Cholilithiasis

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Objectives

Define cholelithiasis and its type,

Describe the pathophisiology of cholelithiasis,

Discuss Sign and Symptoms and diagnostic tests of

Cholelithiasis.

Discuss medical Management of Cholelithiasis.

Define cholelithiasis and its type,

Describe the pathophisiology of cholelithiasis,

Discuss Sign and Symptoms and diagnostic tests of

Cholelithiasis.

Discuss medical Management of Cholelithiasis.

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Shape: Pear shaped

Size: 7-10cm x 3cm

Capacity: 30-50 ml.

Parts: Fundus, Body, Neck

Cystic duct: 3-4 cm long

CBD: 8 cm long

6 mm in diameter

Functions of GB:

1. Storage & conc. of bile

2. Acidification of Bile

Anatomy and physiology of gall bladder

Shape: Pear shaped

Size: 7-10cm x 3cm

Capacity: 30-50 ml.

Parts: Fundus, Body, Neck

Cystic duct: 3-4 cm long

CBD: 8 cm long

6 mm in diameter

Functions of GB:

1. Storage & conc. of bile

2. Acidification of Bile

FUNCTIONS OF THE GALLBLADDER.

The gallbladder functions as a storage for bile.

Bile produced by the hepatocytes enters thegallbladder.

During storage, a large portion of the water in bile isabsorbed through the walls of the gallbladder.

So that gallbladder bile is five to ten times moreconcentrated than that originally secreted by the liver.

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The gallbladder functions as a storage for bile.

Bile produced by the hepatocytes enters thegallbladder.

During storage, a large portion of the water in bile isabsorbed through the walls of the gallbladder.

So that gallbladder bile is five to ten times moreconcentrated than that originally secreted by the liver.

Cont…

When food enters the duodenum, the gallbladdercontracts and the sphincter of Oddi (located at thejunction where the common bile duct enters theduodenum) relaxes. Relaxation of the sphincter ofOddi allows the bile to enter the intestine.

This response is mediated by secretion of thehormone cholecystokinin (CCK) from the intestinalwall.

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When food enters the duodenum, the gallbladdercontracts and the sphincter of Oddi (located at thejunction where the common bile duct enters theduodenum) relaxes. Relaxation of the sphincter ofOddi allows the bile to enter the intestine.

This response is mediated by secretion of thehormone cholecystokinin (CCK) from the intestinalwall.

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Introduction

The incidence of gall stone increases with age as dothe risks associated with Cholelithiasis.

The ratio of Cholelithiasis patients is higher inwomen as compared to men 3:1 by 40 to 60 years ofage.

Clients with Diabetes mellitus, obesity, those withcirrhosis show an increased incidence of cholesterolgallstone is 75% in those of 25years of age.

The incidence of gall stone increases with age as dothe risks associated with Cholelithiasis.

The ratio of Cholelithiasis patients is higher inwomen as compared to men 3:1 by 40 to 60 years ofage.

Clients with Diabetes mellitus, obesity, those withcirrhosis show an increased incidence of cholesterolgallstone is 75% in those of 25years of age.

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Cholelithiasis

Presence of stones in the gallbladder is calledCholelithiasis. They arecrystalline structures formedby mainly cholesterol andbilirubin.

A hard painful mass that canform in the gall bladder(oxford dictionary).

Presence of stones in the gallbladder is calledCholelithiasis. They arecrystalline structures formedby mainly cholesterol andbilirubin.

A hard painful mass that canform in the gall bladder(oxford dictionary).

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Cholelithiasis

Approximately 80% ofgallstones arecomposed primarily ofcholesterol.

20% are black orbrown pigment stonesconsisting of calciumsalts with bilirubin.

Approximately 80% ofgallstones arecomposed primarily ofcholesterol.

20% are black orbrown pigment stonesconsisting of calciumsalts with bilirubin.

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Types of Cholelithiasis

Generally there are three types of gall stones. The incidence ofa pure stone is rare, so that they are classified bypredominant substance.

1. Cholesterol stonesSupersaturated with cholesterol but deficient in bile salts.2. Pigment stonesBile contains an excessive of bilirubin(which is a part of old,

dead blood cells). Mixed stonesCombination of Pigment and Cholesterol stones or either of

these with some other substances (Calcium carbonate,Phosphates etc.)

Generally there are three types of gall stones. The incidence ofa pure stone is rare, so that they are classified bypredominant substance.

1. Cholesterol stonesSupersaturated with cholesterol but deficient in bile salts.2. Pigment stonesBile contains an excessive of bilirubin(which is a part of old,

dead blood cells). Mixed stonesCombination of Pigment and Cholesterol stones or either of

these with some other substances (Calcium carbonate,Phosphates etc.)

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Pathophysiology

Gall stone formation involves several ways. Bile must become supersaturated with cholesterol or calcium. The solute precipitate from solution as solid crystals. Crystals come together and fuse to form stones. Color of gall stones is according to their predominant substances.

Such as cholesterol stones are usually smooth and whitish yellowwhile pigment stones may be black.

Mostly they formed in gall bladder, but may also form in thecommon duct or hepatic ducts of liver.

Gall stone formation involves several ways. Bile must become supersaturated with cholesterol or calcium. The solute precipitate from solution as solid crystals. Crystals come together and fuse to form stones. Color of gall stones is according to their predominant substances.

Such as cholesterol stones are usually smooth and whitish yellowwhile pigment stones may be black.

Mostly they formed in gall bladder, but may also form in thecommon duct or hepatic ducts of liver.

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Etiology According various theories there are three explanations

for stone formation.

1. Abnormalities in the composition in bile.

2. Gall bladder stasis may lead to bile stasis.

- Change the composition of bile.

- Supersaturated bile with cholesterol.

- Precipitate some bile constituents.

3. Inflammation of the gall bladder.

According various theories there are three explanations

for stone formation.

1. Abnormalities in the composition in bile.

2. Gall bladder stasis may lead to bile stasis.

- Change the composition of bile.

- Supersaturated bile with cholesterol.

- Precipitate some bile constituents.

3. Inflammation of the gall bladder.12

Risk factors

Excessive secretion of cholesterol by liver is the most importantfactor of stone formation, it occurs in following conditions.

Obesity. Age (mostly 40 onwards). Sex (male to female ratio 1:3). Multiple Pregnancy. Taking oral Contraceptive Pills. Family history.

Excessive secretion of cholesterol by liver is the most importantfactor of stone formation, it occurs in following conditions.

Obesity. Age (mostly 40 onwards). Sex (male to female ratio 1:3). Multiple Pregnancy. Taking oral Contraceptive Pills. Family history.

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Sign and symptoms Asymptomatic About 80% of cases are asymptomatic Symptomatic Most specific and characteristic sign of gall stone is

pain or biliary colic, caused by biliary ducts spasm. Characteristically pain starts in the upper midline area.

It may radiate around to the back and right shoulderblade.

Client often restless. Nausea and vomiting. Jaundice (if there is common bile duct obstruction)

Asymptomatic About 80% of cases are asymptomatic Symptomatic Most specific and characteristic sign of gall stone is

pain or biliary colic, caused by biliary ducts spasm. Characteristically pain starts in the upper midline area.

It may radiate around to the back and right shoulderblade.

Client often restless. Nausea and vomiting. Jaundice (if there is common bile duct obstruction)

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Diagnostic tests

X-ray Abdomen.

Ultrasound Abdomen

ERCP (Endoscopicretrograde cholangio-Pancreatography)

MRCP (Magnetic ResonanceCholangio-Pancreatography)

X-ray Abdomen.

Ultrasound Abdomen

ERCP (Endoscopicretrograde cholangio-Pancreatography)

MRCP (Magnetic ResonanceCholangio-Pancreatography)

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Surgical ManagementLaparoscopic cholecystectomy It has become the treatment for symptomatic gallbladder

disease. It is suitable for most clients, because there isminimal trauma to the abdominal wall. This makes itpossible for clients to go home within 24 hours afterprocedure and return to work within few days.

Cholecystectomy It consists of excising the gallbladder from posterior liver

wall and ligating the cystic duct, vein, and artery.

Laparoscopic cholecystectomy It has become the treatment for symptomatic gallbladder

disease. It is suitable for most clients, because there isminimal trauma to the abdominal wall. This makes itpossible for clients to go home within 24 hours afterprocedure and return to work within few days.

Cholecystectomy It consists of excising the gallbladder from posterior liver

wall and ligating the cystic duct, vein, and artery.

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Non-Surgical Approachesto Eradicate Stones

Endoscopy Retrograde Endoscopy is done to remove gallstone from the common bile

duct, the Physician passes an endoscope orally into the duodenum and thenpasses a wire snare into the common bile duct.

Gallstone Dissolution (Cholesterol Dissolving Agents) The oral administration of agents for dissolving cholesterol gallstones.

i.e. Chenodeoxycholic Acid, or Ursodeoxycholic Acid, and Ursodiol mayused in those selected clients who refuse or unfit for surgery.

Extracorporeal Shock Wave Lithotripsy It may used in some cases. Stones are fewer than four, each smaller than

3cm in diameter and no history of Liver or Pancreatic disease.

Endoscopy Retrograde Endoscopy is done to remove gallstone from the common bile

duct, the Physician passes an endoscope orally into the duodenum and thenpasses a wire snare into the common bile duct.

Gallstone Dissolution (Cholesterol Dissolving Agents) The oral administration of agents for dissolving cholesterol gallstones.

i.e. Chenodeoxycholic Acid, or Ursodeoxycholic Acid, and Ursodiol mayused in those selected clients who refuse or unfit for surgery.

Extracorporeal Shock Wave Lithotripsy It may used in some cases. Stones are fewer than four, each smaller than

3cm in diameter and no history of Liver or Pancreatic disease.

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Summary

Presence of stones in the gall bladder is called Cholelithiasis. There are three typesof gall stones, 1.Cholesterol stones, (Supersaturated with cholesterol but deficient inbile salts)

Pigment stones (Bile contains an excessive of unconjugated bilirubin) 3. Mixedstones (Cholesterol, pigment stones and mixed with calcium).

Risk factors are Obesity, rapid weight loss, Age (mostly 40 onwards), sex (male tofemale ratio 1:3), Pregnancy.

Priority Nursing Diagnosis is acute pain or chronic pain related to biliary spasms.

To manage gall stones client who is Asymptomatic (no any treatment), while in

Symptomatic clients medicine and care is given as per complain otherwise surgicaland non-surgical techniques are used such as, Laparoscopic cholecystectomy,Cholecystectomy, Endoscopy, Gallstone Dissolution, Lithotripsy.

Presence of stones in the gall bladder is called Cholelithiasis. There are three typesof gall stones, 1.Cholesterol stones, (Supersaturated with cholesterol but deficient inbile salts)

Pigment stones (Bile contains an excessive of unconjugated bilirubin) 3. Mixedstones (Cholesterol, pigment stones and mixed with calcium).

Risk factors are Obesity, rapid weight loss, Age (mostly 40 onwards), sex (male tofemale ratio 1:3), Pregnancy.

Priority Nursing Diagnosis is acute pain or chronic pain related to biliary spasms.

To manage gall stones client who is Asymptomatic (no any treatment), while in

Symptomatic clients medicine and care is given as per complain otherwise surgicaland non-surgical techniques are used such as, Laparoscopic cholecystectomy,Cholecystectomy, Endoscopy, Gallstone Dissolution, Lithotripsy.

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Cholecystitis

Inflammation of gallbladder is called as cholecystitis.

Two types of cholecystitis.

Acute cholecystitis

Chronic cholecystitis.

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Inflammation of gallbladder is called as cholecystitis.

Two types of cholecystitis.

Acute cholecystitis

Chronic cholecystitis.

Cholecystitis

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Acute cholecystitis

Acute cholecystitis is acute inflammation of gallbladder.

It is precipitated 90% of time by gallstones obstruction

of neck or cystic duct.

Acalculous cholecystitis describes acute gallbladder

inflammation in the absence of obstruction by gallstones.

For example: Surgical procedure, sever trauma, severe

burns. 21

Acute cholecystitis is acute inflammation of gallbladder.

It is precipitated 90% of time by gallstones obstruction

of neck or cystic duct.

Acalculous cholecystitis describes acute gallbladder

inflammation in the absence of obstruction by gallstones.

For example: Surgical procedure, sever trauma, severe

burns.

Clinical features

Right upper quadrant pain. Pain radiates to right scapula and right shoulder. Fever. Anorexia. Tachycardia. Diaphoresis. Nausea & vomiting.

Jaundice.

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Right upper quadrant pain. Pain radiates to right scapula and right shoulder. Fever. Anorexia. Tachycardia. Diaphoresis. Nausea & vomiting.

Jaundice.

Pathophysiology(Calculus Cholecystitis)

A gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a

chemical reaction. It causes autolysis and edema. The blood vessels in the gallbladder are

compressed, compromising its vascular supply. Gangrene of gallbladder with perforation may

result. Bacteria play a minor role in acute cholecystitis .i.e.

Enterococci, Staphylococci , E. coli

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A gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a

chemical reaction. It causes autolysis and edema. The blood vessels in the gallbladder are

compressed, compromising its vascular supply. Gangrene of gallbladder with perforation may

result. Bacteria play a minor role in acute cholecystitis .i.e.

Enterococci, Staphylococci , E. coli

Pathophysiology (Acalculus Cholecystitis)

Acalculous cholecystitis describes acute gallbladderinflammation in the absence of obstruction bygallstones.

Acalculous cholecystitis occurs after major surgicalprocedures, severe trauma, or burns.

Other factors: Torsion, cystic duct obstruction, bacterial infections

It results from alterations in fluids and electrolytes andin regional blood flow in the visceral circulation.

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Acalculous cholecystitis describes acute gallbladderinflammation in the absence of obstruction bygallstones.

Acalculous cholecystitis occurs after major surgicalprocedures, severe trauma, or burns.

Other factors: Torsion, cystic duct obstruction, bacterial infections

It results from alterations in fluids and electrolytes andin regional blood flow in the visceral circulation.

Investigations

Ultrasonography

The use of ultrasound is based on reflected soundwaves.

Ultrasonography can detect calculi in thegallbladder or a dilated common bile duct.

To detect gallstones with 95% accuracy.

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Ultrasonography

The use of ultrasound is based on reflected soundwaves.

Ultrasonography can detect calculi in thegallbladder or a dilated common bile duct.

To detect gallstones with 95% accuracy.

Cholescintigraphy (Gall bladder Scan)

Cholescintigraphy is used successfully in thediagnosis of acute cholecystitis.

A radioactive agent (Technitum 99-M) isadministered intravenously.

It is taken up by the hepatocytes and excretedrapidly through the biliary tract.

The biliary tract is then scanned, and images of thegallbladder and biliary tract are obtained.

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Cholescintigraphy is used successfully in thediagnosis of acute cholecystitis.

A radioactive agent (Technitum 99-M) isadministered intravenously.

It is taken up by the hepatocytes and excretedrapidly through the biliary tract.

The biliary tract is then scanned, and images of thegallbladder and biliary tract are obtained.

Surgical Management

Laparoscopic cholecystectomy:

Removal of gallbladder through endoscopicprocedure.

Lithotripsy: Disintegration of gallstones by shockwaves.

Laser cholecystectomy: Removal of gallbladderusing laser rather than scalpel and traditional surgicalinstruments.

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Laparoscopic cholecystectomy:

Removal of gallbladder through endoscopicprocedure.

Lithotripsy: Disintegration of gallstones by shockwaves.

Laser cholecystectomy: Removal of gallbladderusing laser rather than scalpel and traditional surgicalinstruments.

REFERENCES

Porth, MC. (2002). Pathophysiology. (6th Ed:).Philadelphia. USA. Lippincott Willams & Willkins, A

Wolters Kluwer Company

McPhee, J. S., & Papadakis, A. M. (2011). CurrentMedical Diagnosis and Treatment. (50th Ed:).Chicago. USA: Mc Graw Hill

Inam D. M.. (2005). Short Text Book of Pathology, 3rdEdition Paramount Publishing Enterprises. Karachi.Pakistan.

Porth, MC. (2002). Pathophysiology. (6th Ed:).Philadelphia. USA. Lippincott Willams & Willkins, A

Wolters Kluwer Company

McPhee, J. S., & Papadakis, A. M. (2011). CurrentMedical Diagnosis and Treatment. (50th Ed:).Chicago. USA: Mc Graw Hill

Inam D. M.. (2005). Short Text Book of Pathology, 3rdEdition Paramount Publishing Enterprises. Karachi.Pakistan.

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