Download Adult Medical – Surgical Nursing 1

Adult MedicalSurgical Nursing
Gastro-intestinal Module:
Cholelithiasis
Bile Formation
 The liver hepatocytes produce bile:
 Bile conjugates bilirubin (fat-soluble →
water-soluble) for excretion
 Bile emulsifies fats to promote digestion
The Constituents of Bile
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H2O
Electrolytes
Lecithin
Fatty acids
Bilirubin
Bile salts
Cholesterol
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
→
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
 Cholelithiasis
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)
 Bile Pigment Stones
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
 Cholesterol Gall Stones
Cholesterol Gall Stones:
Description/ Pathophysiology
 Cholesterol is insoluble in water and
requires bile salts and lecithin to dissolve
 Cholesterol stone formation occurs
when:
 There is excess cholesterol synthesis
by the liver and
 Insufficient bile salts
Cholesterol Gall Stones:
Aetiology
 High fat diet
 Oestrogen supplements (oral
contraceptive, HRT)
 More common in females
 Increased incidence with age
 Obesity
 Dehydration
 Corticosteroid therapy
Cholelithiasis: Outcomes
 Stones and gravel irritate the gall bladder
→ inflammatory process:
 Cholecystitis
 The bile duct may become occluded by a
stone: →
 Obstructive jaundice
Gall Stones:
Clinical Manifestations
 Spasmodic pain or dull ache in the right
hypochondrium
 Abdominal distension and flatulence
 Anorexia
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 →
Obstructive Jaundice
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Yellow (bile pigment) discoloration of:
Skin
Sclera
Itching
Pale clay - coloured stools (↓ bile
pigment)
 Dark urine (↑ bile pigment)
Gall Stones: Diagnosis
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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)
Gall Stones: Management
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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 →
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)
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
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