CHOLECYSTITIS and cholelithiasis in .pdf

It explains on cholecystitis and how itgoes about

1. CHOLECYSTITIS AND
CHOLELITHIASIS
BY A.C MBULO

2. Introduction
Disordersofgallbladderandductsareextremelycommon
Itsmorecommonlyaffectpeopleofsedentarylifestyleandobesity.
Epidemiology
Inusaaloneitisestimatedthat20millionpeoplehavegallstoneswith
onemillionnewcasesdevelopingeachyear.
About98%ofclientswhopresentwithsymptomaticgallbladderdisease
havegallstones

3. Definition of terms
Cholecystitis:isaninflammationofthegallbladderwallandnearby
abdominallining.
Cholelithiasis:meansastoneinthegallbladderoragallstone
Cholecystectomy:Surgicalremovalofthegallbladder
Cholecystotomy:Anincisioninthegallbladderusuallywithinsertion
ofatubefordrainage

4. Choledocholithiasis:Astoneinthebiliarytract
Choledochitis:Inflammationofthecommonbileduct.
Choledolithotomy:Surgicalremovalofthestonefromthecommon
bileduct

5. The Biliary Tree

6. COMMON BILEDUCT-7-10CMINLENGTHpearshapesac
-6-8MMINDIAMETER
Joinsthemajorpancreaticductinthewallofthe2
nd
partofduodenum
toformtheAmpullaofvater
Intra-duodenalpartofCBDissoroundedbysmoothmusclefibers
calledasSphincterofOddi

7. Dailyupto1000mlofbileissecretedfromtheliver
Containswater98percent
Theremainingisbilesalts,bilepigments,fattyacids,lecithin,cholesterol,
(electrolytes)sodium,potassium,chloride,bicarbonate,calcium,magnesium
Conjugatedbilirubin.
Phmorethan7.0
Gallbladderfunctionistoconcentrateandstorethebile
Capacityis30-50mlwhenobstructed300ml.
Bilesaltsformmicellewhichmakescholesterolsoluble.

8. PHYSIOLOGY OF GALL BLADDER
Thesmoothmusclesinthegallbladderwallcontractleadingtothebile
beingsecretedintotheduodenumtoridthebodyofwastestoredinthe
bileaswellasaidintheabsorptionofdietaryfatbysolubilizingthem
usingbileacids

10. CHOLELITHIASIS.
Thepresenceofgallstonesinthegallbladder.
Gallstonesarecollectionsofcholesterolbilepigmentoracombinationofthetwo
,whichcanforminthegallbladderorwithinthebileductsoftheliver.
TYPES
1.Cholestrolstone
-cholestralsolitaire-radiatingcrystallineappearance
-mostcommontype
-oftensolitary
-smoothandwhitish,yellowtotancolour,

11. 2.Mixed stones
-contains cholesterol,calciumsalts of
phosphate,catbonate,proteins,palmitateand are multiple faceted
3.Pigment stones
-small,blackor greenish black
-multiple
-often they can be sludge like

12. Causes
-change in bile composition
1.Gallblader stasis
2.Supersaturation of bile with cholesterol
3.Infection and tissue injury
4.genetics

13. Commoninpeoplewhoare(thepersonmostatrisk)
1.Female
2.Fat
3.fertile
4.Forty
5.Fair
6.Flatulent

14. Riskfactorsforcholelithiasiscont…
1.Age65andabove.
2.Familyhistoryofgallstones.
3.Obesity,hyperlipidaemia.
4.Rapidweightloss.
5.Femalegender;useoforalcontraceptives.
6.Biliarystasis,pregnancy,fasting,prolongedparenteralnutrition.
7.Diseasesorconditionsoftheliver;livercirrhosis,diseasesorresection.
8.Sicklecellanaemia.

15. Pathophysiology
1.Supersaturationofbilewithcholesterolorcalcium
2.Precipitationofsolutefromsolventtoformsolidcrystals
3.Crystalscometogetherandfusetoformstones
4.Venousandlymphanticdrainageimpaired
5.Proliferationofbacteriaoccur
6.Localisedcellularirritationinfiltration
7.Ischemiaandnecrosis

16. S/S
1.Complainofindigestionaftereatinghighfatfoods
2.Locarizedpainintheright–upperquadrantepigastricregion
3.Increasedheartandrespiratoryrate–causingpatienttobecome
diaphoreticwhichmakepatientthinktheyarehavingheartattack.
4.Lowgradefever

17. 5.Elevatedleucocytecount
6.Mildjaundice
7.Steotorrhea;stoolsthatcontainfat
8.Claycoloredstoolcausedbyalackofbileintheintestinaltract.
9.Urinemaybedarkambertoteacolored.

18. Diagnostic tests
1.History of patient
2.Physical examinations
3.Lab tests for;
-elevated conjugated bilirubin
-elevated alkalinephosphate
-serum amylase and lipase
-elevated WBC Count

19. 4.Fecalstudies
5.Gallbladerultrasound
6.CTscan
7.MRI
8.Cholangiography
9.HIDAhepato-iminodiaceticacid
10.ERCPendoscopicretrogradecholangiopancreatography

20. Medical management
Goals
1.To resolve symptoms
2.To remove stones
3.To prevent complications
1.Pain management
a. analgesics
-antiacids ,h2 blockers or proton pump inhibitors –to neutrolise gastric
acid
b.Antiemetics for nausea and vomiting.
c.Antibiotics

21. GALLSTONEDISSOLUTION
1.Oraladministrationofagents–chonodeoxycholicacidCDCAorchenodal
2.UrsodeoxycholicacidUDCAorursodiol
--action-reducestheamountofcholesterolinbile
3.Lithotripsy;shockwavesbreakstonesintopiecessmallenoughtopass
throughureter.
-extracorporealshockwavelithotripsyESWL1500Nshockwavesdirectedat
stones,usedforfewerthan4stoneseachsmallerthan3cm.
-ifstonesareincommonbileductanendoscopicsphincterotomymustbe
perfomedbeforecholecystectomyisdone.

22. Surgicalmanagement
1.Cholecystectomyorlaparoscopiccholecystectomy
-removalofthegallbladder
Thisisthetreatmentofchoice,thegallbladderalongwiththecysticduct,
veinandarteryareligated.

23. 2.Choledochostomy:Thisisasurgicalprocedureinwhichanincisionis
madeintothecommonbileductforremovalofstones.Aftertheremoval
ofstones,atubeisusuallyinsertedintotheductfordrainage.Thegall
bladderalsoasarulecontainsstonesandsocholecystostomyis
performed.

24. 3.Cholecystostomy:Thisisasurgicalprocedureinwhichanincisionis
madeonthegallbladderforpurposesofpus,stoneorbileremoval.This
isfollowedbyinsertionandsuturingatubesuturedintheopeningfor
drainage.Thisoperationisperformedwhenthepatient’scondition
preventsmoreextensivesurgeryorwhenanacuteinflammatoryreaction
obscuresthebiliarysystem.Asthepatientreturnstobed,thenurse
shouldconnectthetubetoadrainagebottleplacedatthesideofthebed.
Failuretodothismayresultintheleakageofbilearoundthetubeinits
escapeintotheperitonealcavity.

25. Complications
1.Infection
2.Hypostaticpneumonia
3.Atelectasis
4.Thrombophlebitis
5.Jaundice
6.Peritonitis
7.Ileus
8.Steatorrhoea

26. Nursing management
Assesment
-asses the general condition ofpatient
-asses pain of patient
-observe for bleeding

27. Nursingcare
1.Acutepainrelatedtosurgicalprocedure.
-assestheseverity,frequencyandcharacteristicsofpain.
-administerpainrelieversasprescribed
-providedivertionalactivitiessuchasreadingnewspapers
-monitorandrecordvitalsigns.
2.Impairedskinintegrityinvasionofbodystructure.
-monitorpuncturedsites3-5timesifendoscopicprocedureisdone.
-placepatientinloworsemi-fowler’sposition
-observethecolorandcharacterofthedrainage
-changethedressingsasoftenasnecessary

28. 3.Inefectivebreathingpatternduetopain
-observerespiratoryrate,depth
-auscultatebreathsounds
-assistpatienttoturn,coughanddeepbreatheperiodically
-showpatienthowtosplintincision.instructineffectivebreathing
techniques
-elevateheadofbed,maintainlowfowler’sposition
4.Riskfordeficientfluidvolumerelatedtosurgicalprocedure
-monitorvitals,assesmucousmembraines,skinturgor,peripheralpulses
andcapillaryrefill.
-monitorintakeandoutput,includingdrainagefromNGT,Ttubeand
woundweighp.tperiodically.
-observeforsignsofbleeding,hematemesis,malena,petechiae,ecchymosis.
-administerivfluids,bloodproducts,asindicated.

29. Cholecystitis
Thetwomostcommonproblemsthatoccurinthebiletreeare
cholelithiasisandcholecystitis
Cholecystitisasearliermentionedistheinflammationofthegallbladder
Thisinflammationcaneitherbeacuteorchronic

30. •Acutecholecystitis
Itisthesuddeninflammationofthegallbladder.
Itusuallydevelopsinassociationwithcholelithiasis,Bothoftheseconditions
mayoccursinglybutmostoftentheyoccurtogether.
Causes
-gallstoneincysticduct
-obstructionincysticduct
-bacterialinfectiongrampositiveandnegativeaerobesand
anaerobes.E.Coli,klebsiela,clostridiumandstreptococcus.

31. Risk factors
-sedentary life
-obesity
Pathophysiology
-due to etiological factors
-venous and lymphatic drainage impaired
-proliferation of bacteria takes place
-cellular irritation and inflammation
-acute cholecystitis

32. Acalculouscholecystitis
•Thisistheinflammationofthegallbladderwithoutagallstone
•Itisusuallyassociatedwithbiliarystasiscausedbyanyconditionthat
affectregularfillingoremptyingofthegallbladder.
•Forexampledecreasedbloodflowtothegallbladderoranastomotic
problemslikekinkingortwistingofthegallbladderneckorcysticduct

33. •Thiscanresultinpancreaticenzymesrefluxintothegallbladder
causinginflammation.
•Otherprecipitatingfactorsincludebacterialinfection,andobstructing
adenocarcinomaofthegallbladder.
Bacterialcausesofacutecholecystitisonly
•Escherichiacoli(mostcommon)
•Streptococci
•Salmonella

34. Calculouscholecystitis
•Inflammationofthegallbladderwithacalculus
•Thestonecreateinflammatoryresponse
•Theresponsemaybeduetomechanical,chemicalorbacterialprocess
•Thegallbladderisinflamedtrappedbileisisreabsorbedandactsasa
chemicalirritanttothegallbladderwall.

35. •Thepresenceofbileincombinationwithimpairedcirculation,edema
anddistentionofthegallbladdercausesischaemiaofthegallbladder
wall
•Theresultistissuesloughingwithnecrosisandgangrene
•Perforationofthegallbladderwallmayeventuallyoccur.
•Iftheperforationissmallandlocalized,anabscessmayform
•Iftheperforationislargeperitonitiswillfollw

36. Pathologicchanges
•Theexactpathophysiologyofgallstoneisnotknown,butabnormal
metabolismofcholesterolandbilesaltsplayanimportantroleinthere
formation
•Thecontributingfactorsinclude:
•Supersaturationofbilewithcholesterol
•Excessivebilelosses
•Decreasegallbladderemptyingrate
•Changesinbileconcentrationorbilestasiswithinthegallbladder

37. •Thegallstonemayliedormantinthewithinthegallbladderormoveto
otherareasofthebiliarytreeasthegallbladderrefillsandemptieswith
bile
•Thestonemaymigrateandlodgewithinthebladderneck,cysticductor
commonbileductcausingobstruction
•Thiswillleadtovascularcongestionasaresultofimpededvenous
return
•Whenbilecannotflowfromthegallbladder,thestasisofbileandlocal
irritationfromgallstoneleadstocholecystitis

38. •CholangitisusuallyassociatedwithCholedocholithiasisoccurafter
bacterialinversion
•whichcanleadtolifethreateningsuppurativecholangitiswhen
symptomsarenotrecognizedquicklyandpusaccumulateintheduct
system

39. s/s
-complain of pain
1.In right upper quadrant
2.In epigastricregion
3.In right subscapular
4.Onset sudden
5.Peak in 30min

40. 6.Nauseaandvomiting
7.Lowgradefever
8.Mildjaundice
9.Positivemurphy’ssign;askpatienttoexhaleplacehandbelowcostal
marginonrightsideatthemid-clavicularlinepatientinstructedtoinspire
(ifacutecholecystitisp.tstopesbreathinginandwinceswithacatchin
breath

41. Chroniccholecystitis
Thisusuallyfollowsrepeatedepisodesofcysticduct/gallbladder
infectionandobstructionresultinginchronicinflammation.
•Inthistypecalculusarealmostalwayspresent
•Inchroniccholecystitisthegallbladderbecomesfibroticandcontracts
whichresultsindecreasesmotilityanddeficientabsorption.
•Pancreatitisandcholangitiscanfollowascomplications
•Jaundiceisanothercomplicationduetoobstruction

42. Incidence
•More common in white than black people
•Sedentary lifestyle
•Tendency to run in families
•Obesity
•Diabetes
•Middle aged women

43. Sign and symptoms
•Episodes or vague pain in the right upper quadrant of the abdomen that
radiates to the right shoulder; Epigastric pain
•Pain is triggered by a high fat or high volume meal; Fat intolerance
•Anorexia
•Nausea and vomiting Dyspepsia
•Mild to moderate fever
•Heart burn

44. •AcuteabdominaltendernessandapositiveMurphy’ssigh(Palpationof
abdomencausingsevereincreaseinpainandtemporaryrespiratoryarrest)
•Patientmaywakeupatnightduetopain
•Jaundice
•Claycoloredstool
•Indigestion
•Inabilitytoconcentratebile
•Fibrosisofgalltissues

45. Diagnosis
•Classicalsignandsymptomspainintherightupperquadrantofthe
abdomenThatradiatetotheshoulderusuallyprecipitatedby
consumptionoffatdiet.PositiveMurphy’ssign
•Ultrasonographyisthebestdiagnostictestforcholecystitis
•Liverfunctiontestswillbealtered
•Calcifiedstonemaybeseenofabdominalscan
•MRImayalsobeveryusefulwhereavailable

46. Treatment
-goal;totreatsymptomaticcauses
-topreventcomplications
1.Pethidineforpain50-100mgbd(adults)
2.AntispasmodicsandanticholinergicsdrugslikeAtropineandprobanthline
(probanthline)
3.Ivantibiotictopreventortreatbacterialinfectionse.g.Gentamycin80mgtdsfor5/7
IVfluidssuchas5%dextrose1000ml/24hoursorampicillin,thirdgeneration
cephalosporins-ceftriaxone,cefixime,cefotaxime
Surgicalinterventionslikecholecystectomy,choledochostomy

47. Nursingcare
•Promoterecovery
•Promoterest
•Alleyanxiety
•Educate patient about his own condition
Relievepain
•Preparepatientforsurgerywhenindicated
•Offerpostoperativecare

48. •Applygeneralcarebutpayparticularattentiontotheareasmentionedintheaims
Postcholecystectomynursingcare
1.Administeroralanalgesicstofacilitatemovementanddeepbreathing-andto
stayaheadofptspain
2.Observedressingsfrequentlyforexudateandhemorrhage
3.Vitalsignsareroutinelychecked
4.Patientteachingmustunderstandhowtosplinttheabd,beforecoughing
-reportanyabnormalitiessuchasseverepain,tendenessinRUQ,Increasein
pulse,e.t.c
-instructthemtoreturntoworkin3daysandcanresumefullactivityin1week.

49. 5.Fluidbalanceismaintainedi.vpotassiumaddedtocompensateforloss
fromsurgery.
6.Administerdrugsandwatchreactions
7.Observeurineandstoolforalterations.
8.ObserveNGTCONTENTforcolor,consistency,amount
9.Antiemeticsmustbeadministeredifnauseapersists.
10.Observeinputandoutputanddocument.

50. •Conclusion
Biliary disorders are extremely common but diverse in nature.
Incidence rate of the disease is increasing day by day.
Teaching and awareness is vital in prevention and management of the
disease.