PRESENTATION

ON
CHOLELITHIASIS

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

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

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.

 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

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 510 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

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)

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.

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

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

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

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

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)

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

SURGICAL MANAGEMENT
Cholecystectomy
Minicholecystectomy
Laparoscopic cholecystectomy
Percutaneous cholecystostomy

CHOLECYSTECTOMY

CHOLEDOCHOSTOMY

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

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

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