Gerard Danielle K. Sio MD, MOH, FPCOM, PAFP, PAPSHI, CSSBB

Occupational Environmental Health and Safety Systems Operations Policies
Programs Consultant
IT IS AN Industrial Hygiene and Ergonomics Consultant
Certified Six Sigma Black Belt and PMP Holder
OUTSTANDING Certified Professional Life Coach
DAY TO SAVE ACCREDITED AND CERTIFIED OSH CONSULTANT AND WORKPLACE
LIVES HEALTH INDUSTRY EXPERT
Workplace Stakeholders, Government and Private Institutions RESOURCE
SPEAKER
Member, Various expert panels for workplace health and COVID 19
Member, International Commission on Occupational Health
09171339219
https://www.linkedin.com/in/gerard-sio-md-moh-dpcom-pafp-papshi-oshcon-c
ssbb-87402695
doc.gerry.osh@gmail.com
https://www.facebook.com/ekonsultamokaydocgerry/
Health, Safety, Environment, Quality, Dating, Relationship,
Wellness and Motivational Coach
Contributor: DOH Workplace Handbook, Unified Medical Algorithms for COVID
19
HAVE A Member, Philippine Hepatitis B Clinical Practice Guidelines Consensus Panel
Member, Philippine Periodic Health Examination Phase III PHEX 3 Infectious
GREAT DAY Disease Task Force Clinical Practice Guidelines Consensus Panel
AHEAD! Member, Philippine Obesity and Overweight Clinical Practice Guidelines
Consensus Panel
Philippine and International Speaker
Juris Doctor Program (ongoing)
International Masters Degree in Business Administration and International
Master of Arts in Law(ongoing)
GALLBLADDER 101
What is it?
 By definition,
cholecystitis is an
inflammation of the
gallbladder wall and
nearby abdominal
lining.
Abdominal wall

Gallbladder
Etiology / Pathophysiology

 Can be caused by an obstruction,

gallstone or a tumor.
 90% of all cases caused by gallstones.
 The exact cause of gallstone formation is unknown.

 When there is an obstruction, gallstone or

tumor it prevents bile from leaving the
gallbladder.
 Bile gets trapped and acts as an irritant which
causes cellular infiltration within 3 – 4 days.
 This infiltration causes an
inflammatory process – the
gallbladder becomes
enlarged and edematous.
 Eventually this
occlusion along with
bile stasis causes the
mucosal lining of the
gallbladder to become
necrotic.
 Bacterial growth Necrotic Gallbladder
occurs due to
ischemia.
  Rupture of the gallbladder becomes a danger, along with spread
of infection of the hepatic duct and liver.
 If the disease is severe and interferes with the blood supply it
can cause the gallbladder to become gangrenous.

Gangrenous
gallbladder Gallstones
Gallstones . .
 The presence of
gallstones in the
gallbladder is called
cholelithiasis.
Those who are most at risk.
 These are all adjectives to describe the person most at
risk of developing symptomatic gallstones.

FAIR FAT FORTY FEMALE

Something to think about.

 Disorders of the biliary system are

COMMON in the U.S.

 They are responsible for the

hospitalization of more than half a million
people each year.

 The two most common conditions are

cholecystitis & cholelithiasis.
Signs and Symptoms.
 Complaints of indigestion after
eating high fat foods.
 Localized pain in the right-
upper quadrant epigastric
region.
 Anorexia, nausea, vomiting
and flatulence.

 Increased heart and respiratory rate –

causing patient to become diaphoretic
which in turn makes them think they
are having a heart attack.
Signs and Symptoms.

 Low grade fever.

 Elevated leukocyte count.
 Mild jaundice.
 Stools that contain fat – steatorrhea.
 Clay colored stools caused by a lack of
bile in the intestinal tract.
 Urine may be dark amber- to tea-colored.
Diagnostics.
 Fecal studies.

 Serum bilirubin tests.

 Ultrasound of the
gallbladder.
Diagnostics.
 HIDA scan - imaging test used to
examine the gallbladder and the ducts
leading into and out of the gallbladder - also
referred to as cholescintigraphy.

 Oral cholecystogram - the

patient takes iodine-containing tablets by
mouth - iodine is absorbed from the
intestine into the bloodstream - removed
from the blood by the liver and excreted by
the liver into the bile – it is concentrated in
the gallbladder - outlines the gallstones that
are radiolucent (x-rays pass through them).

 Operative cholangiography –
common bile duct is directly injected with
radiopaque dye.
 Recap. Stages of Acute Cholecystitis.
- Gallbladder has a grayish
appearance & is
edematous.
- There is an obstruction of
the cystic duct and the
gallbladder begins to swell.
- It no longer has the "robin
egg blue" appearance of a
normal gallbladder.
- As acute cholecystitis - Gallbladder
progresses, the undergoes
gallbladder begins to gangrenous change
become necrotic and gets and the wall becomes
a speckled appearance as very dark green or
the wall begins to die. black.
- This is the stage
when perforation
occurs.
Medical Management.
 Lithotripsy
 for patients with only
a FEW stones.
 If the attack of
cholelithiasis is mild –
 bed rest is prescribed.
 patient is placed on
NPO to allow GI tract
and gallbladder to rest.
 an NG tube is placed
on low suction.
 fluids are given IV in
order to replace lost
fluids from NG tube
suction.
Medical Management.

Cholecystectomy
or
Laparoscopic Cholecystectomy
– removal of the gallbladder.

This is the treatment of choice.

The gallbladder along with the cystic
duct, vein and artery are ligated.
Medical Management.
 If stones are present in the
common bile duct, an
endoscopic sphincterotomy
must be performed to remove
them BEFORE a
cholecystectomy is done.

 A number of various
instruments are inserted
through the endoscope in
order to "cut" or stretch the
sphincter.
 Once this is done, additional
instruments are passed that
enable the removal of stones
and the stretching of
narrowed regions of the
ducts.
 Drains (stents) can also be
used to prevent a narrowed
area from rapidly returning to
its previously narrowed state.
 Nursing Interventions
Post Op - Cholesystectomy

1. Administer oral analgesics to facilitate movement

and deep breathing – and to stay ahead of pts pain.

2. Observe dressings frequently for exudate and hemorrhage.

3. Vitals are routinely checked.

4. Patient teaching:
-Must understand how to splint the abd. before
coughing.
-Report any abnormalities such as, 5. Fluid balance is maintained IV –
severe pain, tenderness in RUQ, increase in potassium added to compensate
pulse, etc . . for loss from surgery.
-Instructed that they usually can return to work in 3
days & can resume full activity in 1 week.
 Nursing Interventions

Interventions center on keeping patient comfortable by

carefully administering meds and watching for reactions.

1. Urine and stool should be observed for alterations

in the presence of bilirubin.

2. NG tube must be monitored for amount, color & consistency

of output.
Also, tube must be on LOW suction and nasal area should
be monitored for irritation and necrosis.

3. Anti-emetics may be administered if nausea persists.

4. I & O are measured and described carefully.

5. Pt. must understand how to splint the abdomen

for post op coughing, turning and deep breathing.
Will you survive?

 Prognosis is usually excellent with prompt

treatment.

 Laparoscopic surgery has decreased the

number of complications.

 Prognosis is NOT favorable for those who

develop pancreatitis. 
Gallbladder and Biliary
Tract Disease
Cholelithiasis
Cholelithiasis

Cholelithiasis is the pathologic state of stones or

calculi within the gallbladder lumen.

A common digestive disorder worldwide:

• 20 million Americans have gallstones
• 700,000 cholecystectomys performed annually in the U.S.
• Most common gastrointestinal disorder requiring
hospitalization
Cholelithiasis
Most gallstones are composed primarily of bile (80%);
remainder are composed of a mixture of bile components
Each type of stone has a particular pathophysiology and
specific set of risk factors that alter the equilibrium and
solubility of the components of bile.

Cholesterol stones Pigment stones

Cholelithiasis
Asymptomatic gallstone patients develop complications at an
annual rate of 1-2%.
In symptomatic patients, the complication rate increases to 3%.

Manifestations of cholelithiasis:
• Many persons are asymptomatic
• Early symptoms are epigastic fullness after meals or mild
distress
• Biliary colic (if stone is blocking cystic or common bile duct):
steady pain in epigastric or RUQ of abdomen lasting up to 5
hours with nausea and vomiting
• Jaundice may occur if there is obstruction of common bile duct
 Cholelithiasis
Sonography is the procedure of choice for identifying
gallstones.
• Current high-resolution, real-time ultrasound (US) can identify
gallstones as small as 2 mm, with a sensitivity greater than 95%.
• The technique is rapid, noninvasive, can be performed at the bedside,
and does not involve ionizing radiation.

Ultrasonic Criteria for Cholelithiasis

• Intraluminal brightly echogenic structure
• Stones > 3mm will produce an acoustic shadow
• Stones will usually seek gravitational dependency
 Care of the Client with
Disorders of the Gallbladder
Gallbladder Disease

 Two main disorders:

 Cholecystitis
 Cholelithiasis
Risk factors for GB disease

 Higher in women:
multiparous, over 40, on estrogen therapy
 Sedentary lifestyle
 Familial tendency
 Obesity
Etiology of Cholecystitis

 Acute :
- Calculous: with stone obstruction
- Acalculous: absence of stones
 Chronic:
- Repeated attacks, long standing
inflammation
Pathophysiology of Cholecystitis

 Obstruction leads to ischemia of GB

mucosa or wall
 Inflammation may follow: GB is
edematous during acute attack or
distended with bile or pus
 Cystic duct may be occluded
 GB becomes scarred
Clinical Manifestations of
Acute vs Chronic Cholecystitis
Which are acute signs; which are chronic?

 ________  _______
 Usually begins with a  Dull ache
biliary colic attack
 History of fat
 RUQ pain
intolerance
 N/V
 Usually signs of acute  Dyspepsia
inflammation  Increased flatulence
 Possible pus
formationgangreno
us
Cholelithiasis

 Calculi (stones) in the GB

 May obstruct the cystic or CBD
 Choledocholithiasis: stones in the CBD
 Types:
Composed primarily of pigment
Composed primarily of cholesterol
Pathophysiology of Cholelithiasis

 Develops when the balance that keeps

cholesterol, bile salts and calcium is
altered causing precipitation of these
substances
 Conditions affecting balance: infection and
altered metabolism of cholesterol
 Bile in GB and liver become saturated with
cholesterol
Cholesterol vs Pigment Stones
Which is which & which is more common?

 ______________  _____________
 4x more prevalent in  made of other bile
women components (bile
 formation incidence salts, bilirubin, Ca,
increased in use of oral protein)
 undissolvable;
contraceptives, estrogens
requires surgery
 increased risk in:
cirrhosis, hemolysis,
biliary tree infections
Cholesterol stones 1
Cholesterol stones 2
Pigment stones
What Are Gallstones?

 Small, pebble-like
substances
 Multiple or solitary
 May occur
anywhere within
the biliary tree
 Have different
appearance -
depending on their
contents
Pigment Stones
 Small
 Friable
 Irregular
 Dark
 Made of bilirubin and
calcium salts
 Less than 20% of
cholesterol
 Risk factors:
• Haemolysis
• Liver cirrhosis
• Biliary tract infections
• Ileal resection
Cholesterol Stones
 Large
 Often solitary
 Yellow, white or green
 Made primarily of
cholesterol (>70%)
 Risk factors:
• 4 “F” :
 Female
 Forty
 Fertile
 Fat
• Fair (5th “F” - more
prevalent in Caucasians)
• Family history (6th “F”)
 Mixed Stones

 Multiple
 Faceted
 Consist of:
• Calcium salts
• Pigment
• Cholesterol (30% - 70%)
 80% - associated with chronic cholecystitis
Gallstone Prevalence

 10% of people over 40 yrs.

 90% “silent stones”

 Risk factors for becoming symptomatic:

• Smoking
• Parity
Risk Factors
Women

Age > 60 years

American Indians & Mexican Americans

Overweight or obese men and women

People who tend to fast or lose weight quickly
Family history of gallstones

Diabetes
Diet high in cholesterol
Use of OCPs
Pregnancy
Murphy’s Sign: Inspiratory arrest with manual pressure below the gallbladder
 Complications Of Gallstones

 In the GB:
• Biliary colic
• Acute and chronic
cholecystitis
• Empyema
• Mucocoele
• Carcinoma
 In the bile ducts:
• Obstructive jaundice
• Pancreatitis
• Cholangitis
 In the gut:
• Gallstone ileus
Clinical Manifestations of
Cholelithiasis
 “Silent cholelithiasis”
 Pain and biliary colic
 Sx RT bile obstruction
such as jaundice, pruritus,
changes in color of stool
and urine, vitamin
deficiency, bleeding,
steatorrhea
Diagnostic Studies
 History & physical examination
 Would these laboratory tests show
increased or decreased levels?
* Liver function tests
* WBC count
* Serum bilirubin
* Serum amylase
Diagnostic Tests

 Abdominal x-rays
 Ultrasonography – most accurate
 HIDA scan
 Endoscopic retrograde
cholangiopancreatography (ERCP)
 Percutaneous transhepatic
cholangiography
Treatment & Nursing Care
Acute episodes focus on
* Pain control –
- Morphine
- Dilaudid (hydromorphone)
- Ketorolac (Toradol)
- Demerol (Meperidine)
- NSAIDS, anticholinergics
* Infection Control - antibiotics
 Treatment & Nursing Care
continued
 *Fluid and electrolyte balance
- IV fluid
- Antiemetics :
Metoclopramide (Reglan)
Ondansentron (Zofran)
Prochlorperazine (Compazine)
 Gastric Decompression – NGT, NPO

*How/what would you monitor to maintain F & E

balance?
Treatment and Nursing Care
Once attack is over maintain on
 _____ fat diet
 _________ forming foods
 Avoid eggs, whole milk products,
cheese,
ice cream, fried foods, rich foods,
alcohol
 Reduced _______ diet if obese
Treatment & Nursing Care:
Supportive Drug Therapy

* Fat soluble vitamin replacement:

A,D,E,K
* Bile salts: Ex: Decholin; enhance fat
absorption
* Bile acids: Exs: Questran and
Cholestid;
bind bile salts and treat pruritus
Treatment and Nursing Care:
Non Surgical Stone Approaches for
Stone Removal

* endoscopic sphincterotomy (papillotomy)

* mechanical lithotripsy
* cholesterol solvents
* extracorporeal shock wave lithotripsy
Laparoscopic vs Open
Cholestectomy
T tube
Treatment and Nursing Care:
Surgical
Transhepatic
biliary catheter
* to decompress
obstructed
extrahepatic
ducts
Nutrition Guidelines for Management of Gallbladder Disease

 The role of the gallbladder is to store bile, which is made by the liver. Bile helps digest and
break down fat. Gallstones are made when the cholesterol in bile forms hard stones.

 Your risk for developing gallbladder disease may increase if you:

o are a woman, are over the age of 60, take cholesterol-lowering medications, are
pregnant, take hormone replacement therapy, take birth control pills, are overweight,
have diabetes, have lost weight very quickly, fast (go without eating for long periods
of time), are aboriginal.

 It is important to know that there is no specific diet or food that has been proven to prevent
gallbladder disease. The following suggestions may help:

o Eat a healthy diet following Canada’s Food

Guide. www.healthcanada.gc.ca/foodguide

o Eat a diet high in fibre including fruits and vegetables (at least 7 or more servings a
day) and whole grain products (whole wheat bread, pastas, rice, crackers).

o Limit refined sugar such as sweetened beverages (pop, juice, juice beverages), candy,
sweet desserts and foods with added sugar (such as flavoured yogurts, condiments
etc.).
 o Try eating a small portion of nuts a few times a week. Eating 140 g (1 cup) of nuts per
week is associated with a reduced risk of gallstone disease and gallbladder removal
(cholecystectomy). If you are trying to lose weight, do not consume too many nuts as
they are high in calories.

o Choose lower fat dairy products such as 1% MF (milk fat) milk, 2% or less MF yogurt,
20% MF cheese, low fat sour cream, low fat cream cheese.

o Choose leaner meats and poultry. Remove the skin and excess fat from poultry and
meat. Avoid marbled red meats. Choose leaner ground meats. Try meat alternatives
such as lentils, chickpeas, beans and tofu.

o Choose cooking methods such as barbequing, baking, broiling and grilling more often
than frying foods.

o Research shows that following a severely fat restricted diet is inappropriate for the
treatment of gallstones. It is encouraged to consume a healthy diet with moderate
amounts of fat: 20-30% of calories from fat. This equals about 30-45ml or 2-3 tbsp
of fat each day. Use healthy fats such as non-hydrogenated margarine, canola oil,
olive oil, soybean oils, mayonnaise, and salad dressings made with healthy oil. A diet
too low in fat may actually lead to gallstone formation secondary to inadequate bile
production.

o Limit caffeinated beverages to three 8 oz (250 ml) cups per day. This includes coffee,
tea, cola beverages.

o Limit alcohol containing beverages to 1 drink per day (150 ml/ 5 oz wine, 360 ml/ 12
oz beer, 45 ml/ 1.5 oz hard liquor).

 Diet modifications may not offer any advantages for gallbladder disease before surgery as
the passage of gallstones into the ducts is a random event unrelated to the type of food.

 If you have your gallbladder removed, there is no evidence to support the need for a fat-
restricted diet after surgery. The digestion of fat should not be an issue for patients
following gallbladder removal and a normal diet should be tolerated soon after surgery.
Sample Menu:

Breakfast:
¾ cup of whole grain cereal
1 cup of low fat milk (1% MF)
1 slice of whole wheat toast
1 tsp of non-hydrogenated
margarine
1 piece of fruit (or ½ cup)
Tea or coffee or herbal tea

Lunch:
1 cup vegetable soup
1 whole grain pita with 1 ½ oz leftover meat or canned tuna, with lettuce, tomato (any vegetables
you want) and 1 tbsp of mayonnaise or salad dressing
1 low fat yogurt (2% MF)
Glass water
1 piece of fruit (of ½
cup)

Afternoon snack:
1 banana with 1 tbsp of
peanut butter

Supper:
2 ½ oz of lean meat, fish
or poultry
1 cup of brown rice or pasta or 1 medium potato
Vegetables (enough to cover half of your plate)
1 cup of low fat milk (1% MF)
Allow for 2 tsp of oil or margarine in cooking or
for salad dressing

Evening snack:
3 cups of popcorn with 1 tsp of non-
hydrogenated margarine
Please call your doctor or Registered Dietitian if you have any questions or concerns.
*Total fat intake equal to 7 servings
Registered Dietitian: _

Phone Number:
Treatment and Nursing Care: Post
Op Care &Teachings

 Pain Control
 Prevent
Complications
primarily
pulmonary
 Wound Care
 Dietary
modification
Gerontologic considerations

 Gallstones increasingly common

 Differing presenting symptoms
 Surgical risks due to concurrent conditions
 Decreased elective surgery and more
advanced status at time of surgery
 Higher risk of complications and shorter
hospital stays
Gallbladder Cancer

 Uncommon
 Majority are adenocarcinomas
 Early symptoms similar to chronic
cholecystitis and cholelithiasis
 Later symptoms of biliary obstruction
 Poor prognosis
Gallbladder Cancer

 Diagnosis and staging – EUS,

transabdominal US, CT, MRI, MRCP
 If found early – surgery is curative
 Extended cholestectomy with lymph node
dissection – good outcome
 Palliative – stenting of biliary tree,
radiation, chemotherapy
Gallbladder Cancer

 Nursing Management - supportive care

 Nutrition, hydration, skin care, pain relief
 Similar to care for cholecystitis and
cholelithiasis and cancer
Now that’s just scary. ö
I’ll leave you with these. 

Eww!
  
Gerard Danielle K. Sio MD, MOH, FPCOM, PAFP, PAPSHI, CSSBB
Occupational Environmental Health and Safety Systems Operations Policies
Programs Consultant
IT IS AN Industrial Hygiene and Ergonomics Consultant
Certified Six Sigma Black Belt and PMP Holder
OUTSTANDING Certified Professional Life Coach
DAY TO SAVE ACCREDITED AND CERTIFIED OSH CONSULTANT AND WORKPLACE
LIVES HEALTH INDUSTRY EXPERT
Workplace Stakeholders, Government and Private Institutions RESOURCE
SPEAKER
Member, Various expert panels for workplace health and COVID 19
Member, International Commission on Occupational Health
09171339219
https://www.linkedin.com/in/gerard-sio-md-moh-dpcom-pafp-papshi-oshcon-c
ssbb-87402695
doc.gerry.osh@gmail.com
https://www.facebook.com/ekonsultamokaydocgerry/
Health, Safety, Environment, Quality, Dating, Relationship,
Wellness and Motivational Coach
Contributor: DOH Workplace Handbook, Unified Medical Algorithms for COVID
19
HAVE A Member, Philippine Hepatitis B Clinical Practice Guidelines Consensus Panel
Member, Philippine Periodic Health Examination Phase III PHEX 3 Infectious
GREAT DAY Disease Task Force Clinical Practice Guidelines Consensus Panel
AHEAD! Member, Philippine Obesity and Overweight Clinical Practice Guidelines
Consensus Panel
Philippine and International Speaker
Juris Doctor Program (ongoing)
International Masters Degree in Business Administration and International
Master of Arts in Law(ongoing)