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‫ أحمد ثامر‬.‫م‬.‫م‬
‫ تمريض بالغين‬/‫نظري‬
Hepatobiliary disorders ‫مرحلة ثانية‬

Cholelithiasis and Cholecystitis

 Front View of the Gallbladder
The gallbladder is a small pouch that sits just under the liver. The gallbladder
stores bile produced by the liver. After meals, the gallbladder is empty and flat, like
a deflated balloon. Before a meal, the gallbladder may be full of bile and about the
size of a small pear.
In response to signals, the gallbladder squeezes stored bile into the small intestine
through a series of tubes called ducts. Bile helps digest fats, but the gallbladder
itself is not essential. Removing the gallbladder in an otherwise healthy individual
typically causes no observable problems with health or digestion yet there may be a
small risk of diarrhea and fat mal-absorption.

 Disorders of the Gallbladder

Gallbladder disease with gallstones is the most common disorder of the
biliary system. Although not all occurrences of gallbladder inflammation
(cholecystitis) are related to gallstones (cholelithiasis), more than 90% of patients
with acute cholecystitis have gallstones.
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  Cholecystitis
Acute inflammation (cholecystitis) of the gallbladder causes pain,
tenderness, and rigidity of the upper right abdomen that may radiate to the
midsternal area or right shoulder and is associated with nausea, vomiting, and the
usual signs of an acute inflammation
 Cholelithiasis
Calculi, or gallstones, usually form in the gallbladder from the solid
constituents of bile; they vary greatly in size, shape, and composition.

Pathophysiology
Cholelithiasis
Calculi usually from solid constituents of bile; the three major types are:

 Cholesterol gallstones – the most common type, thought to form in

supersaturated bile
 Pigment gallstones – formed mainly of unconjugated pigments in bile
precipitate
 Mixed types – with characteristics of pigment and cholesterol stones.
Gallstones can obstruct the cystic duct, causing cholecystitsi

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  Cholecystitis
 In acute and chronic cholecystitis, inflammation causes the gallbladder wall
to become thickened and edematous and causes the cystic lumen to increase
in diameter.

 If inflammation spreads to the common bile duct, obstruction of bile drainage

can lead to jaundice. Other possible complications include: (Empyema i.e.
pus-filled gallbladder, perforation, emphysematous cholecystitis)

 Risk Factors for Cholelithiasis:

1) Obesity
2) Women, especially those who have had multiple pregnancies
3) Frequent changes in weight
4) Rapid weight loss (leads to rapid development of gallstones and high risk of
symptomatic disease)
5) Treatment with high-dose estrogen (ie, in prostate cancer)
6) Low-dose estrogen therapy—a small increase in the risk of gallstones
7) Ileal resection or disease
8) Cystic fibrosis
9) Diabetes mellitus
 Clinical Manifestations
Signs and symptoms of cholecystitis may include:

1. Severe pain in your upper right or center abdomen

2. Pain that spreads to your right shoulder or back
3. Tenderness over your abdomen when it's touched
4. Nausea
5. Vomiting
6. Fever
Cholecystitis signs and symptoms often occur after a meal, particularly a large or
fatty one.

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  Assessment and Diagnostic Findings

The following tests may also be ordered:

1. Ultrasound: This can highlight any gallstones and may show the
condition of the gallbladder.
2. Blood test: A high white blood cell count may indicate an infection.
High levels of bilirubin, alkaline phosphatase, and serum
aminotransferase may also help the doctor make a diagnosis.
3. Computerized tomography (CT) or ultrasound scans: Images of the
gallbladder may reveal signs of cholecystitis.
4. Hepatobiliary iminodiacetic acid (HIDA) scan: Also known as a
cholescintigraphy, hepatobiliary scintigraphy or hepatobiliary scan, this
scan creates pictures of the liver, gallbladder, biliary tract and small
intestine.
 Medical Management
Teach the client about planned treatments.
 Chenodeoxycholic acid is administered to dissolve gallstones. It is effective
in dissolving about 60% of radiolucent gallstones. Pigment gallstones cannot
be dissolves and must be excised.
 Nonsurgical removal, such as lithotripsy or extracorpeal shock wave therapy,
may be implemented.
Surgical treatment may be ordered.
Laparoscopic cholecytectomy (usually outpatient surgery) is performed through
a small incision made through the abdominal wall in the umbilicus.
 Assess incision sites for infection. Instruct the client to notify the health care
provider if loss of appetite, vomiting, pain, abdominal distention, or fever
occur.

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Cholecystectomy is removal of the gallbladder after ligation of the cystic duct
and artery. Inform the client that a T-tube will be inserted to drain blood;
serosanguineous fluids, and bile and that the T-tube must be taped below the
incision
Choledochostomy is an incision into the common bile duct for calculi removal.
Cholecystomy is the surgical opening of the gallbladder for removal of stones,
bile, or pus, after which a drainage tube is placed.
 Nursing Diagnoses
Based on all the assessment data, the major postoperative nursing diagnoses
for the patient undergoing surgery for gallbladder disease may include the
following:
1. Acute pain and discomfort related to surgical incision
2. Impaired gas exchange related to the high abdominal surgical incision
(if traditional surgical cholecystectomy is performed)
3. Impaired skin integrity related to altered biliary drainage after surgical
intervention (if a T-tube is inserted because of retained stones in the
common bile duct or another drainage device is employed)
4. Imbalanced nutrition, less than body requirements, related to
inadequate bile secretion
5. Deficient knowledge about self-care activities related to incision care,
dietary modifications (if needed), medications, reportable signs or
symptoms (eg, fever, bleeding, vomiting)

Collaborative Problems/ Potential Complications

Based on assessment data, potential complications may include:
1. Bleeding
2. Gastrointestinal symptoms (may be related to biliary leak)

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  Nursing Management
Provide nursing interventions during an acute gallbladder attack.
1. Intervene to relive pain; give prescribed analgesics
2. Promote adequate rest
3. Administer IV fluids, monitor intake and output
4. Monitor nasogastric tube and suctioning
5. Administer antibiotics if prescribed.
6. Provide adequate nutrition: assess nutritional status. Encourage a high-
protein, high-carbohydrate, low-fat diet.

Thank you………..

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