Adult Medical-Surgical Nursing

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Adult Medical-Surgical Nursing

• Gastro-intestinal Module
• Cholelithiasis

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Bile Formation

• The liver hepatocytes produce bile
• Bile conjugates bilirubin (fat-soluble ?
  water-soluble) for excretion
• Bile emulsifies fats to promote digestion

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The Constituents of Bile

• H2O
• Electrolytes
• Lecithin
• Fatty acids
• Bilirubin
• Bile salts
• Cholesterol

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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 ?

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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

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• Cholelithiasis

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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)

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• Bile Pigment Stones

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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

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• Cholesterol Gall Stones

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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

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Cholesterol Gall Stones Aetiology

• High fat diet
• Oestrogen supplements (oral contraceptive, HRT)
• More common in females
• Increased incidence with age
• Obesity
• Dehydration
• Corticosteroid therapy

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Cholelithiasis Outcomes

• Stones and gravel irritate the gall bladder ?
  inflammatory process
• Cholecystitis
• The bile duct may become occluded by a stone ?
• Obstructive jaundice

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Gall Stones Clinical Manifestations

• Spasmodic pain or dull ache in the right
  hypochondrium
• Abdominal distension and flatulence
• Anorexia

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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 ?

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Obstructive Jaundice

• Yellow (bile pigment) discoloration of
• Skin
• Sclera
• Itching
• Pale clay - coloured stools (? bile pigment)
• Dark urine (? bile pigment)

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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)

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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 ?

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Gall StonesSurgical Procedures

• Endoscopic Retrograde Cholangiopancreatography
  (ERCP) with basket retrieval of the stones
• Cholecystectomy (laparoscopic usually)
• (Vitamin K cover for all procedures to assist
  coagulation)

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CholecystitisEmergency 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

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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