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Adult Medical-Surgical Nursing

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Adult Medical-Surgical Nursing Gastro-intestinal Module: Cholelithiasis Bile Formation The liver hepatocytes produce bile: Bile conjugates bilirubin (fat-soluble ... – PowerPoint PPT presentation

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Title: 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
  • Cholesterol stone formation occurs when
  • There is excess cholesterol synthesis 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 StonesSurgical Procedures
  • Endoscopic Retrograde Cholangiopancreatography
    (ERCP) with basket retrieval of the stones
  • Cholecystectomy (laparoscopic usually)
  • (Vitamin K cover for all procedures to assist
    coagulation)

20
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

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
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