This document discusses cholelithiasis, or gallstones. It defines cholelithiasis as the presence of stones in the gallbladder. Risk factors include obesity, a high-fat diet, use of birth control pills, and diabetes. Symptoms depend on whether stones are stationary or mobile, and can include abdominal pain, nausea, and jaundice. Diagnostic tests include ultrasound, CT scans, and blood tests. Treatment options include nonsurgical methods like dissolving stones with solvents or shockwave lithotripsy, or surgical removal of the gallbladder through laparoscopic cholecystectomy. Nursing care focuses on managing pain, impaired mobility, skin integrity issues, and ensuring proper nutrition.

1. CHOLE
LITHIASIS
Presented By:
Mr. Nandish. S
Asso. Professor
Mandya Institute of Nursing Sciences

2. DEFINITION:
o It is the stones or calculi in gallbladder.
o Presence of stones in the gallbladder.
o They vary greatly in size, shape and composition.
o Stones may be lodged in the neck of gall bladder or in cystic duct.
o It affects women more than men. (multiparous, aged over 40 years,
obese, post-menopausal & who are on estrogen therapy)

4. ETIOLOGY :
- Actual / original cause is unknown.
- Stones develop when balance between cholesterol, bile salts and
calcium is altered. Excessive cholesterol in bile ( Bile dissolves
cholesterol)
- Excessive bilirubin in the bile (cirrhosis, infections, blood disorders)
- Stasis of bile (when gallbladder doesn’t empty)

5. RISK FACTORS :
 Heredity
 Obesity
 Consumption of diet rich in Fat
 Lack of physical activity
 Use of birth control pills
 Diabetic patients
 Lose of more weight in short period
 Ileal resection

6. TYPES :
There are two types of stones.
1) Chelesterol stones – They are yellow-green in colour.
- 80 % of stones belongs to this group.
2)Pigment stones - They are smaller & darker.
- They are made up of bilirubin.

9. CLINICAL MANIFESTATIONS :
Symptoms depends whether stones are stationary or mobile.
- Abdominal Pain (biliary colic)
- Tachycardia & diaphoresis
- Nausea & vomiting
- Anorexia
- Intolerance for fatty foods
- Vitamin deficiency
- Obstructive Jaundice
- Dark coloured urine
- Clay coloured stool
- Steatorrhea (excessive loss of fat in the stool)

10. COMPLICATIONS :
- Cholangitis
- Biliary cirrhosis
- Gallbladder Carcinoma
- Peritonitis
- Choledocholithiasis (stone in the common bile duct)
- Pancreatitis

11. DIAGNOSTIC STUDIES :
- History collection & Physical examination
- Liver Function Test
- Serum Bilirubin level
- Abdominal X-Ray
- Ultrasound
- Radionuclide Imaging / Cholescintigraphy (more expensive and
takes long duration, Radio opaque agent is given through IV)
- Oral cholecystography : An Iodide containing contrast agent is
given before 10-12 hrs of X-Ray through orally.
- ERCP
- MRCP

12. TREATMENT :
NUTRITION:
- NPO
- IV therapy
- Low fat diet
- Powdered supplements rich in protein & carbohydrate
- Rice, non –gas forming vegetables, bread, cooked fruits, topioca,
lean meat can be added.
- Avoid egg, cream, pork, fried foods, cheese, gas forming vegetables.
- Alcohol cessation

13. PHARMACOLOGIC THERAPY :
o Cholesterol solvents – Methyl Tertiary Terbutyl Ether (MTBE)
o Gallstone solvents – Urso deoxycholic acid (UDCA)
- Cheno deoxycholic acid (CDCA)
o Other medication are planned as per the symptoms.

14. NON – SURGICAL TREATMENT :
1) Dissolving gallstones :
o It is done by infusion of solvent (Mono-octanoin or Methyl Tertiary
Butyl Ether (MTBE) into the gallbladder.
o Solvent can be infused through a tube or catheter inserted directly
into the gallbladder or drain inserted through a T –Tube tract to
dissolve stones not removed at the time of surgery.
o It is done to the patients with safety concerns regarding general
anesthesia.

15. 2) Stone removal by instrumentation:
- A catheter & instrument with basket attached are threaded through T-
Tube or fistula formed at the time of T-Tube insertion.
- Second procedure is use of ERCP endoscope. After the insertion of
endoscope, cutting instrument is passed into the Ampula of Vater of
common bile duct. It is used to enlarge the opening, which allow
lodged stones to pass spontaneously into the duodenum.
- Another instrument with balloon at its tip may be inserted through
the endoscope to retrieve the stones.

16. 3) Intracarporeal Lithotripsy :
o Here a Laser pulse is directed under fluroscopic guidance.
o Laser produces rapid expansion & disintegration of plasma on the
stone surface resulting in mechanical shock wave.
o Electrohydraulic lithotripsy uses probe with two electrodes that
deliver electric sparks.
o This results in pressure waves that cause stone to fragment.
o The present technique can be used percutaneously with a basket or
balloon catheter system.

17. 4. Extracarporeal Shock Wave Lithotripsy (ESWL)
 It is a non invasive procedure, uses repeated shock waves directed at
the gallstones in gallbladder or common bile duct.
 The waves are transmitted to the body through fluid filled bag or by
immersing patient in water bath.
 After stones are gradually broken up, the stone fragments can be
removed by endoscopy or dissolved with solvents.
 Patients are usually treated on OPD Basis.

20. SURGICAL MANAGEMENT :
Aim :
 To relieve persistent symptoms.
 To remove the cause of biliary colic.
 To treat acute inflammation.
* Surgery is performed on the elective or emergency basis, based on the
patient’s condition.

21. 1) Laproscopic Cholecystectomy:
- It is performed through the small incision or puncture made through
abdominal wall at umbilicus.
- Abdominal cavity is insufflated with carbon dioxide to assist in
inserting laproscope & visualize the abdominal structures.
- Several additional punctures are made to introduce other surgical
instruments into operative field.
- Gallbladder is separated from hepatic bed & removed from
abdominal cavity after bile & stones are aspirated.

25. 2) Cholecystectomy :
- Gallbladder is removed through an abdominal incision after the
cystic duct & artery are ligated.
- It is performed for acute & chronic cholecystitis caused due to gall
stones.
- Drain is typically maintained if there is excess oozing or bile
leakage.

26. 3) Small Incision Cholecystectomy :
• A surgical procedure in which gallbladder is removed through a
small abdominal incision.
• Incision is extended only to remove larger gall stones.
• This procedure is controversial as it limits exposure of biliary
structures.

27. 4) Choledochostomy :
• This procedure involves making an incision in the common bile duct
to remove stones.
• A tube is inserted into the duct for drainage of bile until the edema
subsides.
• This tube is connected for gravity drainage tubing.

28. 5) Surgical Cholecystostomy :
• It is performed when acute inflammatory reaction is severe.
• Gallbladder is surgically opened, stones or purulent discharge are
removed and a drainage tube is secured with a PURSE-STRING
suture.
• A drainage tube is connected to drainage system.
• After recovery, patient may return for subsequent laproscopic
cholecystectomy.

29. 6) Percutaneous Cholecystostomy :
- Under the local anaesthesia, a fine needle is inserted through
abdominal wall & liver edge into the gallbladder with the help of
ultrasound.
- Bile is aspirated to ensure adequate placement of needle & a
catheter is inserted into the gallbladder to remove stones(small in
size).
- Immediate relief from symptoms are reported with this procedure.
- Antibiotics are compulsory through out the process.

30. NURSING MANAGEMENT :
- Pain , acute , abdomen related to surgical incision.
- Impaired gas exchange related to abdominal wound & decreased
thoracic excursion.
- Impaired skin integrity related to surgical intervention.
- Imbalanced nutrition, less than body requirement related to
inadequate bile secretion.
- Ineffective therapeutic regimen management related to self care
activities (incision care, dietary modifications)

31. THANK YOU