Adult Medical-Surgical Nursing

1. Adult Medical-Surgical Nursing Gastro-intestinal Module: Cholelithiasis

2. Bile Formation • The liver hepatocytes produce bile: • Bile conjugates bilirubin (fat-soluble → water-soluble) for excretion • Bile emulsifies fats to promote digestion

3. The Constituents of Bile • H2O • Electrolytes • Lecithin • Fatty acids • Bilirubin • Bile salts • Cholesterol

4. The Enterohepatic Circulation • Bile is produced by the liver hepatocytes • Bile passes through canaliculi (small ducts) to the hepatic duct → gall bladder (storage) • The normal gall bladder stores 50 - 70ml concentrated bile →

5. The Enterohepatic Circulation (cont) • In the presence of fat in the duodenum: • The hormone Cholecystokinin (CCK) stimulates contraction of the gall-bladder and release of bile into the duodenum • Bile salts, cholesterol, lecithin emulsify fats • Bile salts are reabsorbed in the distal ileum into the portal circulation to the liver

6. Cholelithiasis

7. Cholelithiasis: Classification • Cholelithiasis means production of gall stones or calculi in the gall bladder • There are 2 types of gall stone: • Bile pigment (bilirubin) stones • Cholesterol stones (major type)

8. Bile Pigment Stones

9. Bile Pigment Stones: Aetiology • Stones are formed from ↑ bile pigment • Related to: • Haemolytic disease where the liver cannot clear the excess bilirubin • Cirrhosis and liver damage • Hepatic infections • These stones cannot be dissolved and require surgical removal if symptomatic

10. Cholesterol Gall Stones

11. Cholesterol Gall Stones: Description/ Pathophysiology • Cholesterol is insoluble in water and requires bile salts and lecithin to dissolve • Cholesterolstoneformationoccurswhen: • There is excesscholesterolsynthesis by the liver and • Insufficient bile salts

12. Cholesterol Gall Stones: Aetiology • High fat diet • Oestrogen supplements (oral contraceptive, HRT) • More common in females • Increased incidence with age • Obesity • Dehydration • Corticosteroid therapy

13. Cholelithiasis: Outcomes • Stones and gravel irritate the gall bladder → inflammatory process: • Cholecystitis • The bile duct may become occluded by a stone: → • Obstructive jaundice

14. Gall Stones: Clinical Manifestations • Spasmodic pain or dull ache in the right hypochondrium • Abdominal distension and flatulence • Anorexia

15. Cholecystitis: Clinical Manifestations • Severe colicky pain in the right hypochondrium • Pain associated with nausea, vomiting, sweating • Pyrexia and tachycardia • If a stone occludes the bile duct: • Obstructive jaundice →

16. Obstructive Jaundice • Yellow (bile pigment) discoloration of: • Skin • Sclera • Itching • Pale clay - coloured stools (↓ bile pigment) • Dark urine (↑ bile pigment)

17. Gall Stones: Diagnosis • Abdominal Ultrasound • Abdominal Xray • Lipid profile: Cholesterol, HDL: LDL ratio • Serum bilirubin: total, direct, indirect • Liver enzymes • Blood coagulation tests (PT, PTT, INR) • Electrolytes (if cholecystitis and vomiting)

18. Gall Stones: Management • Low fat diet • Anti-lipid drugs: Lipitor • Dissolution of stones by: • UDCA (inhibits synthesis of cholesterol) • Lithotripsy: non-surgical fragmentation of gall-stones by ultrasound or pulse-laser through an endoscope with irrigation • Surgery →

19. Gall Stones:Surgical Procedures • Endoscopic Retrograde Cholangiopancreatography (ERCP) with basket retrieval of the stones • Cholecystectomy (laparoscopic usually) • (Vitamin K cover for all procedures to assist coagulation)

20. Cholecystitis:Emergency Management • Pain relief: • Narcotics (not Morphine as causes spasm of sphincter of Oddi) • IV fluids • Nil by mouth/ fluids only (rest bowel) • IV anti-emetics; IV antibiotics • Acute surgery if obstruction • Otherwise plan for surgery once settled

21. Cholelithiasis/ Cholecystitis: Nursing Care • Patient education related to risk factors, especially dietary • Patient support during procedures • Close monitoring of vital signs, fluid balance • Observe level of jaundice • IV fluids and medications as prescribed