Related literatures

CHOLELITHIASIS
 The presence of stones or calculi (gallstones) in the gallbladder
results from changes in bile components.

 Gallstones are made of cholesterol, calcium bilirubinate, or a

mixture of cholesterol and bilirubin pigment.

 They arise during periods of sluggishness in the gallbladder

resulting from pregnancy, use of oral contraceptives, diabetes
mellitus, Crohn’s disease, cirrhosis of the liver, pancreatitis, obesity,
and rapid weight loss.

 Fifth leading cause of hospitalization among adults and accounts for

90% of all gallbladder and duct diseases.
 Cholecystitis

 An acute or chronic inflammation of the

gallbladder, is usually associated with a gallstone
impacted in the cystic duct; the inflammation
develops behind the obstruction.

 Cholecystitis accounts for 10% to 25% of all

patients requiring gallbladder surgery.

 The acute form is most common during middle

age; the chronic form, among elderly people.
The prognosis is good with treatment.
 Complications

 Cholelithiasis may lead to any of the disorders associated

with gallstone formation:
cholangitis, cholecystitis, choledocholithiasis, or
gallstone ileus.

 Cholecystitis can progress to gallbladder complications:

empyema, hydrops or mucocele, or gangrene.

 Gangrene may lead to perforation, resulting in

peritonitis, fistula formation, pancreatitis, limy bile, and
porcelain gallbladder.
 Signs and symptoms

 Acute abdominal pain(RUQ)

 Fat intolerance
 Biliary colic
 Belching
 Flatulence
 Indigestion
 Diaphoresis
 Nausea and Vomiting
 Chills
 Low-grade fever
 Jaundice
 Collaborative Management
> Relief of pain- Meperidine Hcl (DOC)
> Don’t give Morphine Sulfate.
> Diet: Low fat diet
> Bile salts: Chenooxycholic acid; ursodioxycholic acid(UDCA)
> Surgery: Cholecystectomy
> Pre op Care
 Iv fluid electrolyte
 DBCT exercise Vitamin K injection

>Post op Care
 Position. Low/ Semi fowler’s position
 NGT
 DBCT exercise
 Ambulation after 24 hours post op
 If with CBD exploration: T-tube
 Purpose: To drain bile
 Drainage
 Removal of the Gallbladder?

 In some cases, the gallbladder must be

removed. The surgery to remove the gallbladder
is called a cholecystectomy (pronounced co-lee-
sist-eck-toe-mee). In a cholecystectomy, the
gallbladder is removed through a 5- to 8-inch
long cut in your abdomen.
 Once the gallbladder is removed, bile is
delivered directly from the liver ducts to the
upper part of the intestine.
 Diagnosis
Ultrasonography and X-rays detect gallstones. Specific
procedures include the following:

❑ Ultrasonography
❑ Percutaneous transhepatic cholangiography
❑ Endoscopic retrograde cholangiopancreatography
❑ Hepatobiliary iminodiacetic acid analogue scan
❑ Computed tomography scan
❑ Plain abdominal X-rays
❑ Oral cholecystography

Elevated icteric index and elevated total bilirubin, urine

bilirubin, and alkaline phosphatase levels support the
diagnosis. White blood cell count is slightly elevated
during a cholecystitis attack.
 ANATOMY
&
PHYSIOLOGY
 Located in right hypochondriac
region.
 It is a pear-shaped sac from 7-
10cm long and 3cm broad at its
widest point. Can hold 30-50 ml of
bile.
 Divided into four anatomic
portions: the fundus, the corpus
or body, infundibulum, and the
neck.
 Fundus is the rounded, blind end
 Normally extends beyond the liver's
margin
 It may be unusually kinked and
present the appearance of a
“phrygian cap.”
 It contains most of the smooth
muscle of the organ
 Corpus or body, which is the major storage
area and contains most of the elastic
tissue.
 The body tapers into the neck, which is
funnel-shaped and connects with the cystic
duct.
 The neck usually follows a gentle curve,
the convexity of which may be distended
into a dilatation known as the infundibulum,
or Hartmann's pouch.
 The Gallbladder is a
small, pear-shaped organ
in the abdomen.  Its job
is to store and release
bile, a fluid made by the
liver.  Bile helps break
down fats in the food you
eat.
 Your liver makes bile.
 Most of the bile is
sent through a
network of ducts to
the duodenum (first
part of the small
intestine).  A small
amount of bile is also
sent to the
gallbladder for
storage.
COMPONENTS:
 BILE SALTS, (formed in the liver from
cholesterol) are the most essential part of
bile.
 BILE PIGMENTS-The pigment bilirubin
(red) and biliverdin (green), derived from
hemoglobin, give bile its greenish color
because it secretes bile into ducts.
 CHOLESTEROL
 PHOSPHOLIPIDS
FUNCTIONS OF BILE
1. It breaks down the fats
that you eat so that your
body can utilize them.
2. Bile is a very powerful
antioxidant which helps to
remove toxins from the
liver.
 The gallbladder stores
some bile.  The
gallbladder
concentrates the bile
by removing the
water.  When bile is
needed to digest fats,
hormones (chemical
messengers) signal the
gallbladder to squeeze
bile out through the
cystic duct.
 Bile is sent to the
duodenum. The bile
moves through the
common bile duct to the
duodenum. There, it
mixes with food. The
pancreas  adds other
digestive
juices. Digestion
continues in the small
intestine
PATHOPHYSIOLOGY
 Predisposing Factors Justification
Age (40 and above) Most internal functions decline as one ages. Inevitably resulting in organ
degeneration which also affects the body's metabolism of lipids.
Gender Gallstones is more frequent on women especially who had have had multiple
pregnancies or who are taking oral contraceptives. Increase level of Estrogen
reduces the synthesis of bile acid in women. Female sex hormones have long
been suspected to have a side effect of gallstone formation by altering
respective bile constituents (mainly the FAT metabolism).
Ileal Disease/Resection People who have disease of the terminal ileum or who have undergone resection
of the terminal ileum deplete their bile salt pool and run a greater risk of
developing cholesterol gallstones.
Race Cholesterol stones are common in Northern Europe and in North and South
America.
Genetics Most clinicians have an impression that gallbladder disease characterizes some
families. Indeed, the younger sisters of women with gallstone prove to have
bile more highly saturated with cholesterol than the younger sisters of
women without gallstones, all of which suggests that Cholelithiasis does run
in families.
Inflammation and Inflammation or infection in the biliary structures may provide a focus for stone
infection of the formation or may alter the solubility of the constituents, fostering the
gallbladder- development of a stone.
Hemolytic Disease and In cirrhosis, at least two fifths of patients have gallstones. One possible
Hepatic Cirrhosis mechanism behind the appearance of pigment softness, so far unproven, is
the excretion of unconjugated bilirubin directly into the bile, something that
might happen in patient with hemolysis or in the cirrhotic with his high
incidence of pigment stones, currently estimated at 27 %.
Bile stasis Brown pigment gallstones form when there is stasis of bile (decreased flow), for
example, when there are narrow, obstructed bile ducts.
 Precipitating Justification
Factors
Faulty Diet Excessive intake of high fat or cholesterol food such as pork meat, animal skin (e.g. chicharon
and chicken skin) can result to an increase in cholesterol level in the body, making it hard
for the liver to make bile enough to metabolized the all cholesterol present. Excess
cholesterol present builds up and increases the cholesterol serum level. Normal Liver
function would then try to compensate and excrete excess cholesterol to the bile plus the
body would reabsorb water from the bile making it more concentrated. Supersaturation of
Cholesterol along with other constituents of the bile (bilirubin, lecithin etc.) builds up
microcrystals. When microcrystals aggregate it would result to Gallstones.
Weight Loss Weight loss is associated with an increased risk of gallstones because weight loss increases bile
cholesterol supersaturation, enhances cholesterol crystal nucleation, and decreases
gallbladder contractility.
Obesity Obesity is a major risk factor for gallstones, especially in women. A large clinical study showed
that being even moderately overweight increases the risk for developing gallstones. The
most likely reason is that obesity tends to reduce the amount of bile salts in bile, resulting
in more cholesterol. Obesity also decreases gallbladder emptying.
Pregnancy Altered physiology of the biliary system during pregnancy may play a role in accelerating the
formation of stones in susceptible women.
Treatment with estrogen/ The contraceptive pill not only promotes thromobphlebitis but points to an endocrine background
contraceptives of gallstones by the risk of gallstones in young women taking the pill. This is largely as a
result of increased cholesterol secretion into the bile and a decrease in chenodeoxycholic
acid content, along with impaired emptying of the gallbladder brought about by estrogen.

Frequent Starvation and Starvation decreases gallbladder movement causing the bile to become overconcentrated with
Prolonged parenteral cholesterol. The liver also secretes extra cholesterol into bile adding to the supersaturation
nutrition causing stone formation. Also, fasting persons have a diminished bile salt pool and
lithogenic bile.Gallbladder stasis plays a key role in permitting stone formation. Defective or
infrequent gallbladder emptying occurs in the settings of prolonged fasting, rapid weight
loss, pregnancy, and spinal cord injury.
Clofibrate use and other Drugs that lower the serum level of cholesterol, notably clofibrate, are associated with an
Antilipemic drugs increased incidence of gallstones. Clofibrate presumably increases the secretion of
cholesterol into the bile and apparently also decreases bile acid synthesis, so increasing the
cholesterol saturation of the bile. Clinical reflection of these physiologic abnormalities has
been found in the overwhelming association between clofibrate therapy and gallstones.
 Book Based
Middle age (female > male before age
50), obesity, infection, pregnancy,
hormonal contraceptive, celiac disease.
Cirrhosis, pancreatitis, diabetes mellitus

Cholelithiasis
Refers to the formation of calculi
(e.g. gallstones in the gallbladder)

Major constituents are cholesterol and

pigment

Cholecystectomy Gallstone in bile Pain Fever Nausea and Jaundice

duct vomiting

Removal of the There is inflammation Increase

gallbladder after Bile stasis due to infection Gastric irritation bilirubin
ligation of the
cystic duct

Bile accumulates Bacterial Abnormal fat

Body will return to in the liver proliferation digestion There is restlessness
normal function and Increase in RR,
temp, PR and WBC
values
Gallbladder and Diarrhea
Recovery Cholestatic duct infection

Biliary
cirrhosis Rupture of Cholecystitis If not treated
gallbladder if

Peritonitis Death