Cholecystitis And Cholelithiasis slideshare

Cholecystitis: It is defined as the inflammation of the Gall Bladder.

Cholelithiasis: Stones in the Gall Bladder specially seen in the neck of the Gall Bladder or the cystic duct.
Most important for in GI system.

1. CHOLECYSTITIS AND CHOLELITHIASIS MS. VEDANTI PATEL ASSI. PROFESSOR

2. INTRODUCTION: The most common disorder of biliary tract is Cholelithiasis that is stones of the Gall Bladder. Cholecystitis is usually associated with cholelithiasis. The stones may be lodged in the neck of the Gall Bladder or in the cystic duct. Cholecystitis may be acute or chronic. These conditions usually occur together.

3. DEFINITION: Cholecystitis: It is defined as the inflammation of the Gall Bladder. Cholelithiasis: Stones in the Gall Bladder specially seen in the neck of the Gall Bladder or the cystic duct.

4. CHOLECYSTITIS

5. COMMON RISK FACTORS: Incidence is higher in women , multiparous women and persons over 40 years of age. Postmenopausal women on estrogen therapy are at somewhat greater risk of having gall bladder disease. Sedentary Life style Familial Tendency Obesity

6. CHOLECYSTITIS: Cholecystitis is mostly associated with obstruction caused by gallstones or biliary sludge . Acalculous cholecystitis is most often in older adults, and in patients who have trauma, extensive burns or recent surgery . Acalculous cholecystitis can also occur as a result of prolonged immobility and fasting, prolonged parenteral nutrition, and diabetes mellitus .

7. Continue… Bacterial infection (Escherichia coli, streptococci and salmonellae) Adhesions, neoplasm, anesthesia an narcotics In the majority of patients, gallstones are the cause of acute cholecystitis. The process is one of physical obstruction of the gallbladder by a gallstone, at the neck or in the cystic duct. This obstruction results in increased pressure in the gallbladder.

8. Continue… There are two factors which determine the progression to acute cholecystitis — the degree of obstruction and the duration of the obstruction. If the obstruction is partial and of short duration the patient experiences biliary colic. If the obstruction is complete and of long duration the patient develops acute cholecystitis. 

9. CHOLELITHIASIS: The actual cause of gall stones is unknown. Cholelithiasis develops when the balance that keeps cholesterol, bile salts, and calcium in solution is altered due to that precipitation of these substances occur. Conditions which upset these balance includes: Infection Disturbances in the metabolism of cholesterol

10. CHOLELITHIASIS

11. Continue… Other components of bile that precipitate into stones are bile salts, bilirubin, calcium and protein. In addition, increased levels of the hormone  estrogen , as a result of  pregnancy  or hormonal therapy, or the use of combined (estrogen-containing) forms of  hormonal contraception , may increase cholesterol levels in bile and also decrease gallbladder movement, resulting in gallstone formation.

12. Continue… The stones may remain in the gall bladder or migrate to the cystic duct or to the common bile duct. They cause pain as they pass to the duct or else they may obstruct the duct. Additionally, prolonged use of  proton pump inhibitors  has been shown to decrease gallbladder function, potentially leading to gallstone formation.

13. Pathophysiology of Cholelithiasis and Cholecystitis

14. CLINICAL MANIFESTATION: Cholecystitis: Indigestion Pain and tenderness in right upper quadrant which may be referred to the right shoulder and scapula Nausea and vomiting Restlessness Diaphoresis Leucocytosis and fever due to infection

15. Continue… Right upper quadrant rigidity Chronic cholecystitis includes a history of fat intolerance, dyspepsia, heartburn and flatulence. Ortner's sign — tenderness when hand taps the edge of right costal arch. Myussi's sign (phrenic nerve sign) — pain when press between edges of sternocleidomastoid Boas' sign — Increased sensitivity below the right scapula (also due to phrenic nerve irritation).

16. CHOLELITHIASIS: Cholelithiasis may produce severe symptoms or none at all. Many patients have silent cholelithiasis The severities of symptoms depend on whether the stone are static or mobile and whether obstruction is present or not. Spasm may be felt when a stone is moving to the duct or passing through the duct.

17. Continue… Sometimes patient feels severe pain referred to as Biliary Colic. The attacks of pain frequently occur after a heavy meal or when the patient lies down. When total obstruction occurs, symptoms related to bile blockage are manifested as given in below table.

18. Clinical Manifestation caused by obstructed bile flow CLINICAL MANIFESTATION ETIOLOGY Obstructive jaundice No bile floe into duodenum Dark urine Due to present of Bilirubin No urobilinogen in Urine No bilirubin reaches to small intestine to be converted to urobilinogen Clay colored stool Due to present of Bilirubin Pruritus Deposition of bile salts in skin tissues Intolerance for fatty foods No bile in duodenum for fat digestion Bleeding tendencies Lack of absorption of Vitamin K, resulting in decreased production of prothrombin Steatorrhea No bile salts in duodenum, preventing fat emulsion and digestion

19. DIAGNOSTIC STUDIES: History and physical examination. Ultrasonography is 90-95 % accurate in detecting stones. Liver function test (LFT) WBC count Serum bilirubin ERCP Percutaneous transhepatic Cholangiography to diagnose obstructive jaundice and to locate the stone within bile duct. MRCP Intraoperative cholangiogram

20. COLLABORATIVE CARE: Conservative therapy: IV fluids NPO with NG tube, later progressing to low fat diet Antiemetic Analgesics (e.g., meperidine) Fat soluble vitamins (A,D,E and K) Anticholenergics (Atropine)

21. Continue… Anticholenergics (Atropine) Antispasmodics Antibiotics for secondary infections For treatment of pruritus, Cholestyramine which binds with the bile salts in intestine and increases their excretion in feces. It may be administered in powder form with milk or juice.

22. SURGICAL THERAPY: Name of the surgery Description Cholecystectomy Removal of gall bladder Cholecystostomy Incision into gall bladder usually for removal of stones Choledocholithotomy Incision into common bile duct for removal of stones Cholecystogastrostomy Anastomosis between stomach and gall bladder Cholecystoduodenostomy Anastomosis between gall bladder and duodenum to relieve obstruction at distal end of common bile duct Laparoscopic Cholecystectomy Removal of gall bladder via laparoscopy

23. Cholecystostomy

24. NURSING DIAGNOSIS: Acute pain secondary to biliary obstruction Ineffective coping related to nausea Deficient knowledge related to diagnosis Impaired gas exchange related to high abdominal surgical incision. Impaired skin integrity related to altered biliary drainage after surgical incision. Imbalanced nutrition related to inadequate bile secretion.

25.   NURSING MANAGEMENT: Provide nursing interventions during an acute gallbladder attack . Intervene to relive pain; give prescribed analgesics Promote adequate rest Administer IV fluids, monitor intake and output Monitor nasogastric tube and suctioning Administer antibiotics if prescribed.

26. Continue… Provide adequate nutrition . Assess nutritional status. Encourage a high-protein, high-carbohydrate, low-fat diet. Give fat soluble vitamins Emphasis on more liquid diet when patient is NPO and gradually progress towards low fat diet.