Cholelithiasis and Cholecystitis Overview

Cholelithiasis and Cholecystitis Treatment

• Conservative treatment is recommended for asymptomatic gallstones with a low risk for complications.
• Surgical removal of the gallbladder and stones is usually indicated for patients experiencing frequent symptoms, acute cholecystitis, or very large stones.

Diagnostic Tests

• Elevated direct bilirubin levels can indicate obstructed bile flow in the biliary duct system.
• Elevated white blood cell count may indicate infection and inflammation.
• Serum amylase and lipase levels are measured to identify possible pancreatitis related to common duct obstruction.
• Abdominal x-ray may show gallstones with high calcium content.
• Ultrasonography of the gallbladder is a noninvasive test that accurately diagnoses cholelithiasis and assesses gallbladder emptying.
• Oral cholecystogram evaluates the gallbladder's ability to concentrate and excrete bile using an oral dye.
• Gallbladder scan (cholescintigraphy or HIDA scan) employs an IV radioactive solution to assess cystic duct obstruction and acute/chronic cholecystitis.

Bilirubin Levels

• Total bilirubin includes both indirect (unconjugated) and direct (conjugated) bilirubin.
• Indirect bilirubin is bound to albumin and transported to the liver.
• Direct bilirubin is water-soluble and excreted in bile.
• Normal total bilirubin levels for adults are 0.1 to 1.2 mg/dL.
• Elevated total bilirubin levels can occur due to increased production or impaired metabolism/excretion.
• Normal direct bilirubin levels for adults are 0.1 to 0.3 mg/dL.
• Elevated direct bilirubin levels can occur due to impaired excretion from liver or biliary system obstruction.
• Normal indirect bilirubin levels for adults are less than 1.1 mg/dL.
• Elevated indirect bilirubin levels can occur due to red blood cell hemolysis.

Laparoscopic Cholecystectomy

• Laparoscopic cholecystectomy is the preferred treatment for symptomatic gallstones or gallbladder inflammation.
• This minimally invasive procedure typically results in a short hospital stay of less than 24 hours.
• While generally safe, a laparoscopic cholecystectomy may need to be converted to an open abdominal surgery (laparotomy) during the procedure.

Common Bile Duct Exploration

• When gallstones are lodged in the bile ducts, a cholecystectomy with common bile duct exploration may be performed.
• A T-tube is inserted into the common bile duct to maintain patency and facilitate bile flow.
• Excess bile is collected in a drainage bag secured below the surgical site.

Postoperative Cholangiogram

• If a retained stone is suspected after surgery, a cholangiogram (imaging of the bile ducts) via the T-tube or endoscopic visualization of the duct may be performed.

Alternative Procedures

• Cholecystostomy (draining the gallbladder) or choledochostomy (removing stones and placing a T-tube) may be considered for high-risk patients who are not suitable for laparoscopic cholecystectomy.
• Shock wave lithotripsy, using ultrasound to break down large gallstones, can be used in conjunction with drug therapy.

Extracorporeal Shock Wave Lithotripsy

• This procedure requires precise positioning and typically takes an hour to complete.
• Mild sedation may be administered during the procedure.

Nursing Care After Gallstone Procedures

• Postoperative care includes monitoring for biliary colic (pain from gallbladder contractions to remove fragments), nausea, and transient hematuria (blood in the urine).

Percutaneous Cholecystostomy

• This procedure, using ultrasound guidance to drain the gallbladder, can be performed on high-risk patients to postpone or potentially avoid surgery.

Laparoscopic Cholecystectomy

• The gold standard treatment for symptomatic gallstones or inflammation of the gallbladder
• Minimally invasive, with low complication risk
• Usually requires less than 24 hours of hospital stay
• Some patients may not be candidates for this procedure
• May be converted to laparotomy if necessary during surgery

Cholecystectomy with Common Bile Duct Exploration

• Performed when stones are lodged in the ducts
• T-tube inserted to maintain duct patency and promote bile passage
• Excess bile is collected in a drainage bag
• Post-operative cholangiogram or endoscopy may be performed to check for retained stones

Alternative Treatments

• Cholecystostomy: Drains the gallbladder in high-risk patients
• Choledochostomy: Removes stones and positions a T-tube in the common bile duct (for high-risk patients)
• Shock Wave Lithotripsy: Uses ultrasound to break up large gallstones
• Percutaneous Cholecystostomy: Ultrasound-guided drainage of the gallbladder in high-risk patients

Pharmacologic Therapy

• NSAIDS: Treat chronic pain of gallbladder attacks
• Narcotic Analgesics (e.g., morphine): Used for pain relief during acute attacks
• Dissolving Drugs (e.g., chenodiol, ursodiol): For non-calcified stones less than 20mm in diameter
• Antibiotics: For suspected gallbladder infection
• Cholestyramine (Questran): Binds with bile salts to promote their excretion, treating pruritus

Nonpharmacologic Therapy

• Nasogastric tube: Inserted to relieve nausea and vomiting during acute cholecystitis
• Dietary fat limitation: Especially for obese patients
• Fat-soluble vitamin and bile salt supplementation: If bile flow is obstructed

Nursing Considerations

• Monitor for biliary colic: Following lithotripsy
• Monitor for nausea: Post-procedure
• Monitor for transient hematuria: Post-procedure
• Advise on dietary limitations and potential side effects of medications
• Educate on goldenseal contraindications (pregnancy, breastfeeding)

This quiz covers the diagnosis and treatment of cholelithiasis and cholecystitis. You will learn about conservative treatment options, surgical interventions, and important diagnostic tests such as ultrasound and blood tests. Test your knowledge on this significant topic in gallbladder health.