Cholelithiasis (calculi or gallstones) usually form in the gallbladder from the solid constituents of bile and vary greatly in size, shape and composition.

1. PRESENTATION ON
CHOLELITHIASIS

2. DEFINITION
Cholelithiasis (calculi or gallstones) usually
form in the gallbladder from the solid
constituents of bile and vary greatly in size,
shape and composition.

3. INCIDENCE
•Uncommon in children and young adults
•Increasingly prevalent after age 40.
•The incidence increases thereafter to such an
extent that it has been estimated that by the age
of 75, one of every three people will have gall
stones

4. ANATOMY OF GALL BLADDER
• A pear-shaped, hollow, saclike organ, 7.5 to 10 cm (3-4 inch)
long, lies in a shallow depression on the inferior surface of
the liver, to which it is attached by loose connective tissue.

5. • The capacity of the gallbladder is 30 to 50 ml of bile.
• Its wall is composed largely of smooth muscle.
• The gallbladder is connected to the common bile duct by
the cystic duct

6. PHYSIOLOGY OF GALLBLADDER
• It act as a storage depot for bile
• Between meals, when the sphincter of Oddi is closed, bile produced
by the hepatocytes enters the gallbladder
• During storage, a large portion of the water in bile is absorbed
through the walls of the gallbladder, so that gallbladder bile is 5-10
times more concentrated than that originally secreted by the liver.
• When food enters the duodenum, the gallbladder contracts and the
sphincter of Oddi relaxes, allowing the bile to enter the intestine.
• This response is mediated by secretion of the hormone
cholecystokinin-pancreozymin (CCK-PZ) from the intestinal wall

7. PATHOPHYSIOLOGY
Decreased bile acid synthesis
Increased cholesterol synthesis in the liver
Super saturation of bile with cholesterol
Formation of precipitates
Gall stones (Cholelithiasis)
Inflammatory changes (Cholecystitis)

8. TYPES OF GALLSTONES
• Cholesterol stones
• Pigment stones
• Mixed stones - the most common type. They are comprised of
cholesterol and salts.
• Cholesterol stones are usually yellow-green and are made primarily of
hardened cholesterol.
• Pigment stones are small, dark stones made of bilirubin. The exact
cause is not known. They tend to develop in people who have
cirrhosis, biliary tract infections, and hereditary blood disorders such
as sickle cell anaemia in which too much bilirubin is formed.

9. RISK FACTORS
• Age over 40 years
• Multiparous women
• Obesity
• Users of oral contraceptives
• Hormonal therapy
• Diabetic persons
• Patients with gastro-intestinal diseases

10. CLINICAL MANIFESTATION
• Epigastric distress
• Feeling of Fullness
• Abdominal distention
• Vague pain in the right upper quadrant of the abdomen
• Distress may follow a meal high in fried or fatty foods
• Pain and biliary colic
• Fever
• Palpable abdominal mass
• Biliary colic with excruciating upper right abdominal pain that radiates to the back or right
abdominal pain and radiates to the back or right shoulder, associated with nausea and vomiting
and is noticeable several hours after a heavy meal
• Constant pain, restless in all position
• Jaundice
• Obstruction of the flow of bile into the duodenum results in
• Yellow colour skin and mucous membrane

11. CLINICAL MANIFESTATION Contd…..
• Marked itching of the skin
• Changes in urine and stool colour
• A very dark colored urine
• Grayish, like putty, and usually described as “clay-colored” stool.
• Vitamin deficiency
• Obstruction of bile flow also interferes with absorption of the fat-soluble vitamins
A,D,E, and K
• If gallstone continues to obstruct the duct
• Abscess
• Necrosis
• Perforation
• Generalized peritonitis

12. DIAGNOSTIC EVALUATION
• Abdominal X-ray
• USG
• Radionuclide imaging or cholecintography
• Cholecystography
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Percutaneous transhepatic cholangiography (PTC)

13. MEDICAL MANAGEMENT
• Ursodeoxycholic acid (UDCA)
• Chenodeoxycholic acid (chenodiol or CDCA)
The mechanism of action is the inhibition of liver synthesis and
secretion of cholesterol, thereby desaturating bile. Existing stones can
be decreased in size, small stones dissolved and new stones
prevented from forming (6-12 months therapy)

14. NONSURGICAL REMOVAL
•Dissolving gallstones – MTBE – Methyl tertiary
butyl ether
•A catheter and instrument with basket
•Extracorporeal shock-wave lithotripsy (ESWL)
•Intracorporeal lithotripsy

15. SURGICAL MANAGEMENT
•Cholecystectomy
•Minicholecystectomy
•Laparoscopic cholecystectomy
•Percutaneous cholecystostomy

16. CHOLECYSTECTOMY

17. CHOLEDOCHOSTOMY

18. SUPPORTIVE OR DIETARY MANAGEMENT
• Low fat liquids
• Powdered supplements high in protein and carbohydrates
• Cooked fruits
• Rice or tapioca
• Lean meats
• Smashed potatoes
• Non gas forming vegetables
The following to be avoided
• Eggs
• Cream
• Pork
• Fried foods, cheese and rich dressings
• Gas forming vegetables
• Alcohol

19. NURSING MANAGEMENT
•Relieving pain
•Improving respiratory status
•Promoting skin care and biliary drainage
•Improving nutritional status
•Patient education and home care
considerations
•Monitoring and managing potential
complications

20. THANK YOU