Cholecystitis and cholelithiasis

CHOLECYSTITISCHOLECYSTITIS
&&
CHOLELITHIASISCHOLELITHIASIS
Ms. Sulochana GhimireMs. Sulochana Ghimire
LecturerLecturer
Universal College of Nursing Sciences (UCMS-TH),Universal College of Nursing Sciences (UCMS-TH),
Siddharthanagar-1, Bhairahawa, Rupandehi, NepalSiddharthanagar-1, Bhairahawa, Rupandehi, Nepal

Review AnatomyReview Anatomy
Gallbladder
Gallbladder is a 3-inch
long pear-shaped sac
located on the posterior
border of the
liver.

Review Anatomy Contd..Review Anatomy Contd..
Gallbladder
Connected to the bile ducts of the liver through the cystic
duct, the gallbladder receives bile transported from the liver
for storage on a regular basis to prepare for the digestion of
future meals.
During digestion of a meal, smooth muscles in the walls of
the gallbladder contract to push bile into the bile ducts that
lead to the duodenum. Once in the duodenum, bile helps
with the digestion of fats.

Review Anatomy Contd..Review Anatomy Contd..
• Bile is the greenish-yellow fluid (consisting of waste
products, cholesterol, and bile salts) that is secreted
by the liver cells to perform two primary functions
that is:
To carry away waste.
To break down fats during digestion.
• Bile salt is the actual component which helps to
break down and absorb fats. Bile, which is excreted
from the body in the form of feces, is what gives
feces its dark brown color.

IntroductionIntroduction
Cholecystitis:
Inflammation of the gall bladder is known as cholecystitis.
Incidence:
Overweight especially those with sedentary lifestyle.
Certain ethnic groups-Chinese, Jews, Italian.
Etiology:
Unknown.
Gall stone (Cholelithiasis)
Anatomic abnormalities or kinking or twisting of the bile
ducts.

TypesTypes
Types:
– Acute and Chronic.
– Calculous and acalculous.
Acute calculous:
• It begins suddenly, resulting in severe, steady pain
in upper abdomen.
• Calculus cholecystitis is the cause of more than 90%
of cases of acute cholecystitis.
• The inflammation almost always begins with or
without infection, although infection may follow
later.

Types Contd..Types Contd..
Chronic calculous:
• It is inflammation of the gall bladder that has lasted a
long time.
• It is characterized by repeated attacks of pain.
• The gall bladder is damaged by repeated attack of acute
inflammation, usually due to gall stone, and may
become thick wall.
• The gall bladder contains sludge or gall stone that
blocks its opening in to the cystic duct.

Acalculous cholecystitis:
• It causes acute inflammation of GB in absence of obstruction
by stone.
• It occurs after major surgery, severe trauma, burns, cystic duct
obstruction, bacterial infection of GB, and multiple blood
transfusion.
• It is also caused by alteration in the fluid and electrolyte and
alteration in regional blood flow in the visceral circulation.
• Bile stasis (lack of GB contraction) and increased viscosity of
bile also play role.

Pathophysiology of Calculus CholecystitisPathophysiology of Calculus Cholecystitis
Gall bladder stone
Obstruction of bile flow
Bile remaining in the GB initiates a chemical reaction
Autolysis & edema occur
Blood vessels in the GB are compressed, comprising its vascular supply
Gangrene of the GB with perforation may result.
NOTE:
Bacteria play a minor role in acute cholecystitis; however, secondary
infection of bile with Escherichia coli (60%), Klebsiella species
(22%), Streptococcus (18%) is identified with cultures obtained during
surgery in a small percentage of surgically treated patients.

Pathophysiology of Calculus CholecystitisPathophysiology of Calculus Cholecystitis
Gall bladder stone
Obstruction of cystic duct
Distension of GB
Impaired lymphatic and venous drainage
Proliferation of bacteria
Localized cellular irritation
Area of ischemia developed
Gangrene or necrosis
Fibrosis of GB wall

Clinical FeaturesClinical Features
• Pain, tenderness and rigidity in upper right quadrant that may radiate
to the midsternal area or right shoulder.
• Pain starts suddenly, increases steady and reaches peak in about 30
minutes.
• Nausea and vomiting
• Usual signs of inflammation (Fever)
• Jaundice.
• An empyema of the GB develops if the GB becomes filled with
purulent discharge.

DiagnosisDiagnosis
• USG
• X-ray abdomen
• Blood test- increased WBC
• CT scan

ManagementManagement
Management
Medical:
• Hospitalization
• Antibiotic therapy
• Analgesic
• Antacid
• Antiemetic
• Provide comfort measure
• Monitor fluid and electrolyte
Surgical :
• Cholecystectomy (Open or Laparoscopy)

Nursing ManagementNursing Management
Nursing management
Assessment:
• Characteristics of pain, presence of pain in relation to ingestion of
food high in fat
• Abdomen for tenderness.
• Stools for color, character of urine.
Nursing diagnosis
• Pain related to inflammation of gall bladder
• Hyperthermia related to inflammation of gall bladder
• Fear and anxiety related to disease condition and it’s prognosis.

IntroductionIntroduction
• It is a common disorder of biliary system.
• The term “cholelithiasis” is derived from the Greek word “chole”
meaning “bile”, “lith”, meaning “stone” & “iasis” meaning “process”.
Therefore, the process of stone formation in the bile (gall bladder) is
known as cholelithiasis.
• These stones are composed
of cholesterol, bile
pigments and calcium.

Introduction Contd..Introduction Contd..
Incidence:
• Gall stones are present in about 95% of the patient who have acute
cholecystitis.
• Its incidence is higher in female, obese persons, multiparous women
& persons over 40 years of age.
• They are not common in children & young adults but become
increasingly prevalent after 40 years of age.
• Fertile.

TypesTypes
Characteristics of stone:
• Gall stone can vary in size and shape from as small as a grain of sand
to as a golf ball.
Types of gall stones:
 Cholesterol stones
• It accounts for about 80% of gallstones.
• It may vary from light yellow to dark green or brown & are usually
oval in shape.
• Are about 2-3 cm long, each often having a tiny, dark central point.

 Pigment stones:
• It accounts for 20 % of the cases.
• Are small and dark and comprise bilirubin and calcium salts that are
found in bile.
• They contain less than 20% of cholesterol.
 Mixed stones:
• Typically contain 20-80% cholesterol.
• Other common constituents are calcium carbonate phosphate,
bilirubin and other pigment.
• Because of calcium content, they are often radiographically visible.

Etiology & Risk FactorsEtiology & Risk Factors
Etiology:
The actual cause of gallstone is unknown.
Risk factors:
1.Sex:
Women are twice as men to develop gallstones.
Excess estrogen from pregnancy, hormone replacement
therapy & oral contraceptives increases cholesterol level in
the bile & decreases the gallbladder movement which can
lead to gallstones.

Risk Factors Contd..Risk Factors Contd..
2. Family history:
• Gallstones often run in families.
3. Weight:
• A large clinical study showed that being even moderately
overweight increases the risk for developing gallstones.
• The most likely reason is that the amount of bile salts in bile
is reduced resulting in more cholesterol.
• Increased cholesterol reduces gallbladder emptying which
predisposes stone formation (cholesterol type)

4. Diet:
• Diet high in fat & cholesterol & low in fiber increases the
risk of developing gallstones.
• The excess dietary cholesterol is not converted to bile salts
but is excreted instead as cholesterol crystals in the bile.
5. Rapid weight loss/prolong fasting:
• In prolong fasting & rapid weight loss body metabolizes fat
& is transferred into the liver.
• Liver secrets extra cholesterol in bile can cause gallstones.
• In addition, the gallbladder doesn't empty properly.

6. Age:
• People older than 60 years are more prone because, as
people age increases, the body tends to secrete more
cholesterol in bile.
7. Ethnicity:
• American Indians & Mexican – Americans are at higher risk
for gallstones.
• Gallstones are common in Asian populations.

8. Cholesterol – lowering drugs:
• These drugs actually lowers cholesterol in blood & in turn
increases the amount of cholesterol secreted into the bile
which increases the risk of gallstones.
9. Diabetes:
• These patients have high levels of fatty acids called
triglycerides.
• These fatty acids may increases the risk of gallstones.

10. Cystic fibrosis:
• In cystic fibrosis the bile is dehydrated & becomes more
acidic than normal bile, & its flow into the small intestine is
reduced.
• Dehydrated bile can collect in the GB & can produce
gallstones.
11. Hemolysis:
• Liver is unable to conjugate bilirubin.
• Increased unconjugated bilirubin concentration in bile.
• Formation of pigment stone or bilirubinate stone.

12. Immobility.
13. Stasis of bile.
• Cholesterol precipitates the formation of crystals.
• Bile supersaturated with cholesterol.
• Formation of cholesterol stone.
14. Drugs (oral contraceptives):
• Causes the liver to excrete more cholesterol into the bile.
• Bile supersaturated with cholesterol.
• Formation of cholesterol stone.

PathophysiologyPathophysiology
• Cholesterol, a normal constituent of bile, is insoluble in
water.
• Its solubility depends on bile acids & lecithin
(phospholipids) in bile.
In gallstone prone patients, there is decreased bile acid
synthesis & increased cholesterol synthesis in the liver,
resulting in bile supersaturated with cholesterol.
Decreased contractility of bile flow.

Pathophysiology Contd..Pathophysiology Contd..
Forms small crystals into gallbladder’s mucosal surface
Enlarge to grossly visible stone
Develop several stones
Stone may move in the bile ducts.
Obstruction in the common bile duct.
Appearance of clinical features

Clinical FeaturesClinical Features
1. Gallstones may be silent, producing no pain & only mild
gastrointestinal symptoms. Such stones may be detected
incidentally during surgery or evaluation for untreated
problems.
2. The patient with GB stones develops two types of
symptoms; those due to disease of GB itself & those due to
obstruction of bile flow by the stones.
3. Pain & biliary colic:
– If the gallstone obstructs the cystic duct, the GB becomes
distended, inflamed & eventually infected (acute cholecystitis).

Clinical Features Contd..Clinical Features Contd..
• Develops a fever & may have palpable abdominal mass.
• Such a bout of biliary colic is caused by contraction of the GB,
which cannot release bile because of obstruction by the stone.
• Pt. may have biliary colic with excruciating (intensely painful) upper
right abdominal pain that radiated to the back or right shoulder
(Kher’s Sign).
• When distended, the fundus of the GB comes in contact with the
abdominal wall in the region of the right 9th
& 10th
costal cartilages.
This produces marked tenderness in the right upper quadrant on deep
inspiration & prevents full inspiratory excursion (Murphy’s sign).

• If the gall stone impacted in cystic duct, Gallbladder cannot
empty. Mucus secreted, growth occurs and gall bladder wall is
chemically irritated & continuous dull aching pain occurs.
4. Jaundice:
• Occurs in few patients with GB disease, usually
with obstruction of the common bile duct.
• The bile, which is no longer carried to the
duodenum, is absorbed by the blood & gives the
skin & mucous membranes a yellow color.
• This is a frequently accompanied by marked
pruritus of the skin.

5. Changes in the urine & stool color:
• The excretion of the bile pigments by the kidney gives the
urine a very dark color.
• The feces, no longer colored with bile pigments, are grayish,
like putty & usually described as clay – colored.
6. Vitamin deficiency:
• Obstructions of bile flow also interferes with absorption of
the fat – soluble vitamins A,D,E & K.
• Patients may exhibit deficiencies of these vitamins if biliary
obstruction has been prolonged.
• For e.g. the pt. may have bleeding caused by Vit. K
deficiency.

DiagnosisDiagnosis
History collection.
Physical examination.
Blood test- LFT, CBC.
Abdominal X – ray.
Only 15% - 20% of gallstones are calcified sufficiently to
be visible on X – rays.
USG (90-95%).
The procedure is most accurate if the pt. fast overnight so
that the GB is distended.

Diagnosis Contd..Diagnosis Contd..
Radionuclide imaging or cholescintigraphy:
Used successfully in the diagnosis of acute cholecystitis.
A radioactive agent is administered intravenously.
It is taken up the hepatocytes & excreted rapidly through
the biliary tract.
The biliary tract is scanned & the images of GB & biliary
tract are obtained.

Diagnosis Contd...Diagnosis Contd...
Cholecystography:
An iodide – containing contrast agent is
administered orally & after 10-12 hrs, X- ray
study is done.
The normal GB fills with this radio – opaque
substance. If GB stones are present, they appear as
shadows on the X – ray film.

Percutaneous Transhepatic Cholengiogram (PTCA)
PTCA involves the injection of dye directly into the
biliary tract.
Because of the relatively large concentration of dye that is
introduced into the biliary system, all components of the
system including the hepatic duct, entire length of CBD,
the cystic & GB are outlined clearly.

ERCP (endoscopic retrograde cholangio pancreatography):
The examination of the hepatobiliary system is carried out via a side –
viewing flexible Fiberoptic endoscope inserted through the esophagus to
the descending duodenum.
Fluoroscopy & multiple X-rays are used during ERCP to evaluate the
presence & location of ductal stones.
CT scan
MRI

Medical ManagementMedical Management
• Narcotic to decrease pain.
• Antispasmodics and anticholenergics to reduce spasm and
contraction.
• Antibiotic therapy if infection is suspected.
• Nasogastric suctioning to reduce nausea and eliminating
vomiting.
• UDCA (Ursodeoxycholic acid) & Chenodeoxycholic acid
(Chenodiol /chenix or CDCA) have been used to dissolve
small, radiolucent gallstones composed of cholesterol.

Medical Management Contd..Medical Management Contd..
• It acts by inhibiting the synthesis & secretion of
cholesterol, thereby de-saturating the bile.
Treatment with UDCA can reduce the size of existing
stones, dissolve small stones & prevent new stones from
forming.
6 to 12 months of therapy is required in many patients to
dissolve stones, & monitoring of the patient for
reoccurrence of symptoms or the occurrence of side
effects is required during this time.

Dissolving agents:
By infusing of a solvent (Mono – octanoin or methyl
tertiary butyl ether /MTBE) into the GB via ERCP,
through a tube/catheter inserted percutaneously directly
into the GB.

Stone removal by instrumentation:
A.A catheter & instrument with a basket attached are
threaded through the T – tube tract or fistula formed
at the time of T – tube insertion; the basket is used to
retrieve & remove the stones lodged in common bile
duct.
B.Use of ERCP, cutting instrument & the basket or
balloon.

• Extracorporeal Shock-Wave Lithotripsy.
Extracorporeal shockwave therapy (lithotripsy or ESWL)
has been used for nonsurgical fragmentation of gallstones.
The word lithotripsy is derived from lithos, meaning stone,
and tripsis, meaning rubbing or friction.
This noninvasive procedure uses repeated shock waves
directed at the gallstones in the gallbladder or common bile
duct to fragment the stones.
The energy is transmitted to the body through a fluid-filled
bag, or it may be transmitted while the patient is immersed in
a water bath.
The converging shock waves are directed to the stones to be
fragmented.

• After the stones are gradually broken up, the stone
fragments pass from the gallbladder or common bile
duct spontaneously, are removed by endoscopy, or
are dissolved with oral bile acid or solvents.
• Because the procedure requires no incision and no
hospitalization, patients are usually treated as
outpatients, but several sessions are generally
necessary.

• Intracorporeal Lithotripsy.
Stones in the gallbladder or common bile duct may be
fragmented by means of laser pulse technology.
A laser pulse is directed under fluoroscopic guidance with the
use of devices that can distinguish between stones and tissue.
The laser pulse produces rapid expansion and disintegration
of plasma on the stone surface, resulting in a mechanical
shock wave.
Electrohydraulic lithotripsy uses a probe with two electrodes
that deliver electric sparks in rapid pulses, creating expansion
of the liquid environment surrounding the gallstones.
This results in pressure waves that cause stones to fragment.
This technique can be employed percutaneously with the use
of a basket or balloon catheter system or by direct
visualization through an endoscope.

Surgical ManagementSurgical Management
• Open cholecystectomy:
In this procedure, the gallbladder is removed through an
abdominal incision (usually right subcostal) after the cystic
duct and artery are ligated.
In some patients a drain may be placed close to the
gallbladder bed and brought out through a puncture wound
if there is a bile leak.
Usually only a small amount of serosanguinous fluid will
drain in the initial 24 hours after surgery, and then the drain
will be removed.

Surgical Management Contd..Surgical Management Contd..
• Laparoscopic Cholecystectomy:
Laparoscopic cholecystectomy is performed through a small
incision (up to ½ inch) or puncture made through the
abdominal wall in the umbilicus.
The abdominal cavity is insufflated with carbon dioxide
(pneumoperitoneum) to assist in inserting the laparoscope and
to aid the surgeon in visualizing the abdominal structures.
The fiberoptic scope is inserted through the small umbilical
incision. Several additional punctures or small incisions are
made in the abdominal wall to introduce other surgical
instruments into the operative field.
 The surgeon visualizes the biliary system through the
laparoscope; a camera attached to the scope permits a view of
the intra-abdominal field to be transmitted to a television
monitor.

• Mini-cholecystectomy
Mini-cholecystectomy is a surgical procedure in which the
gallbladder is removed through a small incision.
If needed, the surgical incision is extended to remove large
gallbladder stones. Drains may or may not be used.
The cost savings resulting from the shorter hospital stay have
been identified as a major reason for pursuing this type of
procedure.
Debate exists about this procedure because it limits exposure
to all the involved biliary structures.

• Choledochostomy
Choledochostomy involves an incision into the common
duct, usually for removal of stones.
After the stones have been evacuated, a tube usually is
inserted into the duct for drainage of bile until edema
subsides.
This tube is connected to gravity drainage tubing.
The gallbladder also contains stones, and as a rule a
cholecystectomy is performed at the same time.

• Surgical Cholecystostomy
Cholecystostomy is performed when the patient’s condition
prevents more extensive surgery or when an acute
inflammatory reaction is severe.
The gallbladder is surgically opened, the stones and the bile
or the purulent drainage are removed, and a drainage tube is
secured with a purse-string suture.
The drainage tube is connected to a drainage system to
prevent bile from leaking around the tube or escaping into the
peritoneal cavity.
After recovery from the acute episode, the patient may return
for cholecystectomy.

• Percutaneous Cholecystostomy.
 Percutaneous cholecystostomy has been used in the treatment and diagnosis
of acute cholecystitis in patients who are poor risks for any surgical
procedure or for general anesthesia.
 These may include patients with sepsis or severe cardiac, renal, pulmonary,
or liver failure. Under local anesthesia, a fine needle is inserted through the
abdominal wall and liver edge into the gallbladder under the guidance of
ultrasound or computed tomography.
 Bile is aspirated to ensure adequate placement of the needle, and a catheter
is inserted into the gallbladder to decompress the biliary tract.
 Almost immediate relief of pain and resolution of signs and symptoms of
sepsis and cholecystitis have been reported with this procedure.
 Antibiotic agents are administered before, during, and after the procedure.

Nursing ManagementNursing Management
Assessment:
• Characteristics of pain, presence of pain in relation to ingestion of
food high in fat
• Abdomen for tenderness, Murphy’s sign
• Stools for color, character of urine.
Nursing diagnosis
• Pain related to presence of stone in GB.
• Imbalanced nutrition, less than body requirements related to
inadequate bile secretion.
• Fear and anxiety related to disease condition , treatment and
prognosis.
• Deficient knowledge about self-care activities related to incision care,
dietary modifications (if needed).

Nursing Management Contd..Nursing Management Contd..
Interventions:
1.Teach dietary modification to achieve a low fat intake
because reduced fat absorption
2.Relieve pain by administering narcotics
3.Observe for sign of bleeding and administer vitamin K
preparation as prescribed
4.Care after surgery:
Maintain patency of the tube.
Assess and measure drainage in every shift.

Nursing Management Contd..Nursing Management Contd..
– Monitor intake and output
– Check IV site for phlebitis and operation site for
soakage.
– Keep patient in comfortable position
– Encourage patient for deep breathing and coughing
exercise.
– Evaluate for complications for examples hemorrhage,
post-operative jaundice, sub-hepatic abscess,
pancreatitis, and disruption of the ducts.

ComplicationsComplications
Cholangitis (inflammation of bile duct)
Choledocholithiasis (5-20)% (stone in bile duct)
Necrosis of GB
Perforation of GB develop to peritonitis
Obstructive jaundice
Carcinoma of GB
Pancreatitis

PrognosisPrognosis
Good
0.5% elective surgery mortality
3-5 % emergency surgery mortality

Cholecystitis and cholelithiasis

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