CHOLECYSTITIS and Cholelithiasis

[Pages:9]MED.SUR

Disorders of gallbladder

CHOLECYSTITIS and Cholelithiasis

Cholecystitis:

Chole: bile

cyst: membranous sac itis: inflammation

# Definition:

Inflammation of the gallbladder located on the Rt upper abdomen common hepatic duct pancreatic common bile duct

Duodenum Duct

# Role of the gallbladder:

- It stores bile and releases it into the small intestine.

- help in the digestion of fat. A,K,E,D

- help in the excretion of bilirubin.

pancreatitis hepatitis . perforation or rupture

# Causes:

- Gallstones (the most common cause) 90%

- Bile duct obstruction - Bacterial infection of GB: E.Coli, Klebsilla, Staphyllococcus

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- Post major surgeries

Disorders of gallbladder

Due to prolong NPO, electrolyte imbalance.

- Multiple blood transfusion

120 RBCs

bilirubin hemoglobin and RBCs destruction

- Billiary Tumors

# signs & symptoms of cholecystitis:

- RUQ pain, radiate to Rt shoulder or back. - Nausea & V and sweeting - Slight fever, and a high WBC. - RUQ abd. tenderness and rigidity - symptoms worsen after a meal high in fat. - Empyema (pus). - If obstructed bile flow: autolysis and edema occur; and the blood vessels in

the gallbladder are compressed lead to Gangrene + perforation.

Cholelithiasis

# Definition: Stones in the Gallbladder, vary greatly in size, shape, and composition Incidence: Female, Forty, fatty, Fertile. . ,

# types of stones:

- Composed of pigment (black dark stones), composed of bilirubin and calcium. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones.

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Disorders of gallbladder

The risk of developing such stones is increased in patients with cirrhosis,

hemolysis, and infections of the biliary tract.

Pigment stones cannot be dissolved and must be removed surgically.

- Composed of cholesterol (75%) insoluble in water, yellow gallstone. Cholesterol, which is 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. with cholesterol, which precipitates out of the bile to form stones.

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# Pathophysiology:

decrease bile acid synthesis

increase cholestero l synthesis in the liver

super saturation of bile with cholesterol

formation of

precipitates

Disorders of gallbladder

gallstones

inflammatory change

(cholecystitis)

# clinical manifestation(cholelithiasis):

- Fullness, distention, and pain in the RUQ radiates to the back or right shoulder.

- Nausea and vomiting - Fever - Palpable abdominal mass & tenderness on deep inspiration

- Jaundice and itching if obstruction of the CBD.

The bile, which is no longer carried to the duodenum, is absorbed by the blood, and gives the skin and mucous membranes a yellow color. - Dark urine(bilirubinuria) and grayish stool (clay) - Vitamin Deficiency

. Mal absorption of the fat-soluble vitamins A, D, E, K. . Bleeding due to vitamin K deficiency.

# Diagnostic Finding:

1- Abdominal X-Ray If gallbladder disease is suspected, an abdominal x-ray may be obtained to exclude other causes of symptoms.

2- Ultrasonography is the diagnostic procedure of choice because it is rapid and accurate

and can be used in patients with liver dysfunction and jaundice.

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3- Radionuclide Imaging or Cholescintigraphy

Disorders of gallbladder

Cholescintigraphy is used successfully in the diagnosis of acute cholecystitis or blockage of a bile duct.

4- Oral Cholecystography is used if ultrasound equipment is not available or if the ultrasound results are inconclusive. This study may be performed to detect gallstones and to assess the ability of the gallbladder to fill, concentrate its contents, contract, and empty. 5- (ERCP) This procedure examines the hepatobiliary system via a side viewing flexible

fiberoptic endoscope inserted through the esophagus to the descending duodenum.

.

Before ERCP Education, Keep NPO for several hours, Moderate sedation is used, anticholinergic OR glucagon. During ERCP: monitors IV fluids, administers medications, and positions the patient. After the procedure: Assess V/S, monitor for signs of perforation & side effects of medications and ensure patent airway

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# Medical management:

Disorders of gallbladder

Nutritional and Supportive Therapy 1- low-fat liquids 2-powdered supplements high in protein and carbohydrate 3-Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non?gasforming vegetables, bread, coffee, or tea. 4-The patient should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas forming vegetables, and alcohol. 5-Analgesia: avoid morphine (cause spasm of the sphincter of oddi) Demerol has been used instead.

Pharmacologic Therapy 1-Ursodeoxycholic acid and chenodeoxycholic acid have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol.

Nonsurgical Removal of Gallstones 1- Dissolving Gallstones Several methods have been used to dissolve gallstones by infusion of a solvent (mono-octanoin or methyl tertiary butyl ether [MTBE]) into the gallbladder 2- Stone Removal by Instrumentation A catheter and 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 and remove the stones lodged in the common bile duct. 3- Intracorporeal Lithotripsy (by laser) 4- Extracorporeal Shock Wave Lithotripsy Lithotripsy, which is a noninvasive procedure, uses repeated shock waves directed at the gallstones in the gallbladder or common bile duct to fragment the stones.

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Surgical management

Disorders of gallbladder

Laparoscopic Cholecystectomy

The abdominal cavity is insufflated with carbon dioxide (pneumoperitoneum) to assist in inserting the laparoscope.

carbon dioxide

With laparoscopic:

- no paralytic ileus - less pain. - discharged on the same day or within 1 or 2 days - Back to work within 1 week - Side effect: shoulder pain from co2

# Nursing Diagnosis:

Acute pain related to surgical incision. Impaired gas exchange related to the high abdominal surgical incision. Impaired skin integrity related to altered biliary drainage after surgery. Imbalanced nutrition, less than body requirements related to inadequate

bile secretion. Deficient knowledge about self-care activities

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# Nursing Interventions

Disorders of gallbladder

The patient is placed in the low Fowler position. Fluids may be administered IV, and nasogastric suction (a nasogastric tube

was probably inserted immediately before surgery for a non-laparoscopic

procedure)

Water and other fluids are given within hours after laparoscopic procedures

soft diet is started after bowel sounds return, which is usually the next day if the laparoscopic approach is used

1- RELIEVING PAIN The location of the subcostal incision in non-laparoscopic gallbladder surgery

often causes the patient to avoid turning and moving, to splint the affected site, and to take shallow breaths to prevent pain. Analgesic agents ,Use of a pillow or binder over the incision when coughing

2- IMPROVING RESPIRATORY STATUS The nurse reminds the patient to take deep breaths and cough every hour to

expand the lungs fully and prevent atelectasis.

use of incentive spirometry ,Early ambulation

3- MAINTAINING SKIN INTEGRITY AND PROMOTING BILIARY DRAINAGE Fasten the tubing to the gown & the drainage bag below the waist or common duct level, Change dressings, observe for infection, leakage of bile, bile drainage.

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