiological factors
o Pathophysiology
o Diagnostic
evaluation
o Management
 Nursing
Management
 Potential
Complications
 Summary
10/8/2021 Ms. Sunita Kharel 2

Relevant Anatomy

 A small pouch that sits just under the liver
 Stores bile produced by the liver.
 After meals, the gallbladder is empty and flat, like
a deflated balloon.
 The biliary tract is composed of the gallbladder,
bile ducts, and cystic duct.
 The cystic duct (from the gall bladder) joins with
the hepatic duct (from the liver) to form a
common bile duct.
Relevant Anatomy…

Bile Juice
 Normal adult human produce about 400-800ml bile
per day.
 Produced by liver and stored at gallbladder.
 Ph : 7.4, colour is golden yellow
 Components: bile salts, bile pigments and
cholesterol
 Helps in digestion and absorption of lipids and fats.
 Also neutralizes any excess stomach before
entering ileum
 Helps in absorption and other substances like fat
soluble vitamins, iron, calcium etc.
 Increases peristalsis and thereby help in
defecation.

Physiology of Gall Bladder
 Acts as a storage depot for bile.
 During storage, a large portion of the water in
bile is absorbed through the walls, bile is 5-10
times more concentrated than that originally
secreted by the liver.
 When food enters the duodenum, the
gallbladder contracts & the sphincter of Oddi
relaxes, allowing the bile to enter the intestine.

Introduction
 The presence of gallstones in the gallbladder.
 A gallstone is a crystalline concentration
formed within the gallbladder by accretion of
the bile components.
 These calculi are formed in the gallbladder,
but may pass distally into other parts of the
biliary tract such as cystic duct, common bile
duct, pancreatic duct, or the ampulla of vater.

Introduction
 If gallstones migrate into the ducts of the
biliary tract, the condition is referred to as
choledocholithiasis.
 Gallstones can vary in size and shape from as
small as a grain of sand to as large as a golf
ball.
 The gallbladder may contain a single large
stones or many smaller ones.

Epidemiology
It is uncommon in children and young adults, but
become increasingly prevalent after 40 years of age.
The incidents of cholelithiasis increase thereafter to such
an extent that up to 50% of those over 80 will develop
stones in the bile tract.
In the United States, about 20 millions people (10-20%
of adults) have gallstones.

Contributing Factors
 Five Fs
 Low fiber, high cholesterol and diets high in starchy
foods
 Hereditary: Mutation of ABCG5/G8 (ATP Binding
Cassette Sub family G member 5 and G member 8)
 Rapid weight loss
 Low intakes of the nutrients,
 Deficiency of folate, magnesium, calcium and
vitamin C
 Immobility, pregnancy and inflammatory or
obstructive lesions
 Hormonal factors during pregnancy cause delayed
emptying of the gallbladder

Five Fs

Normal Physiology

Pathophysiology

Gall Stones
 A high percentage of gallstones are precipitated
of cholesterol.
 Other components of bile that precipitate into
stones are bile salts, bilirubin, calcium and
protein.
 The stones sometimes have a mixed consistency.
 Stasis of bile leads to progression of super
saturation and changes in the chemical
composition of the bile.

Types of gallstones
Cholesterol
Pigmented
Mixed

Cholesterol stone
 Most common type
 Incidence
increases with age
 Female> Male
 Smooth & whitish
yellow to tan
colour.

Pigmented Stones
 Excess of
unconjugated
bilirubin
 May be black color
(associated with
hemolysis and
cirrhosis) or earthy
calcium bilirubinate
(associated with
infection)

Mixed Stones
 Combination of cholesterol and
pigment stones or other substance
 Consists of Calcium salts, phosphate ,
bile salts and palmitate.

Sign and Symptoms

 Increased heart and
respiratory rate causing
patient to become
diaphoretic which in
turn makes them think
they are having a heart
attack.
 Biliary Colic: Pain as
stone pass through the
ducts, and they may
lodge in the duct and
produce an obstruction.
Sign and Symptoms

 Low grade fever
 Elevated leukocyte count
 Mild jaundice
 Steatorrhea
 Palpable Abdominal Mass
 Clay colored stools caused by a lack of bile in
the intestinal tract.
 Urine may be dark amber to tea colored
 Anorexia, Nausea, Vomiting, and flatulence is
noticeable several hours after a heavy meal.
Sign and Symptoms…

 Often attacks occur after a particularly fatty
meals and almost always happen at night.
 Vitamin Deficiency
 A positive Murphy’s sign is a common finding
on physical examination.
Sign and Symptoms…

Murphy’s sign

Assessment And Diagnostic Findings
 Fecal Studies
 Laboratory test for:
Elevated conjugated bilirubin
Elevated alkaline phosphate
Serum amylase and lipase
Elevated WBC count
 Ultrasound : gold standard, 90% to 95% accurate in
detecting stones.
 CT scan
 MRI
 Endoplasmic retrograde Cholangiopancreatography
(ERCP)
 Magnetic Resonance Cholangiopancreatography
(MRCP).
 Percutaneous Transhepatic Cholangiogram (PTC).

Ultrasound of gallbladder

Management
Goal
 To resolve symptoms
 To remove stones
 To prevent complications

Management
Medical Management
Pain Management
 Give analgesics
 Antacids, H2 blockers or proton pump inhibitors
– to neutralize gastric acid.
Maintain fluid and electrolyte balance
 IV Fluids
Prevent GB stimulation
 NPO with NG suction
For Nausea and vomiting
 Antiemetics given

Gall Stone dissolution
• Oral ursodeoxycholic acid
• a naturally occurring bile acid which is taken as
either a tablet or liquid
• It works by dissolving the cholesterol that makes
gallstones and inhibiting production of cholesterol in
the liver and absorption in the intestines, which
helps to decrease the formation of gallstones.
• Necessary for the patient to take this medication for
upto two years. Gallstones may recur , however once
the drug is stopped.

Endoscopic retrograde sphincterotomy (ERS)
 Dissolving the gallstones by infusion of solvent
(mono-octanonin) into the gall bladder through
percutaenously insertion of catheter into the GB.
 A tube or drain inserted through T-tube, during
the ERCP endoscope or transmural biliary
catheter.

Lithotripsy
 Extracorporeal shock wave lithotripsy (ESWL)
 Non surgical fragmentation of gallstones
 Uses repeated shock waves directed at the
gallstones in GB or CBD to fragment the stones.
 1500 shock waves directed at stones
 Used for fewer than 4 stones, each smaller than
3 cm.

Surgical management
laparoscopic Cholecystectomy
 Removal of the gall bladder
 This is the treatment of choice.
 The gallbladder along with the cystic duct, vein and
artery are ligated.
 It has a 99% chance of eliminating the recurrence
of cholelithiasis.
 Surgery is only indicated in symptomatic patients.

laparoscopic Cholecystectomy
 Post cholecystectomy syndrome
 Develops in between 10 and 15%
population.
 Cause gastrointestinal distress and
persistent pain in the upper right
abdomen,
 10% has chance of developing chronic
diarrhea.

Related Research Article
 Laparoscopic cholecystectomy: an experience of
university hospital in eastern Nepal
 Bajracharya A. et al. BPKIHS
 Results: A total of 346 laparoscopic cholecystectomy
over a six months period, male to female ratio 1:4.
The most common indication for surgery was biliary
colic/dyspepsia (51%), cholecystitis (chronic- 49.4%,
acute-12%), pancreatitis, gallbladder polyp, history of
recurrent attacks16.5%,obesity 19.1%.
 Despite limited resources, laparoscopic
cholecystectomy is feasible and procedurally safe for
gallstones disease even in developing country like
Nepal

Potential Complications
 Acute Cholecystitis
 Cholangitis (infection or inflammation
of CBD)
 Choledocholithiasis ( gallstones in
CBD)
 Pancreatitis

What is Cholecystitis???
 Cholecystitis is the inflammation of the
gallbladder.

Types of Cholecystitis
Acute Cholecystitis
Chronic Cholecystitis

ACUTE CHOLECYSTITIS
 Acute inflammation of the gallbladder wall.
 Increased incidence in clients who are overweight,
especially those with sedentary life styles.
ACUTE ACALCULOUS CHOLECYSTITIS
 Acute Acalculous (absence of stones) Cholecystitis
accounts for approximately 4% to 8% of all cases of
acute cholecystitis.
 Occurs after or in association with other conditions,
especially major trauma, burns or surgery;
 Other preceding conditions include Bacterial Sepsis,
Postpartum Period, Tuberculosis, and Cardiovascular
disease.

Etiology
 Gall stone in cystic duct
 Obstruction in cystic duct
 Bacterial infection (gram positive and gram
negative aerobes and anaerobes: E.coli,
Klebsiella, Clostridium and streptococcus)
 Sedentary lifestyle
 Obesity

PATHOPHYSIOLOGY

Sign and Symptoms
 Complain of pain
◦ In right upper
quadrant
◦ In epigastric region
◦ In right subscapular
◦ Onset sudden
◦ Peak in 30min
 Nausea and vomiting
 Low grade fever
 Mild jaundice

CHRONIC CHOLECYSTITIS
 Repeated inflammation and infection of
gallbladder
 Arises as a sequela to acute cholecystitis.
 In addition, it is almost always associated
with gallstones.
 Chronic cholecystitis principally affects
middle-aged and older obese women.
 The female to male ratio is 3:1.

Progression of
Chronic Cholecystitis
 There is an obstruction of the
cystic duct and the gallbladder
begins to swell.
 It no longer has the "robin’s
egg blue" appearance of a
normal gallbladder.
 Gallbladder undergoes
gangrenous change and the
wall becomes very dark green
or black. - 10/8/2021 Ms. Sunita Kharel 45

Sign and Symptoms
 Epigastric pain; less severe
 Indigestion
 Fever
 Leucocytes count lower
 Dyspepsia
 Fat intolerance
 Heart burn
 Fibrosis of gall tissues
 Inability to concentrate bile

Diagnostic Investigations
 Ultrasonography- 90% to 95% accurate in
detecting stones.
 ERCP
 Percutaneous Trans hepatic Cholangiography
 Laboratory Investigations
 Bile Culture
 WBC Count:-Increased WBC count as a result of
inflammation
 Alkaline Phosphatase , ALT, AST, Bilirubin (direct),
Serum amylase-Increased if Pancreatic Involvement

 If patients come within 3 days of onset of
symptoms Immediate Cholecystectomy
 If patients come after 3 days of onset of
symptoms do conservative treatment to
cool down the inflammation first and do
elective Cholecystectomy after 45 days.
Management

Conservative Management
A Nutritional and Supportive
therapy
Dietary counselling on
 Low fat liquids
 Weight reduction
 Fat soluble vitamins and bile salts to enhance
absorptions and aid digestion
 High protein, high carbohydrate
 Cooked fruits, non gas forming vegetables,
bread, coffee or tea as tolerated
 Smaller amounts and more frequent meals
 Avoids eggs, cream, fried foods, cheese, gas
forming vegetables and alcohol

B Pharmacologic Therapy
Dissoultion of Gallstone
 Ursodeoxycholic acid (UDCA)
 Chenodeoxycholic acid
 It works by dissolving the cholesterol that makes
gallstones and inhibiting production of cholesterol in
the liver and absorption in the intestines, which helps
to decrease the formation of gallstones.
 Six to Twelve months of therapy are required in many
patients to dissolve stones, and monitoring of the
patient is required during this time.

Antibiotic Therapy
 Third generation cephalosporins- Ceftriaxone,
cefixime, Cefotaxime
 Aminoglycosides – Gentamicin, Amikacin,
Neomycin
 Penicillins – piperacillin or mezlocillin

SURGICAL MANAGEMENT
 Surgical treatment of gallbladder disease
and gallstones is carried out to relieve
persistent symptoms, to remove the cause
of biliary colic, and to treat acute
cholecystitis.
 Surgery may be performed as an
emergency procedure if the patient’s
condition necessitates it.

Surgical Cholecystotomy
 Cholecystotomy is performed when the patient’s
condition prevents more extensive surgery or
when an acute inflammatory reaction is severe.
 The gallbladder is surgically opened, the stones
and the bile or the purulent drainage are removed,
and a drainage tube is secure with a purse string
suture.
 The drainage tube is connected to a drainage
system to prevent bile from leaking around the
tube or escaping into the peritoneal cavity.

PREOPERATIVE- MEASURES
 A chest X-ray, ECG and liver function test may be
performed in addition to X-ray studies of the gallbladder.
 Vitamin K may be administered, if the Prothombin level is
low.
 Blood component therapy may be administered before
surgery.
 Preparation for gallbladder surgery is similar to that for
any upper abdominal surgery like laparotomy or
laparoscopy.
 Instructions and explanations are given before surgery with
regard to deep breathing. 10/8/2021 Ms. Sunita Kharel 54

POTENTIAL COMPLICATIONS
 Empyema of gallbladder
 Pancreatitis
 Bleeding
 Gastrointestinal symptoms ( may be
related to biliary leakage)
 Peritonitis

NURSING MANAGEMENT
ASSESSMENT
 Note a history of smoking, previous respiratory
problems a persistent or ineffective cough etc.
 Onset of pain, severity, duration.
 Alleviating measures and aggravating factors.
 Evaluation of nutritional status.

POST- OPERATIVE NURSING
INTERVENTIONS
 After recovery from anesthesia, the nurse
places the patient in the low fowler’s
position.
 Intravenous fluids may be instituted to
relieve abdominal distention.
 Water and other fluids are given in about
24 hours.
 Soft diet started when bowel sounds
return.

Nursing Interventions
Acute pain and discomfort related to surgical
incision
Relieving Pain
 Comfortable position
 Administer analgesic agent as prescribed to
relieve the pain and to promote well-being in
addition to helping the patient turn, cough,
breathe deeply and ambulate as indicated.
 Use of pillow or binder over the incision may
reduce pain during maneuvers.
 Relaxation therapy

Impaired gas exchange related to the high
abdominal surgical incision.
Improving Respiratory status
 Reminds the patient to take deep breaths and
coughs every hour to expand the lungs fully
and prevent atelectasis.
 Early ambulation prevents pulmonary
complications as well as other complications,
such as thrombophlebitis.

Impaired skin integrity related to altered biliary
drainage after surgical intervention.
Promoting Skin Care and Biliary Drainage
 The drainage tube must be connected to a drainage
receptacle.
 The drainage bag may be placed below the waist or
common duct level.
 Bile may continue to drain from the drainage tract in
considerable quantities for a time, necessitating
frequent changes of the outer dressings and protection
of the skin from irritation because bile is corrosive to
the skin.
 Maintaining a careful record of fluid intake and output
is important.

Imbalanced nutrition, less than body
requirements, related to inadequate bile
secretion.
Improving Nutritional Status
 Encourages the patient to eat a diet low in
fats and high in carbohydrates and
proteins immediately after surgery.

Teaching Patients Self Care
 Instruct the patient about the medications that
are prescribed (vitamins, antispasmodics etc.)
and their action.
 Inform patient and family about symptoms that
should be reported to the doctor, including
jaundice, dark urine, pale colored stools,
Pruritus, pain or fever.
 Instruct them in proper care of the drainage tube
and the importance of reporting to the physician
promptly any changes in the amount or
characteristic of drainage.

Continuity Care
 Asses the patient for adequacy of pain
relief, and pulmonary exercise.
 Asses for signs of infections.
 Emphasize the importance of keeping
follow up appointments.

Summary

References
 Black, J.M., & Hawks J. H. (2009) Medical Surgical
nursing. (8th ed.). St. Louis, Missouri.
 Nettina, S.M., (1998). The lipponcott manual of nursing
practice. (6th ed.). Lippincott Raven Publishers,
Washinton squares, Philadelphia
 Smeltzer, S. C., Bare B.G., Hinkle J.L., Cheever K.H.
(2008). Textbook of medical-surgical nursing. (11th ed.).
Lippincott Williams & Wilkins, Lippincott Company.
 Potter, P.A., Perry A.G. (2005). Fundamentals of
Nursing. (6th ed.). Noinda, U.P, India.
 Lobel, S., Spartto, G. (2003). The nurses drug
handbook. (3rd ed.). Whiley Medical New York, USA.
 https://www.researchgate.net/publication/229810965_L
aparoscopic_cholecystectomy_an_experience_of_unive
rsity_hospital_in_eastern_Nepal [accessed Apr 11
2021].

Any Queries

Cholelithiasis and cholecystitis, sunita kharel

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Cholelithiasis and cholecystitis, sunita kharel

Similar to Cholelithiasis and cholecystitis, sunita kharel (20)

Recently uploaded

Recently uploaded (20)

Cholelithiasis and cholecystitis, sunita kharel