Chole Lithia Sis
Chole Lithia Sis
Chole Lithia Sis
Women Obesity
Mutiparity Diabetes
Most common
Formed in gall bladder
Common in hemolytic disorders,cirrhosis
Multiple , small & hard in consistence.
bilirubinate, phosphate, bicarbonate, calcium.
Brown stones-
Rare
Formed bile duct usually after bacterial
infection
in caused by bile stasis.
The bacteria responsible for the infection
enzymatically catalyze the conversion of bilirubin
glucuronide to insoluble unconjugated bilirubin.
Major constituents are precipitated calcium
bilirubinate & bacterial cell bodies.
MIXED STONES
Most common type.
It may be combination of cholesterol &
pigment stones or either of these with some
other substances.
Calcium carbonate, phosphate, bile salts, &
palmitate make up more common minor
constituents.
CLINICAL MANIFESTATIONS
Abdominal ultrasound
Ultrasonography
Cholecystography
Endoscopic retrograde
cholangiopancreatography
Percutaneous
transhepatic
cholangiography
ABDOMINAL ULTRASOUND
Ifgall bladder stone is suspected, an
abdominal x- ray may be obtained to
exclude other causes of symptoms.
However, only 10 to 15% gall stone are
calcified sufficiently to be visible on such x -
ray studies.
ULTRA SONOGRAPHY
Replaced cholecystography as the diagnostic
procedure of choice
Does not expose patients to ionizing
radiation.
Most accurate if the patients fasts overnight so that
the gall bladder is distended.
Detect calculi in the gall bladder or a dilated
common bile duct with 90% accuracy.
Obesity, ascites & distended bowel may be difficult
to examine satisfactorily with an ultrasound.
Stones are acoustically dense & produce an
acoustic shadow. Stones also move with
changes in position.
Polyps may be calcified & reflect shadows, but
do not move with change in posture.
Thickened gallbladder wall & local tenderness
indicate cholecystitis.
When a stone obstructs the neck of the
gallbladder, the gallbladder may become very
large, but thin walled.
A contracted, thick-walled gallbladder
indicates chronic cholecystitis .
RADIONUCLIDE IMAGING
CHOLESCINTIGRAPHY
Nonsurgical removal
Surgical management
Nursing management
NUTRITIONAL & SUPPORTIVE THERAPY
The diet immediately after an episode is usually
limited to low-fat liquids.
Include powdered supplements ↑ protein &
carbohydrate into skim milk.
Cooked fruits, rice or tapioca, lean meats, mashed
potatoes, non–gas-forming veg, bread, coffee or
tea may be added as tolerated.
Avoid eggs, cream, pork, fried foods, cheese, gas-
forming vegetables & alcohol.
Fatty
foods may bring on
an episode.
Dietarymanagement may
be the major mode of
therapy in patients who
have had only dietary
intolerance to fatty foods
& vague g.i. symptoms
PHARMACOLOGIC
THERAPY
Dissolving Gallstones
Stone Removal by Instrumentation
Intracorporeal Lithotripsy
DISSOLVING GALLSTONES
By infusion of a solvent (mono-octanoin or
methyl tertiary butyl ether [MTBE]) into
the gallbladder.
Can be infused through a tube or catheter
inserted percutaneously directly into the
gallbladder; a tube or drain inserted through a
T-tube tract to dissolve stones not removed at
the time of surgery; an ERCP endoscope; or
a transnasal biliary catheter.
Inthe latter procedure, the catheter is introduced
through the mouth & inserted into the CBD. The
upper end of the tube is then rerouted from the
mouth to the nose & left in place.
This enables the patient to eat & drink normally
while passage of stones is monitored or chemical
solvents are infused to dissolve the stones.
This method of dissolution of stones is not widely
used in patients with gallstone disease.
Method used when the size of stone not more than
20 mm in diameter.
STONE REMOVAL BY
INSTRUMENTATION
used to remove stones that were not removed at
the time of cholecystectomy or have become
lodged in the CBD.
A catheter & instrument with a basket attached are
threaded through the T-tube tract or fistula formed
at the time of T-tube insertion; the basket is used to
retrieve & remove the stones lodged in the
common bile duct.
A second procedure involves the use of the ERCP
endoscope .After the endoscope is inserted, a
cutting instrument is passed through the
endoscope into the ampulla of Vater of CBD.
Another instrument with a small basket or balloon at
its tip may be inserted through the endoscope to
retrieve the stones.
The patient is closely observed for bleeding,
perforation & the development of pancreatitis or
sepsis.
The ERCP procedure is particularly useful in the
diagnosis & treatment of patients who have
symptoms after biliary tract surgery, for patients with
intact gallbladders, & for patients in whom surgery
is particularly hazardous.
EXTRACORPOREAL SHOCK-WAVE
LITHOTRIPSY
Used for nonsurgical fragmentation of
gallstones.
Derived from lithos, meaning stone & tripsis,
meaning rubbing or friction.
Uses repeated shock waves directed at the
gallstones in the gallbladder or CBD to
fragment the stones.
The energy is transmitted to the body
through a fluid-filled bag, or it may be
transmitted while the patient is immersed in
a water bath.
Converging shock waves are directed to the stones
to be fragmented.
After the stones are gradually broken up, the stone
fragments pass from the gallbladder or CBD
spontaneously are removed by endoscopy, or
dissolved with oral bile acid or solvent.
Requires no incision & no hospitalization, patients
are usually treated as OPD , but several
sessions are generally necessary.
INTRACORPOREAL LITHOTRIPSY
Relief of pain
Adequate ventilation.
Absence of complications.
Choledocholithiasis
Cholangitis,
Gallstone pancreatitis,
Gallstone ileus,
Gallbladder carcinoma
MANAGING COMPLICATIONS
Bleeding
Managing Pain
Sitting upright in bed or a chair or walking may
ease the discomfort.
Analgesic medications as needed & as
prescribed
Report to surgeon if pain is unrelieved even
with analgesic use.
Resuming Activity-
Light exercise (walking) immediately.