CHOLELITHIASIS

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

Types of Gall stones

1. Cholesterol stones radiating crystal like appearance
2. Mixed stones- Most common type of stones;contains
cholesterol, calcium salts of phosphates and carbonates,
palmitate ,proteins and are multiple faceted.
3. Pigment stones- small, black or greenish black, multiple
and often sludge like.

Pigment stones
Black pigment stones
Most common
Formed in gall bladder
Made of Calcium
bilirubinate,phosphate,bic
arbonate
Common in hemolytic
disorders,cirrhosis
Multiple , small & hard in
consistency

Brown pigment
stones
Rarely form in gall
bladder
Formed in bile duct
Related to bile stasis
& infected bile
E.coli, Bacteroides

ETIOLOGY/CAUSES
It's not clear what causes gallstones to form.
Doctors think gallstones may result when:
Your bile contains too much
cholesterol. Normally, your bile contains enough
chemicals to dissolve the cholesterol excreted by your
liver. But if your liver excretes more cholesterol than
your bile can dissolve, the excess cholesterol may form
into crystals and eventually into stones.

 Your bile contains too much

bilirubin. Bilirubin is a chemical that's produced
when your body breaks down red blood cells. Certain
conditions cause your liver to make too much bilirubin,
including liver cirrhosis, biliary tract infections and
certain blood disorders. The excess bilirubin
contributes to gallstone formation.

Your gallbladder doesn't empty correctly. If

your gallbladder doesn't empty completely or often
enough, bile may become very concentrated and this
contributes to the formation of gallstones.

RISK FACTORS

Liver Cirrhosis
Hemolysis
Infection in the Biliary System
Infection in the Biliary Tract
Geriatrics
GI Disease/ T-Tube Fistula
DM insulin increase the ablity to take up glucose
Cystic Fibrosis defective chloride channels which causes cells to
produce thick, viscous, mucous secretion Prevents pancreatic
enzymes in reaching the duodenum Results to slowed fat digestion
5 Fs Fair, Fat, Fertile, Female, Fourty

 FAT /FEMALE: decrease bile salts in the bile and

excess estrogen is prevalent
FERTILE: Hormonal Replacement Therapy,
intake of oral contraceptives which increases the
saturation of cholesterol ; CLOFIBRATE
FAIR : Genetically speaking is candidate for
gallstone formation
FORTY: DEGENERATIVE PROCESS - Increase
in risk of stone formation as there is an increase
in age because hepatic secretion of cholesterol
is increasing and there is a decrease bile acid
synthesis

 MULTIPARITY
Benign Cholestatic jaundice of Pregnancy, with
retention of conjugated bilirubin probably
secondary to unusual sensitivity to the hormones of
pregnancy
Repeated pregnancy causes increased gallstone
formation due to changes in gallbladder kinetics
leading to stasis and stone formation

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 5-10
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 cholecystokininpancreozymin (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)

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 color skin and mucous membrane

 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

Complications of Gall stones

In Gall BladderAcute cholecystitis
Chronic cholecystitis
Empyema of gall bladder
Mucocele gall bladder
Perforation leading to
biliary peritonitis
Gangrene of gall bladder
Carcinoma

In Bile ductObstructive jaundice

Cholangitis
Acute pancreatitis

In IntestineAcute intestinal
obstruction

Management
Investigations
USG abdomen posterior
acoustic shadowing
Plain X RAY abdomen
LFT- Increased
conjugated bilirubin
Increased Alkaline
Phosphate, GGT, 5Nucleotidase

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

D/D of radio-opaque shadow

on x-ray

Renal stone
Calcified 12th rib tip
Phlebolith
Faecolith
Calcified lymph node
Renal cell Ca calcification
Calcified Adrenal tumor

Treatment
Medical therapy GALL STONE DISSOLUTION
Ursodeoxycholic acid (UDCA) with a
functioning Gall bladder with stone less
than 10 mm
10-15 mg/kg/day
Pigment stones are non responsive to
medical therapy

 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
Laparoscopic
cholecystectomy is
ideal.
Open cholecystectomy
is done if patient unfit
for laparoscopy
through Right Subcostal(KOCHERSs)
incision.

Cholecystectomy
Minicholecystectomy
Laparoscopic cholecystectomy
Percutaneous cholecystostomy

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

NURSINGMANAGEMENT

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

THANK
YOU