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Epidemiology
Fat, Female, Fertile, Fourty inaccurate, but reminder of
the typical patient
F:M = 2:1
10% of British women in their 40s have gallstones
Genetic predisposition – ask about family history
Cholesterol
Imbalance between bile salts/lecithin and cholesterol allows
cholesterol to precipitate out of solution and form stones
Pigment
Occur due to excess of circulating bile pigment (e.g.
Heamolytic anaemia)
Mixed
Same pathophysiology as cholesterol stones
Other Factors
Stasis (e.g. Pregnancy)
Ileal dysfunction (prevents re-absorption of bile salts)
Obesity and hypercholesterolaemia
b. Most gallstones are composed primarily of bile
(80%); remainder are composed of a mixture of bile
components
c. Excess cholesterol in bile is associated with
obesity, high-cholesterol diet and drugs that lower
cholesterol levels
d. If stones from gallbladder lodge in the cystic
duct
◦ 1. There can be reflux of bile into the gallbladder
and liver
◦ 2. Gallbladder has increased pressure leading to
ischemia and inflammation
◦ 3. Severe ischemia can lead to necrosis of the gall
bladder
◦ 4. If the common bile duct is obstructed, pancreatitis
can develop
Risk factors for cholelithiasis
a. Age
b. Family history, also Native Americans
and persons of northern European heritage
c. Obesity, hyperlipidemia
d. Females, use of oral contraceptives
e. Conditions which lead to biliary stasis:
pregnancy, fasting, prolonged parenteral
nutrition
f. Diseases including cirrhosis, ileal
disease or resection, sickle-cell anemia,
glucose intolerance
Manifestations of cholelithiasis
a. Many persons are asymptomatic
b. Early symptoms are epigastic fullness
after meals or mild distress after eating a
fatty meal
c. Biliary colic (if stone is blocking cystic or
common bile duct): steady pain in epigastric
or RUQ of abdomen lasting up to 5 hours
with nausea and vomiting
d. Jaundice may occur if there is
obstruction of common bile duct
Manifestations of acute cholecystitis
a. Episode of biliary colic involving RUQ pain
radiating to back, right scapula, or shoulder;
the pain may be aggravated by movement, or
deep breathing and may last 12 – 18 hours
b. Anorexia, nausea, and vomiting
c. Fever with chills
Complications of cholecystitis
a. Chronic cholecystitis occurs after
repeated attacks of acute cholecystitis;
often asymptomatic
b. Empyema: collection of infected fluid
within gallbladder
c. Gangrene of gall bladder with
perforation leading to peritonitis, abscess
formation
d. Pancreatitis, liver damage, intestinal
obstruction
Collaborative Care
a. Treatment depends on the acuity of symptoms and
client’s health status
b. Clients experiencing symptoms are usually treated
with surgical removal of the stones and gallbladder
Diagnostic Tests
a. Serum bilirubin: conjugated bilirubin is elevated with
bile duct obstruction
b. CBC reveals elevation in the WBC as with infection
and inflammation
c. Serum amylase and lipase are elevated, if obstruction
of the common bile duct has caused pancreatitis
d. Ultrasound of gallbladder: identifies presence of
gallstones
e. Other tests may include flat plate of the abdomen,
oral cholecytogram, gall bladder scan
Treatment
a. Treatment of choice is laparoscopic
cholecystectomy
b. If surgery is inappropriate due to client
condition
1. May attempt to dissolve the gallstones with
medications
2. Medications are costly, long duration
3. Stones reoccur when treatment is stopped
Laparoscopic cholecystectomy
a. Minimally invasive procedure with low risk of
complications; required hospital stay< 24 hours.
b. Learning needs of client and family/caregiver
include pain control, deep breathing, mobilization,
incisional care and nutritional/fluids needs
c. Client is given phone contact for problems
Some clients require a surgical laparotomy (incision inside
the abdomen) to remove gall bladder
a. client will have nasogastric tube in place post-
operatively and require several days of hospitalization
b. If exploration of the common bile duct is done with
the cholecystectomy, the client may have a T-tube
inserted which promotes bile passage to the outside as
area heals
Nursing Diagnoses
a. Pain
b. Imbalanced Nutrition: Less than body requirements
c. Risk for Infection
Biliary Colic
Acute Cholecystitis
Gallbladder Empyema
Gallbladder gangrene
Gallbladder perforation
Obstructive Jaundice
Ascending Cholangitis
Pancreatitis
Gallstone Ileus (rare)
Bloods (already discussed)
AXR (10% gallstones are radio-opaque)
E-CXR (to exclude perforation – MUST!)
ECG (to exclude MI)
USS: first line investigation in gallstone disease
Confirms presence of gallstones
Gall bladder wall thickness (if thickened suggests cholecystitis)
Biliary tree calibre (CBD/extrahepatic/intrahepatic) – if dilated suggests stone in CBD (normal CBD <8mm).
Sometimes CBD stone can be seen.
MRCP: To visualise biliary tree accurately (much more accurate than USS)
Diagnostic only but non-invasive
Look for biliary dilatation and any stones in biliary tree
ERCP: Diagnostic and therepeutic in biliary obstruction
Diagnostic and therepeutic but invasive
Look for biliary tree dilatation and stones in biliary tree
Stones can be extracted to unobstruct the biliary tree and perform sphincterotomy
Risk of pancreatitis, duodenal perforation
PTC
To unobstruct biliary tree when ERCP has failed
Invasive – higher complication rate than ERCP
CT: Not first line investigation. Mainly used if suspicion of gallbladder empyema, gangrene, or
perforation and in acute pancreatitis (USS not good for looking at pancreas)
Pathogenesis
Stone intermittently obstructing cystic duct
(causing pain) and then dropping back into
gallbladder (pain subsides)
Treatment
Analgesia
Fluid resuscitation if vomiting
If pain and vomiting subside does not need
admitting
Pathogenesis:
Due to obstruction of cystic duct by gallstone:
Cystic duct blockage by gallstone
Obstruction to secretion of bile from gallbladder
Bile becomes concentrated
Chemical inflammation initially
Secondarily infected by organisms released by liver into bile stream
Treatment
Admit for monitoring
Analgesia
Clear fluids initially, then build up oral intake as cholecystitis settles
IVF
Antibiotics
95% settle with above management
If do not settle then for CT scan
Empyema percutaneous drainage
Gangrene/perforation with generalised peritonitis emergency surgery
Pathogenesis:
Stone obstructing CBD (bear in mind there are other causes for obstructive
jaundice) – danger is progression to ascending cholangitis.
USS
Will confirm gallstones in the gallbladder
CBD dilatation i.e. >8mm (not always!)
May visualise stone in CBD (most often does not)
MRCP
In cases where suspect stone in CBD but USS indeterminate
E.g.1 obstructive LFTs but USS shows no biliary dilatation and no stone in CBD
E.g. 2 normal LFTS but USS shows biliary dilatation
ERCP
If confirmed stone in CBD on USS or MRCP proceed to ERCP which will confirm this (diagnostic)
and allow extraction of stones and sphincterotomy (therepeutic)
Treatment
Must unobstruct biliary tree with ERCP to prevent progression to ascending
cholangitis
Whilst awaiting ERCP monitor for signs of sepsis suggestive of cholangitis
Pathogenesis:
Stone obstructing CBD with infection/pus
proximal to the blockage
Treatment
ABC
Fluid resuscitation (clear fuids and IVF, catheter)
Antibiotics (Augmentin)
HDU/ITU if unwell/septic shock
Pus must be drained* - this is done by
decompressing the biliary tree
Urgent ERCP
Urgent PTC – if ERCP unavailable or unsuccesful
Pathogenesis
Obstruction of pancreatic outflow
Pancreatic enzymes activated within pancreas
Pancreatic auto-digestion
Treatment
Analgesia
Fluid resuscitation
Pancreatic rest – clear fluids initially
Identify underlying cause of pancreatitis
Treatment
NBM
Fluid resuscitation + catheter
NG tube
Analgesia
Surgery (will not settle with conservative management) – enterotomy +
removal of stone
Indications
A single complication of gallstones is an indication for
cholecystectomy (this includes biliary colic)
After a single complication risk of recurrent complications
is high (and some of these can be life threatening e.g.
cholangitis, pancreatitis)
Advantages:
Less post-op pain
Shorter hospital stay
Quicker return to normal activities
Disadvantages:
Learning curve
Inexperience at performing open cholecystectomies
After acute cholecystitis, cholecystectomy traditionally performed
after 6 weeks