Adult Medical-Adult Medical-Surgical Nursing Surgical Nursing Gastro-intestinal Module: Gastro-intestinal Module:

CholelithiasisCholelithiasis

Bile FormationBile Formation

The liver hepatocytes produce bile:The liver hepatocytes produce bile:

Bile conjugates bilirubin (fat-soluble → Bile conjugates bilirubin (fat-soluble → water-soluble) for excretionwater-soluble) for excretion

Bile emulsifies fats to promote digestionBile emulsifies fats to promote digestion

The Constituents of BileThe Constituents of Bile

H2OH2O ElectrolytesElectrolytes LecithinLecithin Fatty acidsFatty acids BilirubinBilirubin Bile saltsBile salts CholesterolCholesterol

The Enterohepatic The Enterohepatic CirculationCirculation

Bile is produced by the liver hepatocytesBile is produced by the liver hepatocytes

Bile passes through canaliculi (small Bile passes through canaliculi (small ducts) to the hepatic duct → gall bladder ducts) to the hepatic duct → gall bladder (storage)(storage)

The normal gall bladder stores 50 - 70ml The normal gall bladder stores 50 - 70ml concentrated bile →concentrated bile →

The Enterohepatic The Enterohepatic Circulation (cont)Circulation (cont)

In the presence of fat in the duodenum:In the presence of fat in the duodenum: The hormone Cholecystokinin (CCK) The hormone Cholecystokinin (CCK)

stimulates contraction of the gall-bladder stimulates contraction of the gall-bladder and release of bile into the duodenum and release of bile into the duodenum

Bile salts, cholesterol, lecithin emulsify Bile salts, cholesterol, lecithin emulsify fatsfats

Bile salts are reabsorbed in the distal Bile salts are reabsorbed in the distal ileum into the portal circulation to the liver ileum into the portal circulation to the liver

CholelithiasisCholelithiasis

Cholelithiasis: ClassificationCholelithiasis: Classification

Cholelithiasis means production of gall Cholelithiasis means production of gall stones or calculi in the gall bladderstones or calculi in the gall bladder

There are 2 types of gall stone:There are 2 types of gall stone:

Bile pigment (bilirubin) stonesBile pigment (bilirubin) stones Cholesterol stones (major type)Cholesterol stones (major type)

Bile Pigment StonesBile Pigment Stones

Bile Pigment Stones: Bile Pigment Stones: AetiologyAetiology

Stones are formed from ↑ bile pigmentStones are formed from ↑ bile pigment Related to:Related to: Haemolytic disease where the liver Haemolytic disease where the liver

cannot clear the excess bilirubincannot clear the excess bilirubin Cirrhosis and liver damageCirrhosis and liver damage Hepatic infectionsHepatic infections These stones cannot be dissolved and These stones cannot be dissolved and

require surgical removal if symptomatic require surgical removal if symptomatic

Cholesterol Gall StonesCholesterol Gall Stones

CholesterolCholesterol Gall Stones: Gall Stones: Description/ Description/

PathophysiologyPathophysiology Cholesterol is insoluble in water and Cholesterol is insoluble in water and

requires bile salts and lecithin to dissolverequires bile salts and lecithin to dissolve

CholesterolCholesterol stonestone formationformation occursoccurs whenwhen::

There is There is excessexcess cholesterolcholesterol synthesissynthesis by the liver andby the liver and

Insufficient bile saltsInsufficient bile salts

Cholesterol Gall Stones: Cholesterol Gall Stones: AetiologyAetiology

High fat dietHigh fat diet Oestrogen supplements (oral contraceptive, Oestrogen supplements (oral contraceptive,

HRT)HRT) More common in femalesMore common in females Increased incidence with ageIncreased incidence with age ObesityObesity DehydrationDehydration Corticosteroid therapyCorticosteroid therapy

Cholelithiasis: OutcomesCholelithiasis: Outcomes

Stones and gravel irritate the gall bladder Stones and gravel irritate the gall bladder → inflammatory process: → inflammatory process:

CholecystitisCholecystitis

The bile duct may become occluded by a The bile duct may become occluded by a stone: → stone: →

Obstructive jaundice Obstructive jaundice

Gall Stones: Gall Stones: Clinical ManifestationsClinical Manifestations

Spasmodic pain or dull ache in the right Spasmodic pain or dull ache in the right hypochondriumhypochondrium

Abdominal distension and flatulenceAbdominal distension and flatulence

AnorexiaAnorexia

Cholecystitis: Cholecystitis: Clinical ManifestationsClinical Manifestations

Severe colicky pain in the right Severe colicky pain in the right hypochondriumhypochondrium

Pain associated with nausea, vomiting, Pain associated with nausea, vomiting, sweatingsweating

Pyrexia and tachycardiaPyrexia and tachycardia If a stone occludes the bile duct:If a stone occludes the bile duct: Obstructive jaundice →Obstructive jaundice →

Obstructive JaundiceObstructive Jaundice

Yellow (bile pigment) discoloration of:Yellow (bile pigment) discoloration of: SkinSkin ScleraSclera ItchingItching Pale clay - coloured stools (↓ bile Pale clay - coloured stools (↓ bile

pigment)pigment) Dark urine (↑ bile pigment)Dark urine (↑ bile pigment)

Gall Stones: DiagnosisGall Stones: Diagnosis

Abdominal UltrasoundAbdominal Ultrasound Abdominal XrayAbdominal Xray Lipid profile: Cholesterol, HDL: LDL ratioLipid profile: Cholesterol, HDL: LDL ratio Serum bilirubin: total, direct, indirectSerum bilirubin: total, direct, indirect Liver enzymes Liver enzymes Blood coagulation tests (PT, PTT, INR)Blood coagulation tests (PT, PTT, INR) Electrolytes (if cholecystitis and vomiting)Electrolytes (if cholecystitis and vomiting)

Gall Stones: ManagementGall Stones: Management

Low fat dietLow fat diet Anti-lipid drugs: LipitorAnti-lipid drugs: Lipitor Dissolution of stones by: Dissolution of stones by: UDCA (inhibits synthesis of cholesterol)UDCA (inhibits synthesis of cholesterol) Lithotripsy: non-surgical fragmentation of Lithotripsy: non-surgical fragmentation of

gall-stones by ultrasound or pulse-laser gall-stones by ultrasound or pulse-laser through an endoscope with irrigation through an endoscope with irrigation

Surgery →Surgery →

Gall Stones:Gall Stones:Surgical ProceduresSurgical Procedures

Endoscopic Retrograde Endoscopic Retrograde Cholangiopancreatography (ERCP) with Cholangiopancreatography (ERCP) with basket retrieval of the stonesbasket retrieval of the stones

Cholecystectomy (laparoscopic usually)Cholecystectomy (laparoscopic usually)

(Vitamin K cover for all procedures to (Vitamin K cover for all procedures to assist coagulation)assist coagulation)

Cholecystitis:Cholecystitis:Emergency Management Emergency Management Pain relief: Pain relief: Narcotics (not Morphine as causes Narcotics (not Morphine as causes

spasm of sphincter of Oddi)spasm of sphincter of Oddi) IV fluidsIV fluids Nil by mouth/ fluids only (rest bowel)Nil by mouth/ fluids only (rest bowel) IV anti-emetics; IV antibioticsIV anti-emetics; IV antibiotics Acute surgery if obstructionAcute surgery if obstruction Otherwise plan for surgery once settled Otherwise plan for surgery once settled

Cholelithiasis/ Cholecystitis: Cholelithiasis/ Cholecystitis: Nursing CareNursing Care

Patient education related to risk factors, Patient education related to risk factors, especially dietaryespecially dietary

Patient support during proceduresPatient support during procedures Close monitoring of vital signs, fluid Close monitoring of vital signs, fluid

balancebalance Observe level of jaundice Observe level of jaundice IV fluids and medications as prescribedIV fluids and medications as prescribed