Discussion Of Disease (cholecystitis

Jean Paola M. Nolasco Cherry Ann Landrito BSN004 Group15 DISCUSSION OF DISEASE: Cholecystitis with Cholelithiasis Cholecystitis

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is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly.

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leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli and Bacteroides species.

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the gallbladder's wall becomes inflamed.

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extreme cases may result in necrosis and rupture.

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inflammation often spreads to its outer covering, thus irritating surrounding structures such as the diaphragm and bowel.

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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

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are crystalline bodies formed within the body by accretion orconcretion of normal or abnormal bile components.

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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".

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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.

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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.

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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.

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More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis

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very dark urine, clay-colored stool

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deficiencies of vitamin A,D,E and K (fat-soluble vitamins)

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abscess, necrosis and perforation with peritonitis of he gallstone continues to obstruct the duct.

Assessment and Diagnostic Methods:

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abdominal radiograph, ultrasonography or cholecystography

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endoscopic retrograde cholangiopancreatography (ERCP)

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percutaneous transheaptic cholangiography (PTC)

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Cholecystitis is usually diagnosed by a history of the above symptoms, as well examination findings:

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fever (usually low grade in uncomplicated cases); tender right upper quadrant ( +/- Murphy's sign )

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medical and surgical options:

Treatment:

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.

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Obstruction of the common bile duct with gallstones can sometimes be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP).

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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. 