It includes about the details of cholelithiasis.

1. CHOLELITHIASIS
Prepared by:
Prabita Shrestha

2. ANATOMY AND PHYSIOLOGY OF GALL
BLADDER:
• Gallbladder is a muscular organ that serves as a reservoir for
bile, present in most vertebrates.
• In humans, it is a pear-shaped membranous sac on the
undersurface of the right lobe of the liver just below the lower ribs.
• It is generally about 7.5 cm (about 3 inch) long and 2.5 cm (1
inch) in diameter at its thickest part; it has a capacity varying from
1 to 1.5 fluid ounces.
• The body (corpus) and neck (collum) of the gallbladder extend
backward, upward, and to the left. The wide end (fundus) points
downward and forward, sometimes extending slightly
beyond the edge of the liver.

3. Contd…
• Structurally, the gallbladder consists of an outer peritoneal
coat (tunica serosa); a middle coat of fibrous tissue and
unstriped muscle (tunica muscularis); and
an inner mucous membrane coat (tunica mucosa).
• The function of the gallbladder is to store bile, secreted by the
liver and transmitted from that organ via the cystic and hepatic
ducts, until it is needed in the digestive process.
• The gallbladder, when functioning normally, empties through
the biliary ducts into the duodenum to aid digestion by
promoting peristalsis and absorption, preventing putrefaction,
and emulsifying fat.

4. Introduction of cholelithiasis:
• Cholelithiasis is the process of stone formation in the gall bladder.
• Cholecystitis is an inflammation of the gall bladder which can be
acute and chronic and usually precipitated by gall stone impacted
in the cystic duct, causing distension of the gall bladder.
• Stones are made up of cholesterol, calcium bilirubinate, or a
mixture caused by changes in the bile composition.
• Gall stones can develop in the common bile duct, cystic duct,
hepatic duct, small bile duct and pancreatic duct. Crystals can
also form in the submucosa of the gall bladder causing
widespread inflammation.

6. Contd…
• Digestion of fat occurs mainly in the small intestine,
by pancreatic enzymes called lipases.
• The purpose of bile is to help the lipases to work, by
emulsifying fat into smaller droplets to increase access for the
enzymes, enable intake of fat, including fat-soluble vitamins:
Vitamin A, D, E, and K, rid the body of surpluses and
metabolic wastes cholesterol and bilirubin.

7. Contd:
• Cholelithiasis is one of the very common health problems in
Nepal and all over the world.
• It is four times more common in women than in men.
• It occurs frequently in middle ages or in old age group.
• It is the most common disorder of the biliary tract.
• It is more common in obese person, those who have diabetes
mellitus and other endocrine problem.

8. Aetiology :
Hereditary
Diet pattern – especially excessive fatty consumption
Obese person may be due to impaired fat metabolism
Birth control period-alters hormone levels
Multiple pregnancy
Inflammation of biliary tract
Stagnant bile in gall bladder

9. The following are more likely to develop
gallstones:
• Bone marrow or solid organ transplant
• Diabetes
• Failure of the gallbladder to empty bile properly (this is more likely
to happen during pregnancy)
• Liver cirrhosis and biliary tract infections (pigmented stones)
• Medical conditions that cause the liver to make too much bilirubin,
such as chronic hemolytic anemia, including sickle cell anemia
• Rapid weight loss from eating a very low-calorie diet, or after
bariatric surgery
• Receiving nutrition through a vein for a long period of time.

10. Pathophysiology:
• Gallstones are composed of cholesterol, bile salts, calcium,
bilirubin and proteins.
• However, the exact cause of gallstone formation is not clearly
understood.
• There are 3 specific factors which appear to contribute to the
formation of gall stones.

11. metabolic
disorders
increased
serum
cholesterol
cholesterol
stones
bilirubin
stones
calcium
stones
biliary stasis
bile
stagnates in
gall bladder
leading to
excessive
absorption
of water
causing
precipitation
of salts
forms mixed
stones of
various
sizes
inflammation
of biliary
system
causing
bile
constituents
altered
inflammed gall
bladder
mucosa
absorbs more
of bile acids
resulting in
reduced
solubility of
cholesterol
CHOLELITHIASIS

12. Clinical features:
Acute abdominal pain in right hypochondric region.
Tachycardia
Diaphoresis
Nausea / vomiting
Chills and rigor
Jaundice
Stool will be clay colored due to loss of urobilinogen.
Dyspepsia
Bilirubin will be excreted in urine.
Sometimes a sausage – shaped mass may be felt when abdomen
is palpated.

13. Investigations:
A complete blood count is obtained routinely in patients
suspected of cholelithiasis.
CBC might serve as a preoperative lab test normally obtained
in patients undergoing major surgery, such as laparoscopic
cholecystectomy.
An elevated white blood cell count alerts the clinician to the
possibility of acute cholecystitis, a condition requiring more
urgent treatment.

14. Abdominal plain X-ray

15. USG

16. Cholescintigraphy

17. Endoscopic retrograde
cholangiopacreatography

19. Percutaneous transhepatic
cholangiography

20. Contd…
CT Scan of Hepatobiliary system
Cholecystography

21. Nutritional and supportive therapy
 Rest, IV fluids, NG suction, analgesic and antibiotic agents.
 Diet
Pharmacological therapy
 Ursodeoxycholic acid (UDCA)
 Chenodeoxycholic acid (CDCA)
Non-surgical removal of gallstones
 Contact dissolution therapy
 Extracorporeal shock wave lithotripsy
Medical management:

22. Surgical management:
1. Cholecystectomy:
Cholecystectomy is the surgical removal of the gallbladder.
It is a common treatment of symptomatic gallstones and other
gallbladder conditions.
Surgical options include the standard procedure,
called laparoscopic cholecystectomy, and an older more invasive
procedure, called open cholecystectomy.
Its indications are: cholecystitis, biliary colic, risk factors for gall
bladder cancer, and pancreatitis caused by gall stones.
The most serious complication of cholecystectomy is damage to
the common bile duct. This occurs in about 0.25% of cases.

24. 2. Intraoperative cholangiography and choledochoscopy:
Intraoperative cholangiography is an examination of the bile
ducts following administration of a radiopaque contrast
medium during operation.
Choledochoscopy is the direct visualization of the biliary tract
with an endoscope through a t-tube or incision into the
common bile duct. Small calculi can be removed from the
common bile duct during this procedure.
.

25. 3. Placement of a T-tube:
In this procedure, T tube is placed in the common bile duct to
decompress the biliary tree and allow access into the biliary tree
postoperatively
After an open cholecystectomy, a wopund drain removes
exudates from the area formerly occupied by the gallbladder,
and a T-tube diverts bile, which is still forming.

26. Nursing management:
Assessment:
 Obtain history and demographic data that may indicate risk
factors for biliary disease.
 Assess patient’s pain for location, description, intensity,
relieving and exacerbating factors.
 Assess for signs of dehydration: dry mucous membranes,
poor skin turgor, low urine output with elevated specific
gravity.
 Assess sclera and skin for jaundice
 Monitor temparature and WBC for indications of infection.

27. Nursing diagnosis:
1. Acute Pain related to:
biological trauma obstruction / spasm tract inflammatory
processes, ischemia / tissue necrosis.
2. Risk for Deficient Fluid Volume related to:
 Increase in gastric fluid loss: vomiting, gastric distention
 Treatment has the effect of reducing the fluid.
 The freezing process

28. 3. Imbalanced Nutrition Less Than Body Requirements related
to:
 Risk factors that affect:
Imposed on themselves and given limited food, nausea,
vomiting, dyspepsia, pain.
 Loss of nutrients, affect digestion due to disturbance / narrowing
of the bile duct.
4. Deficient Knowledge: about prognosis and treatment needs
related to:
 Re asking about information.
 Information misinterpretation.
 Have not / do not know the source of information

29. Nursing Interventions
• Place the patient in low Fowler’s position.
• Provide intravenous fluids and nasogastric suction.
• Provide water and other fluids and soft diet, after bowel
sounds return.
• Instruct the patient to use a pillow to splint incision.
• Administer analgesic agents as ordered.
• Remind patient to expand lungs fully to prevent atelectasis.
• Promote early ambulation.
• Monitor elderly and obese patients most closely for respiratory
problems,

30. • Place drainage bag in patient’s pocket when ambulating.
• Observe for indications of infection, leakage of bile, or
obstruction of bile drainage.
• Observe for jaundice.
• Note and report right upper quadrant pain, nausea, and
vomiting.
• Change dressing frequently, using ointment to protect skin
from irritation

31. Evaluation: expected
outcomes
• Verbalizes reduced pain level
• Tolerate oral fluids and solid fluids; adequate urine output

32. References:
1. Lippincott, Manual Of Nursing Practice, 8th Edition, Page No. :
709-712
2. Lippincott, Atlas Of Pathophysiology, 2nd Edition, Page No. : 162-
163
3. HLMC, Textbook of Adult Nursing, 1st Edition, Page No. : 7-9,
Page No. : 97-100
4. Brunner and Suddarth’s, Medical-Surgical Nursing, 10th Edition,
Page No. :1115-1119
5. Dr. Sudeep K. Yadav, A Book On Pathophysiology, 2nd Edition,
Page No. : 130-135
6. http://spareyourtummy.wordpress.com/2012/05/23/cholelithi
asis/