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Cholelithiasis

Terms in this set (17)

Cholelithiasis (most common disorder in US)
Made up of cholesterol mainly, but can be made up of other items: calcium, etc.
Definition
Formation or presence of stones in the gallbladder
Cholelithiasis (most common disorder in US)
Etiology & Pathophysiology
Cause is unknown
Risk factors
Females, multiparous, overweight
Other: over age 40, sedentary lifestyle, family tendencies (genetic), high fat diet, alcoholism, estrogen therapy
Cholelithiasis: Clinical Manifestation

When stones start to move that is when the pain starts.
Severe symptoms or "silent cholelithiasis"
Biliary colic (pain/discomfort)
Severe excruciating pain
RUQ tenderness
Blockage of flow of bile from the liver to the intestine
Bile is yellow green fluid, produced by the liver and stored in the gallbladder.
Eating=gallbladder contracts and empties bile into the small intestine
What triggers these symptoms?
High fat meal, heavy meal, laying down directly after eating
What would be a sign of a blockage?
Steatorrhea, dark amber urine, constipation, jaundice, clay colored stools, pruritus (itchy)
Diagnostic Studies

Lab values
WBC count elevated (leukocytosis) normal is 5-10K , liver function studies (enzymes could be high), serum bilirubin (enzymes could be high)
Ultrasound
Percutaneous transhepatic cholangiography - insertion of needle directly into gallbladder duct followed by injection of contrast materials.
ERCP (endoscopic retrograde cholangiopancreatography) - tube down throat, uses and endoscope passed to duodenum to visualize the gallbladder and ducts through the scope, can also widen the sphincter of Oddi. (Can snag the stone with basket or if not reached the stone will be passed later on
Collaborative Care
Treatment depends on gallstones and stage of disease. Bile acids(cholesterol solvents) can dissolve acids, stones usually not treated with medication
Nonsurgical removal of stones
ERCP (endoscopic retrograde cholangiopancreatography) with sphincterotomy - widening of sphincter (more stones can form later)
After care: Monitor patient for HYPOVOLEMIA - low blood volume, check gag reflex (did they have one before?), check vital signs, may be nauseated - antiemetic, esophagus may get perforated.

ESWL (extracorporeal shock-wave lithotripsy) used when stones are too large to pass. Shockwaves used to dissolve the stone, not used very often though. Used in conjunction with meds to assist with dissolving of stones
Nursing Management

Treatment of choice for symptomatic cholelithiasis is surgical removal of gallbladder
Surgical care
Preoperative care
Depends on type of surgery.
Teach about Hypostatic pneumonia (cough and deep breath) - secretions stay in one spot, don't move.
Importance of moving and turning
If laproscoptic surgery: key holes in abd, explain how pain will be dealt with.
Postoperative care
Monitor dressings, pain level, vital signs
*main complication is injury to the common bile duct
Monitor any tubes (T-tube or transhepatic biliary catheter): relieves an obstruction
-bile drains into the bag, may stay in a week or a couple weeks.
-Why? Biliary obstruction is a common problem
What are the common foods intolerances for clients with cholelithiasis?
-fried, spicy foods
Cholecystitis

Acute inflammation of the gallbladder

Cholecystitis:Etiology & Pathophysiology
Usually caused by obstruction from gallstones
Other causes
Older adults, trauma victims, burns, DM, bacteria: E. coli. Recent surgery
Cholecystitis:Complications
Gangrenous cholecystitis -inflamed, edematous, filled with pus
Bile peritonitis - rupture
Other
Older patients and DM most at risk for these complications
Cholecystitis:Clinical Manifestations

Pain & tenderness RUQ
Referred pain to right shoulder/scapula
Indigestion, N/V
Restless
Fever
Diaphoretic
Leukocytosis
ABD firm, rigid
Heartburn with chronic cholecystitis
Flatulence with chronic cholecystitis
Cholecystitis Collaborative Care

Control of pain
Control of possible infection - ATB to Tx or prevent
Maintain fluid & electrolyte balance
Monitor I&O
NG tube/gastric decompression for severe N/V (helps to prevent further gallbladder stimulation) NPO
Oral care
Nostril care if they have an NG tube
Cholecystitis Nursing Management
Supportive treatment of symptoms
Surgical care
Laparoscopic Cholecystectomy (Lap chole) - key hole surgery. 90% of all chole's are laproscopic.
Incisional (open) Cholecystectomy (if unable to be removed laparoscopic)
Greater risk of infection
*Morphine is believed to cause biliary spasms. Demerol is preferred analgesic. Elder should not be given Demerol risk of acute confusion and sezuires
Cholecystectomy
Laparoscopic Cholecystectomy
Preoperative Care
-Turn
-Cough
-Deep
-Breath
-Teach about incentive spirometer
Postoperative Care
-Diet
-Few activity restrictions
-May shower the day after
-May have shoulder pain - Due to CO2 migrating and irritating phrenic nerve and diaphragm and leading to shoulder pain. Moving around, pain meds, and lying in Sims position will help.
Incisional (open) Cholecystectomy
Preoperative Care
-TCDB
-teach incentive spirometer
-what to expect with incision: cleaning, cleaning, etc.
-hospital stay: 2-3 days
-No heavy lifting for 4-6 weeks
-possible dehiscence


Postoperative Care
-liquid to bland diet AFTER the return of bowel sounds
-restrict fat in diet for a while.
-TCDB at least every 2 hours
-smokers have an increased with pneumonia, atelectasis.

*bile color should be gold to dark green
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