Cholelithiasis RL

8/7/2019 Cholelithiasis RL

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Related literaturesRelated literatures


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CHOLELITHIASISCHOLELITHIASIS

The presence of stones or calculi (gallstones) in the gallbladderresults from changes in bile components.

Gallstones are made of cholesterol, calcium bilirubinate, or amixture of cholesterol and bilirubin pigment.

They arise during periods of sluggishness in the gallbladderresulting from pregnancy, use of oral contraceptives, diabetesmellitus, Crohns disease, cirrhosis of the liver, pancreatitis, obesity,and rapid weight loss.

Fifth leading cause of hospitalization among adults and accounts for90% of all gallbladder and duct diseases.


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CholecystitisCholecystitis

An acute or chronic inflammation of theAn acute or chronic inflammation of thegallbladder, is usually associated with agallbladder, is usually associated with agallstone impacted in the cystic duct; thegallstone impacted in the cystic duct; theinflammation develops behind the obstruction.inflammation develops behind the obstruction.

CholecystitisCholecystitis accounts for 10% to 25% of allaccounts for 10% to 25% of allpatients requiring gallbladder surgery.patients requiring gallbladder surgery.

The acute form is most common during middleThe acute form is most common during middleage; the chronic form, among elderly people.age; the chronic form, among elderly people.The prognosis is good with treatment.The prognosis is good with treatment.


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ComplicationsComplications

CholelithiasisCholelithiasis may lead to any of the disorders associatedmay lead to any of the disorders associatedwith gallstone formation:with gallstone formation:

cholangitischolangitis,, cholecystitischolecystitis,, choledocholithiasischoledocholithiasis, or, orgallstonegallstone ileusileus..

CholecystitisCholecystitis can progress to gallbladder complications:can progress to gallbladder complications:

empyemaempyema,, hydropshydrops oror mucocelemucocele, or gangrene., or gangrene.

Gangrene may lead to perforation, resulting inGangrene may lead to perforation, resulting inperitonitis, fistula formation, pancreatitis, limy bile, andperitonitis, fistula formation, pancreatitis, limy bile, andporcelain gallbladder.porcelain gallbladder.


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Signs and symptomsSigns and symptoms

Acute abdominal pain(RUQ)Acute abdominal pain(RUQ) Fat intoleranceFat intolerance BiliaryBiliary coliccolic BelchingBelching FlatulenceFlatulence IndigestionIndigestion DiaphoresisDiaphoresis Nausea and VomitingNausea and Vomiting

ChillsChills LowLow--grade fevergrade fever JaundiceJaundice


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Collaborative ManagementCollaborative Management

> Relief of pain> Relief of pain-- MeperidineMeperidine HclHcl (DOC)(DOC)

> Dont give Morphine Sulfate.> Dont give Morphine Sulfate.

> Diet: Low fat diet> Diet: Low fat diet

> Bile salts:> Bile salts: ChenooxycholicChenooxycholic acid;acid; ursodioxycholicursodioxycholic acid(UDCA)acid(UDCA)

>

Surgery:>

Surgery: CholecystectomyCholecystectomy> Pre op Care> Pre op Care Iv fluid electrolyteIv fluid electrolyte

DBCT exercise Vitamin K injectionDBCT exercise Vitamin K injection

>Post op Care>Post op Care Position. Low/ Semi fowlers positionPosition. Low/ Semi fowlers position

NGTNGT

DBCT exerciseDBCT exercise

Ambulation after 24 hours post opAmbulation after 24 hours post op If with CBD exploration: TIf with CBD exploration: T--tubetube

Purpose: To drain bilePurpose: To drain bile

DrainageDrainage


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Removalof the Gallbladder?Removalof the Gallbladder?

In some cases, the gallbladder must beIn some cases, the gallbladder must beremoved. The surgery to remove the gallbladderremoved. The surgery to remove the gallbladder

is called ais called a cholecystectomycholecystectomy (pronounced co(pronounced co--leelee--sistsist--eckeck--toetoe--meemee). In a). In a cholecystectomycholecystectomy, the, thegallbladder is removed through a 5gallbladder is removed through a 5-- to 8to 8--inchinchlong cut in your abdomen.long cut in your abdomen.

Once the gallbladder is removed, bile isOnce the gallbladder is removed, bile isdelivered directly from the liver ducts to thedelivered directly from the liver ducts to theupper part of the intestine.upper part of the intestine.


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DiagnosisDiagnosisUltrasonographyUltrasonography and Xand X--rays detect gallstones. Specificrays detect gallstones. Specific

procedures include the following:procedures include the following:

UltrasonographyUltrasonography PercutaneousPercutaneous transhepatictranshepatic cholangiographycholangiography Endoscopic retrogradeEndoscopic retrograde cholangiopancreatographycholangiopancreatography

HepatobiliaryHepatobiliary iminodiaceticiminodiacetic acid analogue scanacid analogue scan Computed tomography scanComputed tomography scan Plain abdominal XPlain abdominal X--raysrays OralOral cholecystographycholecystography

ElevatedElevated ictericicteric index and elevated totalindex and elevated total bilirubinbilirubin, urine, urinebilirubinbilirubin, and alkaline, and alkaline phosphatasephosphatase levels support thelevels support thediagnosis. White blood cell count is slightly elevateddiagnosis. White blood cell count is slightly elevatedduring aduring a cholecystitischolecystitis attack.attack.


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ANATOMYANATOMY

&&PHYSIOLOGYPHYSIOLOGY


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Located in right hypochondriacLocated in right hypochondriacregion.region.

It is a pearIt is a pear--shaped sac from 7shaped sac from 7--

10cm long and 3cm broad at its10cm long and 3cm broad at itswidest point. Can hold 30widest point. Can hold 30--50 ml of50 ml ofbile.bile.

Divided into four anatomicDivided into four anatomic

portions: the fundus, the corpusportions: the fundus, the corpusor body, infundibulum, and theor body, infundibulum, and theneck.neck.


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Fundus is the rounded, blind endFundus is the rounded, blind end

Normally extends beyond the liver'sNormally extends beyond the liver's

marginmargin It may be unusually kinked andIt may be unusually kinked andpresent the appearance of apresent the appearance of aphrygian cap.phrygian cap.

It contains most of the smoothIt contains most of the smoothmuscle of the organmuscle of the organ


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Corpus or body, which is the majorCorpus or body, which is the majorstorage area and contains most of thestorage area and contains most of the

elastic tissue.elastic tissue. The body tapers into the neck, which isThe body tapers into the neck, which isfunnelfunnel--shaped and connects with theshaped and connects with thecystic duct.cystic duct.

The neck usually follows a gentle curve,The neck usually follows a gentle curve,the convexity of which may be distendedthe convexity of which may be distendedinto a dilatation known as theinto a dilatation known as the

infundibulum, or Hartmann's pouch.infundibulum, or Hartmann's pouch.


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The Gallbladder is aThe Gallbladder is asmall, pearsmall, pear--shaped organshaped organin the abdomen.in the abdomen. Its jobIts job

is to store and releaseis to store and releasebile, a fluid made by thebile, a fluid made by theliver.liver. Bile helps breakBile helps breakdown fats in the food youdown fats in the food you

eat.eat.


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Your liver makes bile.Your liver makes bile. Most of the bile isMost of the bile is

sent through asent through a

network of ducts tonetwork of ducts tothe duodenum (firstthe duodenum (firstpart of the smallpart of the smallintestine).intestine). A smallA small

amount of bile is alsoamount of bile is alsosent to thesent to thegallbladder forgallbladder forstorage.storage.


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COMPONENTS:COMPONENTS:

BILE SALTSBILE SALTS, (formed in the liver from, (formed in the liver fromcholesterol) are the most essential part ofcholesterol) are the most essential part of

bile.bile. BILEBILE PIGMENTSPIGMENTS--The pigment bilirubinThe pigment bilirubin

(red) and biliverdin (green), derived from(red) and biliverdin (green), derived fromhemoglobin, give bile its greenish colorhemoglobin, give bile its greenish color

because it secretes bile into ducts.because it secretes bile into ducts. CHOLESTEROLCHOLESTEROL PHOSPHOLIPIDSPHOSPHOLIPIDS


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FUNCTIONS OF BILEFUNCTIONS OF BILE

1.1. It breaks down the fatsIt breaks down the fatsthat you eat so that yourthat you eat so that yourbody can utilize them.body can utilize them.

2.2. Bile is a very powerfulBile is a very powerfulantioxidant which helps toantioxidant which helps toremove toxins from theremove toxins from the

liver.liver.


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The gallbladder storesThe gallbladder storessome bile.some bile. TheThegallbladdergallbladderconcentrates the bileconcentrates the bile

by removing theby removing thewater.water. When bile isWhen bile isneeded to digest fats,needed to digest fats,hormones (chemicalhormones (chemical

messengers) signal themessengers) signal thegallbladder to squeezegallbladder to squeezebile out through thebile out through thecystic duct.cystic duct.


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Bile is sent to theBile is sent to the

duodenum. The bileduodenum. The bilemoves through themoves through thecommon bile duct to thecommon bile duct to theduodenum.duodenum. There, itThere, it

mixes with food.mixes with food. TheThepancreaspancreas adds otheradds otherdigestivedigestivejuices.juices. DigestionDigestioncontinues in the smallcontinues in the smallintestineintestine


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PATHOPHYSIOLOGYPATHOPHYSIOLOGY


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Predisposing FactorsPredisposing Factors JustificationJustification

Age (40 and above)Age (40 and above) Most internal functions decline as one ages. Inevitably resulting in organMost internal functions decline as one ages. Inevitably resulting in organdegeneration which also affects the body's metabolism of lipids.degeneration which also affects the body's metabolism of lipids.

GenderGender Gallstones is more frequent on women especially who had have had multipleGallstones is more frequent on women especially who had have had multiplepregnancies or who are taking oral contraceptives. Increase level of Estrogenpregnancies or who are taking oral contraceptives. Increase level of Estrogenreduces the synthesis of bile acid in women. Female sex hormones have longreduces the synthesis of bile acid in women. Female sex hormones have longbeen suspected to have a side effect of gallstone formationbeen suspected to have a side effect of gallstone formation by alteringby alteringrespective bile constituents (mainly the FAT metabolism).respective bile constituents (mainly the FAT metabolism).

Ileal Disease/ResectionIleal Disease/Resection People who have disease of the terminal ileum or who have undergone resectionPeople who have disease of the terminal ileum or who have undergone resectionof the terminal ileum deplete their bile salt pool and run a greater risk ofof the terminal ileum deplete their bile salt pool and run a greater risk ofdeveloping cholesterol gallstones.developing cholesterol gallstones.

RaceRace Cholesterol stones are common in Northern Europe and in North and SouthCholesterol stones are common in Northern Europe and in North and SouthAmerica.America.

GeneticsGenetics Most clinicians have an impression that gallbladder disease characterizes someMost clinicians have an impression that gallbladder disease characterizes somefamilies. Indeed, the younger sisters of women with gallstone prove to havefamilies. Indeed, the younger sisters of women with gallstone prove to havebile more highly saturated with cholesterol than the younger sisters ofbile more highly saturated with cholesterol than the younger sisters ofwomen without gallstones, all of which suggests that Cholelithiasis does runwomen without gallstones, all of which suggests that Cholelithiasis does runin families.in families.

Inflammation andInflammation andinfection of theinfection of thegallbladdergallbladder--

Inflammation or infection in the biliary structures may provide a focus for stoneInflammation or infection in the biliary structures may provide a focus for stoneformation or may alter the solubility of the constituents, fostering theformation or may alter the solubility of the constituents, fostering thedevelopment of a stone.development of a stone.

Hemolytic Disease andHemolytic Disease andHepatic CirrhosisHepatic Cirrhosis

In cirrhosis, at least two fifths of patients have gallstones. One possibleIn cirrhosis, at least two fifths of patients have gallstones. One possiblemechanism behind the appearance of pigment softness, so far unproven, ismechanism behind the appearance of pigment softness, so far unproven, isthe excretion of unconjugated bilirubin directly into the bile, something thatthe excretion of unconjugated bilirubin directly into the bile, something thatmight happen in patient with hemolysis or in the cirrhotic with his highmight happen in patient with hemolysis or in the cirrhotic with his highincidence of pigment stones, currently estimated at 27 %.incidence of pigment stones, currently estimated at 27 %.

Bile stasisBile stasis Brown pigment gallstones form when there is stasis of bile (decreased flow), forBrown pigment gallstones form when there is stasis of bile (decreased flow), forexample, when there are narrow, obstructed bile ducts.example, when there are narrow, obstructed bile ducts.


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PrecipitatingPrecipitatingFactorsFactors

JustificationJustification

Faulty DietFaulty Diet Excessive intake of high fat or cholesterol food such as pork meat, animal skin (e.g. chicharonExcessive intake of high fat or cholesterol food such as pork meat, animal skin (e.g. chicharonand chicken skin) can result to an increase in cholesterol level in the body, making it hardand chicken skin) can result to an increase in cholesterol level in the body, making it hardfor the liver to make bile enough to metabolized the all cholesterol present. Excessfor the liver to make bile enough to metabolized the all cholesterol present. Excesscholesterol present builds up and increases the cholesterol serum level. Normal Livercholesterol present builds up and increases the cholesterol serum level. Normal Liver

function would then try to compensate and excrete excess cholesterol to the bilefunction would then try to compensate and excrete excess cholesterol to the bile plus theplus thebody would reabsorb water from the bile making it more concentrated. Supersaturation ofbody would reabsorb water from the bile making it more concentrated. Supersaturation ofCholesterol along with other constituents of the bile (bilirubin, lecithin etc.) builds upCholesterol along with other constituents of the bile (bilirubin, lecithin etc.) builds upmicrocrystals. When microcrystals aggregate it would result to Gallstones.microcrystals. When microcrystals aggregate it would result to Gallstones.

Weight LossWeight Loss Weight loss is associated with an increased risk of gallstones because weight loss increases bileWeight loss is associated with an increased risk of gallstones because weight loss increases bilecholesterol supersaturation, enhances cholesterol crystal nucleation, and decreasescholesterol supersaturation, enhances cholesterol crystal nucleation, and decreasesgallbladder contractility.gallbladder contractility.

ObesityObesity Obesity is a major risk factor for gallstones, especially in women. A large clinical study showedObesity is a major risk factor for gallstones, especially in women. A large clinical study showedthat being even moderately overweight increases the risk for developing gallstones. Thethat being even moderately overweight increases the risk for developing gallstones. Themost likely reason is that obesity tends to reduce the amount of bile salts in bile, resultingmost likely reason is that obesity tends to reduce the amount of bile salts in bile, resultingin more cholesterol. Obesity also decreases gallbladder emptying.in more cholesterol. Obesity also decreases gallbladder emptying.

PregnancyPregnancy Altered physiology of the biliary system during pregnancy may play a role in accelerating theAltered physiology of the biliary system during pregnancy may play a role in accelerating theformation of stones in susceptible women.formation of stones in susceptible women.

Treatment with estrogen/Treatment with estrogen/contraceptivescontraceptives

The contraceptive pill not only promotes thromobphlebitis but points to an endocrineThe contraceptive pill not only promotes thromobphlebitis but points to an endocrinebackground of gallstones by the risk of gallstones in young women taking the pill. This isbackground of gallstones by the risk of gallstones in young women taking the pill. This islargely as a result of increased cholesterol secretion into the bile and a decrease inlargely as a result of increased cholesterol secretion into the bile and a decrease inchenodeoxycholic acid content, along with impaired emptying of the gallbladderchenodeoxycholic acid content, along with impaired emptying of the gallbladder broughtbroughtabout by estrogen.about by estrogen.

Frequent Starvation andFrequent Starvation and

ProlongedProlongedparenteral nutritionparenteral nutrition

Starvation decreases gallbladder movement causing the bile to become overconcentrated withStarvation decreases gallbladder movement causing the bile to become overconcentrated with

cholesterol. The liver also secretes extra cholesterol into bile adding to the supersaturationcholesterol. The liver also secretes extra cholesterol into bile adding to the supersaturationcausing stone formation. Also, fasting persons have a diminished bile salt pool andcausing stone formation. Also, fasting persons have a diminished bile salt pool andlithogenic bile.Gallbladder stasis plays a key role in permitting stone formation. Defectivelithogenic bile.Gallbladder stasis plays a key role in permitting stone formation. Defectiveor infrequent gallbladder emptying occurs in the settings of prolonged fasting, rapid weightor infrequent gallbladder emptying occurs in the settings of prolonged fasting, rapid weightloss, pregnancy, and spinal cord injury.loss, pregnancy, and spinal cord injury.

Clofibrate use and otherClofibrate use and otherAntilipemic drugsAntilipemic drugs

Drugs that lower the serum level of cholesterol, notably clofibrate, are associated with anDrugs that lower the serum level of cholesterol, notably clofibrate, are associated with anincreased incidence of gallstones. Clofibrate presumably increases the secretion ofincreased incidence of gallstones. Clofibrate presumably increases the secretion ofcholesterol into the bile and apparently also decreases bile acid synthesis, so increasing thecholesterol into the bile and apparently also decreases bile acid synthesis, so increasing thecholesterol saturation of the bile. Clinical reflection of these physiologic abnormalities hascholesterol saturation of the bile. Clinical reflection of these physiologic abnormalities hasbeen found in the overwhelming association between clofibrate therapy and gallstones.been found in the overwhelming association between clofibrate therapy and gallstones.


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Middle age (female > male before age 50),obesity, infection, pregnancy, hormonalcontraceptive, celiac disease. Cirrhosis,

pancreatitis, diabetes mellitus

CholelithiasisRefers to the formation of calculi

(e.g. gallstones in the gallbladder)

Major constituents are cholesterol andpigment

Cholecystectomy

Removal of thegallbladder afterligation of the

cystic duct

Gallstone in bileduct

Bile stasis

Body will return tonormal function

Recovery

Bile accumulatesin the liver

Cholestatic

Biliarycirrhosis

Bacterialproliferation

Gallbladder andduct infection

Rupture ofgallbladder

Cholecystitisif

Peritonitis Death

Abnormal fatdigestion

Diarrhea

Pain Fever Nausea andvomiting

Gastric irritation

There is restlessnessand Increase in RR,temp, PR and WBC

values

Jaundice

Increasebilirubin

There is inflammationdue to infection

If not treated

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