1. PRESENTATION ON CHOLELITHIASIS

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

3. INCIDENCE Uncommon in children and young adults
Increasingly prevalent after age 40.
The incidence increases thereafter to such an extent that it has been estimated that by the age of 75, one of every three people will have gall stones

4. 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.

5. 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

6. 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 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 cholecystokinin-pancreozymin (CCK-PZ) from the intestinal wall

7. 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)

8. TYPES OF GALLSTONES Cholesterol stones Pigment stones
Mixed stones - the most common type. They are comprised of cholesterol and salts.
Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol.
Pigment stones are small, dark stones made of bilirubin. The exact cause is not known. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anaemia in which too much bilirubin is formed.

9. RISK FACTORS Age over 40 years Multiparous women Obesity
Users of oral contraceptives
Hormonal therapy
Diabetic persons
Patients with gastro-intestinal diseases

10. 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 colour skin and mucous membrane

11. CLINICAL MANIFESTATION Contd…..
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
If gallstone continues to obstruct the duct
Abscess
Necrosis
Perforation
Generalized peritonitis

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

13. MEDICAL MANAGEMENT Ursodeoxycholic acid (UDCA)
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)

14. NONSURGICAL REMOVAL
Dissolving gallstones – MTBE – Methyl tertiary butyl ether
A catheter and instrument with basket
Extracorporeal shock-wave lithotripsy (ESWL)
Intracorporeal lithotripsy

15. SURGICAL MANAGEMENT
Cholecystectomy
Minicholecystectomy
Laparoscopic cholecystectomy
Percutaneous cholecystostomy

16. CHOLECYSTECTOMY

17. CHOLEDOCHOSTOMY

18. 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

19. NURSING MANAGEMENT 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

20. THANK YOU