Jean Paola M.

Nolasco
Cherry Ann Landrito
BSN004 Group15

DISCUSSION OF DISEASE: Cholecystitis with Cholelithiasis

Cholecystitis
- is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the
gallbladder), with choleliths most commonly blocking the cystic duct directly.
- leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut
organisms, predominantly E. coli and Bacteroides species.
- the gallbladder's wall becomes inflamed.
- extreme cases may result in necrosis and rupture.
- inflammation often spreads to its outer covering, thus irritating surrounding structures
such as the diaphragm and bowel.
- in debilitated and trauma patients, the gallbladder may become inflamed and infected in
the absence of cholelithiasis, and is known as acute acalculous cholecystitis.
Cholelithiasis
- are crystalline bodies formed within the body by accretion orconcretion of normal or
abnormal bile components.
- can occur anywhere within the biliary tree, including the gallbladder and the
commonbile duct. Obstruction of the common bile duct is choledocholithiasis;
obstruction of the biliary tree can cause jaundice; obstruction of the outlet of the
pancreatic exocrine system can causepancreatitis. Cholelithiasis is the presence of stones
in the gallbladder or bile ducts: chole- means "bile", lithia means "stone", and -sis means
"process".
- may cause obstruction and the accompanying acute attack. The patient might develop a
chronic, low-level inflammation which leads to a chronic cholecystitis, where the
gallbladder is fibrotic and calcified.
- can be subdivided into the two following types:
A. Cholesterol stones are usually green, but are sometimes white or yellow in color.
They are made primarily of cholesterol, the proportion required for classification as a
cholesterol stone being either 70% (Japanese classification system) or 80% (US
system)
B. Pigment stones are small, dark stones made of bilirubin and calcium salts that
are found in bile. They contain less than 20% of cholesterol. Risk factors for
pigment stones include hemolytic anemia,cirrhosis, biliary tract infections, and
hereditary blood cell disorders, such as sickle cell anemia andspherocytosis.

Clinical Manifestations:
- may be silent producing no pain and only mild GI symptoms.
- if the cystic duct is obstructed, the gallbladder becomes distended and eventually
infected; fever, palpable abdominal mass, biliary colic with excruciating upper right
 abdominal pain, radiating to back or right shoulder with nausea and vomiting several
hours after a heavy meal; restlessness and constant or colicky pain.
- More severe symptoms such as high fever, shock and jaundice indicate the development
of complications such as abscess formation, perforation or ascending cholangitis
- very dark urine, clay-colored stool
- deficiencies of vitamin A,D,E and K (fat-soluble vitamins)
- abscess, necrosis and perforation with peritonitis of he gallstone continues to obstruct the
duct.

Assessment and Diagnostic Methods:

- abdominal radiograph, ultrasonography or cholecystography
- endoscopic retrograde cholangiopancreatography (ERCP)
- percutaneous transheaptic cholangiography (PTC)
- Cholecystitis is usually diagnosed by a history of the above symptoms, as well
examination findings:
- fever (usually low grade in uncomplicated cases); tender right upper quadrant
( +/- Murphy's sign )
Treatment:
- medical and surgical options:
A. Cholesterol gallstones can sometimes be dissolved by oral ursodeoxycholic acid, but
it may be required that the patient takes this medication for up to two years.
Gallstones may recur however, once the drug is stopped.
B. Obstruction of the common bile duct with gallstones can sometimes be relieved
by endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde
cholangiopancreatography (ERCP).
C. Gallstones can be broken up using a procedure
called lithotripsy (Extracorporeal Shock Wave Lithotripsy) which is a method of
concentrating ultrasonic shock waves onto the stones to break them into tiny
pieces. They are then passed safely in the feces. However, this form of
treatment is only suitable when there are a small number of gallstones.
D. Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the
recurrence of cholelithiasis. Only symptomatic patients must be indicated to
surgery. The lack of a gall bladder does not seem to have any negative
consequences in many people. However, there is a significant proportion of
the population - between 5-40% - who develop a condition
called postcholecystectomy syndrome. which may cause gastrointestinal distress
and persistent pain in the upper right abdomen. In addition, as many as 20%
of patients develop chronic diarrhea.
There are two surgical options for cholecystectomy:

 Open cholecystectomy: This procedure is performed via an incision into the abdomen
(laparotomy) below the right lower ribs. Recovery typically consists of 3–5 days of
hospitalization, with a return to normal diet a week after release and normal activity several
weeks after release.
 Laparoscopic cholecystectomy: This procedure, introduced in the 1980s. is performed
via three to four small puncture holes for a camera and instruments. Post-operative care
typically includes a same-day release or a one night hospital stay, followed by a few days of
home rest and pain medication. Laparoscopic cholecystectomy patients can generally resume
normal diet and light activity a week after release, with some decreased energy level and
minor residual pain continuing for a month or two. Studies have shown that this procedure is
as effective as the more invasive open cholecystectomy, provided the stones are accurately
located by cholangiogram prior to the procedure so that they can all be removed.