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Cholelithiasis
- stones in the gallbladder
- actual cause is unknown
- - disturbance in balance and precipate forms
- - supersaturation in gallbladder
- infection, changes in cholesterol metabolism. bile statis, impaired gallbladder motility (contractility)
- bile salts, bilirubin, calcium, protein, ***cholesterol***
- bile salts/lecithinin- inc choles- inc risk for stone formation
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Cholelithiasis
risk factor
- most formed in the gall bladder
- may also form in the CBD (choledecholithiasis)
- risk factor:
- FAIR- white complexion
- FAT- diet inc in choles and truncal obesity
- FEMALE- higher estrogen
- FORTY- pre menuopausal
- FERTILE
- bad fats, genetics
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other factors
cholelithiasis
- Diet:
- - fatty meals, high fat diet
- - fast food test (not actual test but if pt goes to fast food place and then a few hours experience pain)
- Genetics:
- - American indians- highest in US
- Diabetes:
- - incr in trig can chx composition in bile
- Rapid weight loss, yo yo diet
- - changes bile makeup and may decr GB contractions
- - gastric bypass pt are at high risk for this
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Cholelithiasis
decrease risk by
- maintaining a healthy body weight
- avoiding crash diets esp < 800 cal
- excerising regularly
- low fat, high fiber diet- dec animal fat, butter, margarine, mayo, fried food
- dec alcohol
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Cholecystitis
- Inflammation of the gallbladder
- usually caused by obstruction of bile by gallstones or billary sludge (sticky mud in ducts)
- acute or chronic
- confined in mucous lining or entire GB wall
- distended and congested during acute attack
- scarring with attack my reduce function
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Manifestations
- silent cholelithiasis- 1%
- mild pain to severe unrelenting pain
- similar to agina, heart attack (r/o cardiac), peptic ulcer disease, hepatitis, appendicitis
- vary from indigestion to pain, fever, jaundice
- severity depends on where the stones are, are they moving, obstruction, GB colic, spasm
- pain moves cause the stone is moving
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Acute Cholecystitis
- RUQ pain that incr with deep breath (Murphy's sign), may radiate to right shoulder or scapula
- May be colicky (passing thru the ducts, come and go)
- - can be described as excruciating
- - tachycardia, diaphoresis, restless
- - nausea, and vomiting
- - last up to an hour
- - residual tenderness
- - usually occurs 3-6 hours after meal, lying down
- RUQ tenderness and abd rigidity
- - slight fever, elevated WBC
- - Jaundice only if CBD obstructed (clay stools ect)
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chronic cholecystitis
- dyspepsia
- heartburn
- flatulence
- intolerance for fatty foods
- - nausea, fullness
- steatorrhea- no bile
- vitamin def
- -fat soluble vitamins ADEK
- recurring attacks, scar tissue
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Cholecystitis
accurate physical exam
- nature of pain
- US
- ERCP- tx and dx
- CT
- MRI
- cholangiography
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Cholecystitis
labs
- elev WBC- inflammation
- incr bili- if obstruction
- LFT's elev- if obstruction
- amylase-if pancreas
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Cholecystitis
complications- usually delay in seeking care
- subphrenic abscess
- pancreatitis
- cholangitis
- fistulas
- GB ileus
- GB rupture
- peritonitis
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Cholecystitis
treatment
- acute attack: alleviate symptoms (morphine, toradol)
- - analgesics, antiemetics (zofran), anticholinergics (spasm of sphrincter, s/e dry mouth, confusion, blurred vision, urine retention), NGT (get rid of secretion)
- preventing/controlling infections
- - antibiotics
- maintaining fluid and electrolytes balance
- - NPO, IVF
- 80% of supportive care
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Cholecystitis
non surgical
- ERCP- 90% effective
- - stents, papillotomy, lithotripsy
- Medication- for poor surgical canididates
- - 6m to 2 yrs
- - antigal and chenix (change synthesis of chol s/e GI hepatoxity)
- ESWL- shock waves crush stones
- - 1-2 hrs under conscious sedation
- - out pt multi session
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Cholecystitis
laparascopic cholecystectomy
- tx of choice whenever possible
- 4 small incisions
- *** CBD stones or GB is perforiated is contraindicated
- minimal pain, d/c within 24 hours
- resume normal activities, return to work in a wk
- pain referred to right shoulder or difficulty breathing is common post op problem- due to CO2
- - sims position- left side knees flexed
- b/c gases rise
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Open cholecystectomy
- larger incision, more involved surgery
- increased postop pain, longer hospital stay (up to 1 wk) longer rehab several weeks
- may NG tube
- T tube if CBD explored
- - ensure patency of CBD
- - drain bile each day it should go down. it should be green/yellow not bleedins
- remember things to worry about after surgery- infection, DVT, respiration (pnuemonia), constipation
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cholecystectomy
post op care
- pain control
- respiratory assessment
- maintain skin integrity
- promoting self care and activity
- diet management
- next slide
- assessment post op c/o
- follow up care
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cholecystectomy
diet
- lap- liquid until next day, the "light for a few days
- open- liquids to bland when bowel sounds return
- both- amt of fat depends on tolerance
- - usually low fat, high CHO and proteins in early post op period
- - fat restriction for 4-6 weeks by some MD's
- takea body time to adjust to fat in diet
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