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KOLESISTITIS(Akut)
Ok obstruksi di duktus sistikus oleh batu,ok iritasi
garam empedu di ikuti infeksi bakteri.
Serangan berakhir bila batu melewati duktus
koledokus atau jatuh kembali ke dlm kandung empedu.
Sbgn kecil didapat tanpa adanya batu.
Klinis,inflamasi ringan smp gangren fuminan kandung
empedu.Biasanya:gemuk,wanita lbh 40 thn.
Nyeri di abdomen kanan atas atau epigastrium,kadang
menjalar ke pundak/skapula kanan,dpt berlangsung 1
jam.Suhu bdn naik,bila ikterus,menandakan
koledokolitiasis
Px:teraba masa empedu(Murphy (+)
Lab.Lekositosis

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Cholecystitis & Cholelithiasis
Inflammation of gallbladder and stone formed in
the gallbladder.
Clinical Manifestations:
1. Changes in the urine and stool colour.
2. Fat soluble vitamin deficiency.
3. Pain and billiary colic.
4. Jaundice.
Diagnostic Evaluation:
1. Abdominal X ray.
2. Ultrasonography.
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Cholecystitis & Cholelithiasis (contd)

Medical Management:
1. Medications to dissolve stone.
2. Antibiotics.
3. Removal of gallbladder (cholecystectomy)
Nursing Management:
1. Provide rest.
2. NG suctioning.
3. Provide low fat diet.
4. Provide pre & post op. care.

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 KOLESISTITIS(Akut)
Ok obstruksi di duktus sistikus oleh batu,ok iritasi
garam empedu di ikuti infeksi bakteri.
Serangan berakhir bila batu melewati duktus
koledokus atau jatuh kembali ke dlm kandung empedu.
Sbgn kecil didapat tanpa adanya batu.
Klinis,inflamasi ringan smp gangren fuminan kandung
empedu.Biasanya:gemuk,wanita lbh 40 thn.
Nyeri di abdomen kanan atas atau epigastrium,kadang
menjalar ke pundak/skapula kanan,dpt berlangsung 1
jam.Suhu bdn naik,bila ikterus,menandakan
koledokolitiasis
Px:teraba masa empedu(Murphy (+)
Lab.Lekositosis

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Cholecystitis Clinical
Manifestations
episodic or vague/samar pain
Anorexia
Nausea or vomiting
Dyspepsia
Flatulence
Feeling of abdominal fullness
Rebound tenderness
Fever
Jaundice, clay-colored stools, dark urine,
steatorrhea
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Cholecystitis: Assessment
and Diagnostics
Abdominal x-ray
Ultrasound
Radionuclide imaging or
cholescintigraphy
Cholecystography
Endoscopic Retrograde Cholangio
Pandratography (ERCP)
Percutaneous transhepatic
cholangiography
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 Cholecystitis
Assessment
Epigastric pain- after eating
Pain- localized in RUQ because of somatic sensory nerves.
Murphys sign- cant take a deep inspiration when
assessors fingers are pressed below hepatic margin. Pain
begins 2 to 4 hours after eating fried or fatty foods and
persist more than 4 to 6 hours.
Nausea, vomiting, anorexia
Low-grade fever
Jaundice
Weight loss

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 Cholecystitis
Surgical Management
Cholecystectomy- removal of gallbladder after ligation of the cystic
duct and vessels.
Choledochostomy-opening into the common bile duct for removal of
stones. T-tube inserted into duct and connected to drainage bottle.
Purpose- to decompress biliary tree and allow for postoperative
cholangiogram.
Endoscopic cholecystectomy-removal of gallbladder through small
puncture hole in the abdomen. Laser dissects gallbladder.

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 Cholecystitis
Implementation
Position in low-to semi fowlers position to facilitate bile
drainage.
Maintain skin integrity.
Prevent respiratory complications:
IF NGT is inserted-to relieve distention and increase
peristalsis.
If t-tube inserted-measure color. Clamp tube before
eating. As t-tube clamp-observe for abdominal
discomfort and distention.
Provide low-fat high carb. and high protein. Maintain for
at least 2 to 3 months postoperatively.

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 Cholecystitis (1 of 2)

Pathophysiology
Inflammation of
the gallbladder
Cholelithiasis
Chronic
cholecystitis
Bacterial infection
Acalculus
cholecystitis
Burns, sepsis,
diabetes
Multiple organ
failure
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 Cholecystitis (2 of 2)

Signs and symptoms

URQ abdominal pain
Murphys sign
Nausea, vomiting
History of cholecystitis
Treatment
Follow general treatment guidelines.

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 Acute Cholecystitis2

Thickened gallbladder wall or edema

Pericholecystic Fluid
Sonographic Murphys Sign

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Acute Cholecystitis

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 Acute Cholecystitis
Early stages Edema and hyperemia
Later stages Adhesions, fibrosis, and necrosis
Triangle of Calot visible in early stages
Courtesy of Nette

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Management of Acute Cholecystitis
Supportive care with IVFs, bowel rest, &
Abx
Almost half of patients have positive bile
cultures
E. Coli is most common organism
Antibiotic choice: Ampicillin +
Aminoglycoside
or 3rd generation cephalosporin

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 Management cont.

No evidence exists showing a definite

benefit with use of antibiotics

NSAIDs may improve course of acute

cholecystitis6

SURGERY is the only definitive treatment

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 Cholecystitis

Acute inflammation of the

gallbladder
Causes:
90% gallstones

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Diagnosis of acute cholecystitis
Utility of U/S
Sonographic murphys sign
Sens 63%, specificity 93.6%
PPV 72.5% NPV 90.5%

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 Acute Cholecystitis

RUQ Pain
Fever
Leukocytosis

Severe persistent pain

+/- Jaundice
Positive Murphys Sign

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 Acute Cholecystitis3

Persistent cystic duct obstruction

Pain lasts > 4 hours
Usually fatty food ingestion 1 hr before pain
Biliary Colic
3= Cleveland Clinic Journal of
Med 21
 Acute Cholecystitis

Distention and inflammation of the

gallbladder
Obstruction of cystic duct Chemical
irritants in the bile
Lysolecithin
Prostaglandins

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UptoDate 2003

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 Cholelithiasis-
Di ngr Barat,batu kolesterol dan
pigmen
Patogenesis batu empedu
Batu empedu kolesterol:terbentuknya tgt
produksi empedu,cukup/tdk untuk pertahankan
kolesterol.dlm bentuk micellar.Ok kenaikan
sekresi kolesterol/penurunan produksi
empedu.Adanya infeksi kandung empedu
menambah terjadinya batu empedu,mengubah
komposisi kimia empedu,mudah presipitasi,juga
usis,obesitas,wanita,kurang sayuran,.

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 Cholelithiasis-
Batu empedu pigmen:hitam
(black pigmen stone terbentuk dlm
kandung empedu,hemolisis kronik/CH tanpa
infeksi.dan coklat(brown pigmen stone),bntk lbh
besar,lapis-lapis,di temukan sepanjang saluran
empedu,ada bendungan dan infeksi.
Batu empedu intra hepatik:batu pigmen
coklat,kambuh walau tlh di
operasi(Jepang,/Taiwan)
Batu saluran empedu: hub.dg divertikla
dudenum.

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Cholelithiasis

Presence of one or more gallstones

Stones form when bile hardens
Abnormal metabolism of
cholesterol/bile salts
Etiology:
Familial tendency
Dietary habits
Sedentary lifestyle
Impaired fat metabolism
Increased cholesterol 26
Cholelithiasis-- Interventions

Nonsurgical Surgical
Nutritional and supportive Laproscopic
therapy cholecystectomy
Drug therapy Cholecystectomy
Stone removal by
Mini-cholecystectomy
instrumentation
Intracorpreal or
Choledocholithotomy
Extracorporeal shock wave Percutaneous
lithotripsy cholecystectomy
Percutaneous transhepatic Cholecystostomy
biliary chatheter

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Nursing Care Measure
Relieve pain
Improve respiratory status
Promote skin care
Promote biliary drainage
Improve nutritional status
Monitor for and manage potential
complications

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 Cholelithiasis
Definition, Incidence, Predisposing Factors

Also known as stones in the gallbladder

It is the most common disorder
of the biliary system and it has been
estimated that 8-10% of all adults
in the U.S. have this condition.
Predisposing factors includes: gender, age, estrogen,
sedentary lifestyle, family history and obesity.
Cholecystitis- inflammation of the gallbladder.

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30
 Cholelithiasis
Diagnostic Test
Ultrasound-best way to dx; 90-
95% effective.
Serum studies- liver function test
and serum amylase
Cholangiogram
Gallbladder x-ray test.

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 Cholelithiasis
Interventions
Provide relief from vomiting. NGT-
reduces distention & eliminates gastric
juices that stimulate cholecystokinin.
Maintain fluid and electrolyte balance.
Monitor drug therapy. Administer broad
spectrum Abx. Chenodeoxycholic acid-
bile acid dissolves cholesterol calculi
(60% of the stone).
NTG & papaverine to reduce spasms of duct.
Synthetic narcotics (Demerol, methadone) MSO4 may
cause spasms of Oddi and increase spasms. 32
 Cholelithiasis
Interventions cont..
Provide low-fat diet to decrease
gallbladder stimulation; avoid alcohol
and gas forming foods.
Maintain bedrest
Extracorporeal shock wave lithotripsy-
shock wave that disintegrates stones in
the biliary system. Ultrasound is used
for stone localization before the
lithotriptor send waves through a water
bag upon which the patient is lying.
Analgesics and sedatives to reduce pain
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during procedures.
 Cholelithiasis
Clinical Manifestations
Sudden-onset pain in the right upper quadrant (RUQ) of the
abdomen. Severe and steady in quality. Frequently radiates to the
right scapula or shoulder. Persists for abt. 1 to 3 hours. May awaken
the patient at night. May be associated with consumption of a large
fatty meals.
Anorexia, nausea and vomiting.
Mild to moderate fever
Decreased or absent bowel sounds
Acute abdominal tenderness
Elevated WBC, slightly elevated bilirubin,
and alkaline phosphatase.

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 Statistics

About 3 million adults in the U.S. have gallstones

Elderly, diabetics, obese patients, debilitated

patients increased incidence of gallstones

90% of acute cholecystitis cases due to gallstones

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 Background
Aging is the most significant factor higher
incidence of acute cholecystitis1

Acute Cholecystitis is the initial presentation of

symptomatic gallstones in 15% - 20% of
patients3

THE END 36
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