Cholelithiasis/Cholecystitis

How do gallstones develop?

-Gallstones develop when the balance that keeps cholesterol, bile salts, and calcium is altered so that precipitation of these substances occurs. -Infection and disturbances in the metabolism of cholesterol may cause this.

Collaborative Care of Cholelithiasis

-IV fluids -NPO with NG tube then progress to low fat diet -Antiemetics -Analgesia -Fat soluble vitamins A, D, E, K -Anticholinergics (Antispasmodics) -Antibiotics (if 2ndary infection) -ERCP -Extracorporeal shock wave lithotripsy **May use acids to try to dissolve (Actigall/chenodiol) **Surgical Therapy = laparoscopic cholecystectomy or open cholecystectomy ***may need low fat diet for 4-6 weeks following surgical procedure***

Most common drug therapy with gall bladder disease

-analgesics -anticholinergics (antispasmodics) -fat soluble vitamins (A, D, E, K) -bile salts *morphine may be used initially for pain

Complications of cholelithiasis

-cholangitis -biliary cirrhosis -carcinoma -perionitis -choledocholithiasis (stone in the common bile duct)

Post-Op Care for a Laparoscopic Cholecystectomy

-comfort -monitor for complications like bleeding -Sim's position (left side/rt knee bent) helps keep gas pockets away from the diaphragm -encourage deep breathing/movement/ambulation -NSAIDs for pain -clear liquids -may use restroom to void **focus on adequate ventilation and prevention of respiratory complications ***monitor drainage

Collaborative care for cholecystitis

-control of pain -positioning to 'take pressure off' -control of possible infection -maintain fluid electrolyte balance -NG tube/gastric decompression for severe nausea/vomiting

Triggers of cholelithiasis

-fatty foods- attacks often occur 3-6 hours after a high fat meal or when a patient lies down.

Risk factors for developing cholelithiasis.

-females -multiparous -overweight -over age 40 -sedentary lifestyle -familial tendency -post menopausal woman on estrogen therapy -more common in whites and Native Americans

Patho of cholecystitis

-most commonly associated with obstruction caused by gallstones or biliary sludge. -if it occurs w/out obstruction it is usually in older patients or those who have a trauma, extensive burns, or recent surgery.

Clinical manifestations of cholecystitis

-pain and tenderness in RUQ -referred pain to right shoulder/scapula -indigestion -nausea/vomiting -restlessness -fever -jaundice -history of fat intolerance, dyspepsia, heart burn and flatulence.

Other causes of cholecystitis

-prolonged immobility -prolonged fasting -prolonged parenteral nutrition -diabetes mellitus -bacteria/chemical irritants (e. Coli is most common) -adhesions -neoplasms -anesthesia -narcotics

Clinical manifestations of obstructed bile flow

-steatorrhea (white, fatty, floaters) -bleeding tendencies (decreased vit K absorption) -Intolerance for fatty foods (no bile for digestion) -obstructive jaundice (no bile flow in duodenum) -dark amber urine that foams (soluble bilirubin in urine) -no urobilinogen in urine/clay colored stools -pruritis (deposition of bile salts in skin tissues)

Clinical manifestations of cholelithiasis

-symptoms may be severe -'silent cholelithiasis' - no symptoms at all -biliary colic (severe excruciating pain) -RUQ tenderness -tachycardia -diaphoresis -prostration -residual tenderness once pain subsides -symptoms are often related to whether a stone is mobile or stationary.

Diagnostic Studies for cholelithiasis

-ultrasonography is often used to diagnose gall stones (does not depend on liver functioning or use of contrast) -Lab Values: *elevated WBC *liver function studies *serum bilirubin -Percutaneous transhepatic cholangiography -ERCP

What is the difference between Percutaneous transhepatic cholangiography and ERCP?

PTC is usually done after ultrasonography indicates a blockage. PTC is the insertion of a needle in to the gallbladder duct followed by injection of contrast materials. ERCP goes a little further and allows for viewing of the gallbladder, cystic duct, common hepatic duct, and common bile duct. Bile collected during ERCP is sent for culture to identify possible infecting organisms.

Cholelithiasis

The most common disorder of the biliary system. (Stones in the gallbladder.)

Cholecystitis

inflammation of the gall bladder. Usually associated with cholelithiasis.