CHOLELITHIASIS DEFINITION Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile and vary

y greatly in size, shape, and composition. - Smeltzer, S.C., Bare, B.G. Brunner & suddarths Textbook of Mecial-Surgical Nursing !0th Edition. Stones on the gallbladder or biliary tree are referred to collectively as cholelithiasis. Most patients have multiplestones, sometimes several dozen.Most gallstones (80%) are cholesterol gallstones, which form when bilebecomes oversaturated with cholesterol. Pigment gallstones, accounting for the remaining 20% of gallstones arecomposed of bilirubin and bile substances other than cholesterol. - McConnell, T. H., The Nature of Disease Pathology for the Health Professions. 2007 Gallstones are hard, pebble-like deposits that form inside the gallbladder. Gallstones may be as small as a grain of sand or as large as a golf ball, depending on how long they have been forming. - http ://w ww.n l m .n i h .go v /m e d l i ne p l u s /e n c y/a r ti c l e /0 0 02 73 .htm ANATOMY AND PHYSIOLOGY Gastroinstestinal Tract The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food entersthe mouth, continuing through the pharynx, esophagus, stomach and intestines to the rectum and anus, where food isexpelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into itscomponent nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestivesystem. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls. The primarypurpose of the gastrointestinal tract is to break down food into nutrients, which can be absorbed into the body to provide energy. Focus: GALLBLADDER The gallbladder (or cholecyst, sometimes gall bladder) is a smallorgan whose function in the body is to harborbile and aid in the digestive process. Anatomy The cystic duct connects the gall bladder to the common hepatic duct to form the common bile duct. The common bile romero duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla. The fundus of the gallbladder is the part farthest from the duct, located by the lower border of the liver. It is at the same level as the transpyloric plane. Microscopic anatomy The different layers of the gallbladder are as follows: The gallbladder has a simple columnar epithelial lining characterized byrecesses called Aschoff's recesses, which are pouches inside the lining. Under the epithelium there is a layer of connective tissue (lamina propria). Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in response to

cholecystokinin, a peptide hormone secreted by the duodenum. There is essentially no submucosa separating the connective tissue from serosa and adventitia. Size and Location of the Gallbladder The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm broad at its widest point.It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It lies on the undersurface of the livers right lobeand is attached there by areolar connective tissue. Structure of the Gallbladder Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach. Function of the Gallbladder The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During this time the gallbladderconcentrates bile fivefold to tenfold. Then later, when digestion occurs in the stomach and intestines, the gallbladdercontracts, ejecting the concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and mucosa,results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in thefeces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue enters the blood and isdeposited in the tissues. The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of bile, which is releasedwhen food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, producedin the liver, emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum. ETIOLOGY Predisposing Factors Justification Age (40 and above) Most internal functions decline as one ages. Inevitably resulting in organ degeneration which also affects the body's metabolism of lipids. Gender Gallstones is more frequent on women especially who had have had multiple pregnanciesor who are taking oral contraceptives. Increase level of Estrogen reduces the synthesis ofbile acid in women. Female sex hormones have long been suspected to have a side effectof gallstone formation by altering respective bile constituents (mainly the FAT metabolism). Ileal Disease/Resection People who have disease of the terminal ileum or who have undergone resection of theterminal ileum deplete their bile salt pool and run a greater risk of developing cholesterolgallstones. Race Cholesterol stones are common in Northern Europe and in North and South America. Genetics Most clinicians have an impression that gallbladder disease characterizes some families.Indeed, the younger sisters of women with gallstone prove to have bile more highlysaturated with cholesterol than the younger sisters of women without gallstones, all ofwhich suggests that Cholelithiasis does run in families.

Inflammation and infection of the gallbladderInflammation or infection in the biliary structures may provide a focus for stone formation or may alter the solubility of the constituents, fostering the development of a stone. Hemolytic Disease and Hepatic Cirrhosis In cirrhosis, at least two fifths of patients have gallstones. One possible mechanism behindthe appearance of pigment softness, so far unproven, is the excretion of unconjugatedbilirubin directly into the bile, something that might happen in patient with hemolysis or inthe cirrhotic with his high incidence of pigment stones, currently estimated at 27 %. Bile stasis Brown pigment gallstones form when there is stasis of bile (decreased flow), for example, when there are narrow, obstructed bile ducts. Precipitating Factors Justification Faulty Diet Excessive intake of high fat or cholesterol food such as pork meat, animal skin (e.g.chicharon and chicken skin) can result to an increase in cholesterol level in the body,making it hard for the liver to make bile enough to metabolized the all cholesterol present.Excess cholesterol present builds up and increases the cholesterol serum level. NormalLiver function would then try to compensate and excrete excess cholesterol to the bile plusthe body would reabsorb water from the bile making it more concentrated. Supersaturationof Cholesterol along with other constituents of the bile (bilirubin, lecithin etc.) builds upmicrocrystals. When microcrystals aggregate it would result to Gallstones. Weight Loss Weight loss is associated with an increased risk of gallstones because weight lossincreases bile cholesterol supersaturation, enhances cholesterol crystal nucleation, anddecreases gallbladder contractility. Obesity Obesity is a major risk factor for gallstones, especially in women. A large clinical studyshowed that being even moderately overweight increases the risk for developinggallstones. The most likely reason is that obesity tends to reduce the amount of bile salts inbile, resulting in more cholesterol. Obesity also decreases gallbladder emptying. Pregnancy Altered physiology of the biliary system during pregnancy may play a role in accelerating the formation of stones in susceptible women. Treatment with estrogen/ contraceptives The contraceptive pill not only promotes thromobphlebitis but points to an endocrinebackground of gallstones by the risk of gallstones in young women taking the pill. This islargely as a result of increased cholesterol secretion into the bile and a decrease inchenodeoxycholic acid content, along with impaired emptying of the gallbladder broughtabout by estrogen. Frequent Starvation and Prolonged parenteral nutrition Starvation decreases gallbladder movement causing the bile to become overconcentratedwith cholesterol. The liver also secretes extra cholesterol into bile adding to thesupersaturation causing stone

formation. Also, fasting persons have a diminished bile saltpool and lithogenic bile.Gallbladder stasis plays a key role in permitting stone formation.Defective or infrequent gallbladder emptying occurs in the settings of prolonged fasting,rapid weight loss, pregnancy, and spinal cord injury. Clofibrate use and other Antilipemic drugs Drugs that lower the serum level of cholesterol, notably clofibrate, are associated with anincreased incidence of gallstones. Clofibrate presumably increases the secretion ofcholesterol into the bile and apparently also decreases bile acid synthesis, so increasingthe cholesterol saturation of the bile. Clinical reflection of these physiologic abnormalitieshas been found in the overwhelming association between clofibrate therapy and gallstones. SYMPTOMATOLOGY SIGNS AND SYMPTOMS JUSTIFICATION Jaundice Jaundice results from an abnormally high accumulation of bilirubin in the blood as a result ofwhich there is a yellowish discoloration to the skin and deep tissues. Jaundice becomesevident when the serum bilirubin level rises above 2.0 to 2.5 mg/dL. Pale Stool Bilirubin together with cholesterol is normally absorbed in the intestines and is usuallyexcreted within the feces. The bile gives the stool its brown to black color. Obstruction in thebile flow lessens and may hinder the absorption of bile in the intestines making the stool palein color. Dark Urine Normally urine are not dark in color, excess bilirubin are excreted by the kidneys as a compensatory mechanism to balance the bile level in the body. Pruritus or generalized itching Prutitus is the most common presenting symptom in persons with cholestasis, probably relatedto an elevationin plasma bile acids Pain Due to the gallstones and microcrystals present inside the gall bladder, the gallbladder can'tcontract properly which creates pain in the epigastric area (right side of the abdominal area),often with reffered pain, above the waist , the right shoulderand the right scapula or themidscapular region. -A gallstone produces visceral pain by obstructing the cystic duct or ampulla of Vater, resulting in distention of the gallbladder or biliary tree Epigastric Distress Nausea & Vomiting Fullness Indigestion Less or absence of bile acid in the doudenum means less or no digestion of fats. Increased bilirubin in the blood When gallstones obstruct the bile going to the intestine, bilirubin tends to return the bodys circulation. Vitamin deficiencies

Obstruction of bile flow also interferes with absorption of the fat-soluble vitamins A, D, E & K.Therefore the patient may exhibit deficiencies of these vitamins if biliary obstruction hasbeen prolonged