Cholecystitis and Choldocholithiasis seminar

1. SEMINAR
ON
CHOLECYSTITIS AND
CHOLEDOCHOLITHIASIS
PRESENTED BY:
Ms. Navaneeta Kusum
M.Sc.Nsg.2nd Year
CON-ILBS

2. CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

3. Common terms r/t GB:
Cholecystitis: inflammation of the gallbladder
Cholelithiasis: the presence of calculi in the gallbladder
Cholecystectomy: removal of the gallbladder
Cholecystostomy: opening and drainage of the gallbladder
Choledochotomy: opening into the common duct
Choledocholithiasis: stones in the common duct
Choledocholithotomy: incision of common bile duct for removal of stones
Choledochoduodenostomy: anastomosis of common duct to duodenum
Choledochojejunostomy: anastomosis of common duct to jejunum

4. Cholecystitis
 Cholecystitis is an inflammation of the gallbladder.
GB stores fluid (bile) which passes out of the gallbladder on its way to
the small intestine.
If the flow of bile is blocked, it builds up inside the gallbladder, causing
swelling, pain and possible infection.
In most cases, gallstones leading to cause cholecystitis.

5. Epidemiology
 10-20% of people have gallstones and 1/3rd of these people develop
acute cholecystitis.
 Cholecystectomy for either recurrent biliary colic is the most common
major surgical procedure performed by general surgeons, resulting
in approximately 5,00,000 operations annually.
 In the United States, white people have a higher prevalence than
black people.
 Gallstones are 2-3 times more frequent in F > M

6. Etiology
Gallstones: can block the cystic causing bile to build up and resulting in
inflammation.
Tumor: may prevent bile from draining out of GB properly.
Bile duct blockage: Kinking or scarring of the bile ducts can cause
blockages.
Injury: Trauma to the abdomen or surgery.
Infection: within the bile, the gallbladder can become inflamed.

7. CHOLELITHIASIS
is the formation of stones in the gallbladder, composed primarily of
cholesterol.
Gallstones Formation
Unknown
but the Cholesterol may supersaturate the bile in the GB. After a time, the
supersaturated bile crystallizes and begins to form stones.
Another type of gallstone is a pigment stone. Pigment stones appear to be
composed of calcium bilirubinate, which occurs when free bilirubin combines
with calcium.

8. Pathophysiology
Cholesterol, a normal constituent of bile, is insoluble in water.
Its solubility depends on bile acids and lecithin (phospholipids) in bile.
In gallstone-prone patients, there is decreased bile acid synthesis and
increased cholesterol synthesis in the liver, resulting in bile
supersaturated, which precipitates out of the bile to form stones.
Acts as an irritant, producing inflammatory changes in the gallbladder.

9. RISK FACTORS
Calculous cholecystitis:
Sex: Women > Men. Excess estrogen from Pg, HRT, and birth control pills
increase cholesterol levels in bile and decrease gallbladder movement.
Family history
Weight: overweight, amount of bile salts in bile is reduced, resulting in
more cholesterol. Increased cholesterol reduces gallbladder emptying.
Diet: High in fat and cholesterol and low in fiber
Rapid weight loss: As the body metabolizes fat during prolonged fasting

10. Age: older than 60
Ethnicity: American, Indians have a genetic predisposition to secrete high
levels of cholesterol in bile.
Cholesterol-lowering drugs: Actually increase the amount of
cholesterol secreted into bile.
Diabetes: have high levels of fatty acids (triglycerides). These fatty acids
may increase the risk of gallstones.

11. Acalculous cholecystitis:
Critical illness
Major surgery or severe trauma/burns
Sepsis
Long-term total parentral nutrition (TPN)
Prolonged fasting
MI
HIV Pt.

12. Signs and symptoms
Pain:
Severe steady pain in right upper quadrant.
Radiate to the right shoulder or back.
often a history of fatty food ingestion about one hour or more before the initial
onset of pain.
Other symptoms:
Fever and chills, N/V, Sweating, Anorexia

13. Diagnostic Evaluation
History and physical examination
fever, tachycardia, and tenderness in the right upper quadrant or epigastric
region, often with guarding or rebound.
Murphy sign positive- A palpable gallbladder or fullness of the right
upper quadrant is present in 30-40% of cases.
Jaundice may be in approx 15% of patients.

14. Laboratory Studies
CBC: Leucocytosis, Bilirubin mildly elevated (1- 4 mg/dL), CRP , AST/ ALT,
Amylase, ALP (25%)
Abdominal USG
Abdominal CT scan and MRI
EUS
ERCP
Oral cholecystogram
Gallbladder radionuclide scan

15. Complications
Gangrene (tissue death)
Perforation (a hole that forms in the wall of the gallbladder)
Pancreatitis
Persistent bile duct blockage
Inflammation of the CBD

16. Treatment
Conservative Management
Rehydration
NPO
Correction of clotting abnormalities
Broad-spectrum antibiotics and strong painkiller such as meperidine, NSAIDS.
Antiemetics and NG suction.
Once the patient has been resuscitated, relief of the obstruction is essential.

17. Definitive Management
Surgery to remove the gallbladder
Laparoscopic cholecystectomy
Percutaneous Drainage: For high surgical risk, placement of
IMAGE guided percutaneous transhepatic cholecystostomy drainage
tube coupled with the administration of antibiotics may provide
definitive therapy.
ERCP for visualization of the anatomy and therapeutically removal
of stones.

18. Nonsurgical Treatment
Oral dissolution therapy
Drugs made from bile acid are used to dissolve gallstones.
Ursodiol(Actigall) and chenodiol (Chenix) work best for small cholesterol stones.
Months or years of treatment may be necessary before all the stones dissolve.
Both drugs may cause mild diarrhea, and chenodiol may temporarily raise levels
of blood cholesterol and the liver enzyme transaminase.

19. contd…
Contact dissolution therapy
Injecting a drug directly into the gallbladder to dissolve cholesterol
stones. Drugs ethyl propionate, methyl tertiary butyl ether can dissolve
some stones in 1 to 3 days
Serious side effects include severe burning pain.
Extracorporeal shock wave lithotripsy

20. Prognosis
In more than 60% to 80% of cases, individuals never experience symptoms.
Small stones often pass into the intestine without difficulty and are eliminated in
the stool.
The mortality rate for an elective cholecystectomy is 0.5% with less than 10%
morbidity.
Following cholecystectomy, stones may recur in the bile duct.

21. CHOLEDOCHOLITHIASIS

22. Stones inside the common bile duct and billiary tree.
 Important Cause for developing Obstructive Jaundice

23. CLASSIFICATION
PRIMARY:Formed in CBD and biliary tree itself
 Rare
 Brown pigment or mixed type stones..
 Multiple, often sludge like, extends into hepatic duct.

24. PRIMARY STONES ETIOLOGY:
Defective pathophysiology of biliary tree causing stasis, biliary
dyskinesia, benign biliary stricture, sclerosing cholangitis, biliary
dilatation etc.
Congenital conditions like Caroli’s disease, choledochal cyst.
Infections & infestations like clonorchiasis, ascariasis.
Others: Low protein diet, malnutrition, obesity, females, old
age.

25. Secondary: They are from gallbladder (gall stones), pass through
Cystic Duct to CBD. Here CBD & biliary tree are otherwise normal.
 Common
 black pigment stones/cholesterol stones
(75% are cholesterol & 15% are pigment stones)
 15% of gall stone disease
 Secondary stones are better and easier to manage than primary stones
 Commonly gall stones get impacted in supraduodenal
portion of the CBD.

26. CLINICAL FEATURES
50% asymptomatic
 Biliary colic because of CBD obstruction by stone – pain in Right
Hypochondrium & Epigastrium
 Jaundice more likely to be painful with rapid distension of biliary duct
Stimulating pain fibres.
Fever with chills & rigor also common .

27. CLINICAL FEATURES CONTD.
Charcot’s Triad:-
 Intermittent Fever with chills
 Intermittent jaundice &
 Intermittent colicky pain.
Feature of Ascending Cholangitis. If untreated may progress to Septic
Shock..
Reynold’s Pentad-
 Hypotension & altered mental status with Charcot’s Triad.
 Both evidence of shock from a biliary source. Found in Suppurative
Cholangitis.

28. CLINICAL FEATURES CONTD.
COURVOISIER’S LAW:
“In a patient with Jaundice
if gall bladder is palpable , it is not due to stones.”
 Double impacted stone-one in CBD & one in Cystic Duct, with
mucocele of gall bladder .
 Large stone in Hartman’s Pouch
 Empyema Gall bladder.

29. COMPLICATIONS
Liver Dysfunction & Biliary atresia
White Bile formation & liver failure
Suppurative Cholangitis
Liver abscess
Septicemia
Pancreatitis if CBD stone is near sphincter of Oddi blocking drainage of Bile
& Pancreatic Duct.

30. INVESTIGATIONS
 USG Abdomen:
 It may show Gallstones,
 Dilated CBD>8mm with symptoms ,
 Dilated CBD even without biliary colic in presence of gall
stones highly suggestive of biliary obstruction

31. MRCP

32. CT Scan:-
 It shows stones , location, ductal stricture or block , dilatation,
intra hepatic biliary changes & stones.
 Helical CT cholangiography is also useful but bilirubin level
should be normal which is the limitation.

33.  EUS(Endoscopic Ultrasonography):- Useful & accurate
but is invasive
 PTC- done only when indicated like in case of previous Gastrectomy,
failed ERCP. Not routinely done.
 ERCP- now a days mostly Therapeutic use.

34. Peroperative cholangiography

35. LABORATORY:
CBC- WBC, Platelet Count
LFT:-
 S. Bilirubin-
 S. ALP & GGT-
 S. ALT & AST-
 S. Protein-
 Prothombin Time-
S. Amylase-
S. Lipase-
Urine-

36. TREATMENT
Laparoscopic Cholecystectomy.
In absence of such facilities,
Conventional Open Cholecystectomy with Bile duct exploration is the
standard choice.
•In a similar setting but with a dilated biliary tree, drainage of the biliary
tree through a separate choledochoenterostomy can be successful. The
two options for drainage are a
•Choledochoduodenostomy &
• Roux-en-Y choledochojejunostomy

37. ERCP
Pt with highest risk such as those with cholangitis or jaundice should
undergo ERCP.
 More than 50% of all patients have recurrent symptoms of biliary tract disease if they
are not also treated by cholecystectomy.

38. Choledochoduodenostomy

39. T TUBE CHOLANGIOGRAPHY

40. Nursing Diagnosis
1. Acute Pain related to obstruction, inflammatory process, tissue
ischemia/necrosis
2. Deficient fluid volume related to excessive vomiting, losses through gastric
suction.
3. Deficient knowledge related to unfamiliarity with information resources,
information misinterpretation
4. Risk for imbalanced nutrition less than body requirements related to dietary
restrictions, nausea/vomiting, dyspepsia, pain.
5. Risk for impaired skin integrity related to surgical incision and T-tube drainage
6. Risk for ineffective breathing pattern related to abdominal incision

41. Nursing Interventions
1. For relieving pain
•Observe and document location, severity (0–10 scale), and character
of pain (steady, intermittent, colicky).
•Promote bedrest, allowing patient to assume position of comfort.
•Encourage use of relaxation techniques.
•Provide diversional activities.
•Make time to listen to and maintain frequent contact with patient.
•Maintain NPO status, insert and/or maintain NG suction as indicated

42. 2. For improving deficient fluid volume
•Maintain accurate record of I&O, noting output less than intake, increased urine
specific gravity.
•Assess skin and mucous membranes, peripheral pulses, and capillary refill.
•Monitor for signs and symptoms of increased or continued nausea or vomiting,
abdominal cramps, weakness.
•Administer IV fluids.
•Perform frequent oral hygiene with alcohol-free mouthwash, apply lubricants.

43. 3. For improving imbalanced nutrition
•Calculate caloric intake and weigh as indicated.
•Ask patient about likes and dislikes, foods that cause distress, and preferred meal
schedule.
•Provide a pleasant atmosphere at mealtime; remove noxious stimuli.
•Provide oral hygiene before meals.
•Assess for abdominal distension, frequent belching, guarding, reluctance to move.
•Ambulate and increase activity as tolerated.

44. 5. For impaired skin integrity
•Change the patient’s position frequently.
•Encourage the patient to stay in a low semi-Fowler’s position as much as possible.
•Inspect the cholecystectomy incision frequently for excessive drainage or evidence of
infection such as redness, edema, or warmth.
•Change dressings frequently to protect the skin around the incision site.
•Protect the skin with a skin barrier product or bag such as those used with colostomies
if bile is leaking around the T-tube site.

45. 6. For Ineffective Breathing Pattern
•Deep breathing and coughing after any surgical procedure
•Instruct the patient in the proper techniques before surgery and give the
opportunity to practice with spirometry.
•After surgery, encourage the patient to cough and deep breathe at every
encounter.
•If the patient is reluctant to cough because of pain, the pain medication regimen
may need to be evaluated.
•Encourage the patient to walk when permitted.

46. Patient Education
•Deep-breathing exercises until the incision is completely healed.
•The continued use of opiate analgesics for 7 to 10 days may necessitate the use of
laxatives or suppositories.
•Instruct the patient to report to the physician if any new symptoms occur, such as the
appearance of jaundice accompanied by pain, chills and fever, dark urine, or light-
colored stools.
•Usually, the patient has no complications and is able to resume normal activity within a
few weeks.
•Instruct the patient who treated nonsurgically with bile salts for low-fat diet to avoid
recurrence of gallstones.

47. Discharge Advice
•After a laparoscopic cholecystectomy, the patient goes home within 24 hours
after surgery.
•Explain the possibility of abdominal and shoulder pain caused by the
instillation of carbon dioxide during operation so that if the pain occurs, the
patient will not experience unnecessary anxiety about a heart attack.
•Teach the patient to take prescribed antibiotics for further assurance against
infection, and to watch the incisions for signs of infection.

48. contd…
•Instruct the patient on the care of abdominal wound including changing dressing
and protection of drains if any.
•Education focusing on diet- high-protein, low-fat diets.
•Encourage obese patients to lose weight.
•Explain about the importance of follow-up visit with histopathology report if biopsy
sample is sent for examination.

49. REFERENCES
1. Smeltzer SC, Bare B. Textbook of medical surgical nursing. 10th edition. Philadelphia: Lippincott Williams and Wilkins; 2004.
2. Black JM, Hawks JK. Medical and surgical nursing. 8th edition. Philadelphia: Elsevier Publication; 2012.
3. Williams LD, Hopper PD. Understanding medical surgical nursing. 2nd edition. Philadelphia: F. A. Davis Company; 2003.
4. Basavanthappa BT. Medical surgical nursing. 2nd edition. New Delhi: Jaypee Brothers Medical Publisher; 2009.
5. Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo J. Harrison's principles of internal medicine. 18th edition.
USA: McGraw Hill Companies, Inc; 2012.
6. Nettina, Sandra M. Lippincott Manual of Nursing Practice. 8th Edition. Philadelphia: Lippincott Williams & Wilkins; 2006.