Cholelithiasis

Gallstones can occur anywhere within the biliary tree, including the gallbladder and the common bile 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 cause pancreatitis. Cholelithiasis is the presence of
stones in the gallbladder or bile ducts: chole- means "bile", lithia means "stone", and -sis means "process".

Most gallstones result from supersaturation of cholesterol in the bile, which acts as an irritant, producing
inflammation in the gallbladder, and which precipitates out of bile, causing stones. Risk factors include gender (women
four times as like to develop cholesterol stones as men), age (older than age 40), multiple parity, obesity, use of
estrogen and cholesterol-lowering drugs, bile acid malabsorption with GI disease, genetic predisposition, rapid weight
loss. Pigment stones occur when free bilirubin combines with calcium. These stones occur primarily in patients with
cirrhosis, hemolysis, and biliary infections.

Pathophysiology
 Gallstones have different appearance, depending on their contents. On the basis of their contents,
gallstones can be subdivided into the two following types:

 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).
 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 (such as sickle cell anemia and hereditary Gall bladder opened to show numerous
spherocytosis), cirrhosis, and biliary tract infections. gallstones. Their brownish to greenish color
suggest they are cholesterol calculi.
The proportions of these different types of stone found varies
between samples and is thought to be affected by the age and ethnic
or regional origin of the patients.

Mixed stones

All stones are of mixed content to some extent. Those classified as mixed, however, contain between
30% and 70% of cholesterol. In most cases the other majority constituent is calcium salts such as
calcium carbonate, palmitate phosphate, and/or bilirubinate. Because of their calcium content, they can
often be visualized radiographically.

Pseudoliths

Also known as "Fake stones," they are sludge-like gallbladder secretions that act like a stone.

Causes

Researchers believe that gallstones may be caused by a combination

of factors, including inherited body chemistry, body weight,
gallbladder motility (movement), and perhaps diet.

Pigment gallstones

Most commonly seen in the developing world. People with

erythropoietic protoporphyria (EPP) are at increased risk to
develop gallstones.

Conditions causing hemolytic anemia can cause pigment

gallstones.

Cholesterol gallstones
Cholesterol gallstones develop when bile contains too much cholesterol and not enough bile salts.
Besides a high concentration of cholesterol, two other factors seem to be important in causing
gallstones. The first is how often and how well the gallbladder contracts; incomplete and infrequent
emptying of the gallbladder may cause the bile to become overconcentrated and contribute to gallstone
formation. The second factor is the presence of proteins in the liver and bile that either promote or
inhibit cholesterol crystallization into gallstones.

In addition, increased levels of the hormone estrogen as a result of pregnancy, hormone therapy, or the
use of combined (estrogen-containing) forms of hormonal contraception, may increase cholesterol
levels in bile and also decrease gallbladder movement, resulting in gallstone formation.

No clear relationship has been proven between diet and gallstone formation; however, low-fiber, high-
cholesterol diets and diets high in starchy foods have been suggested as contributing to gallstone
formation. Other nutritional factors that may increase risk of gallstones include rapid weight loss,
constipation, eating fewer meals per day, eating less fish, and low intakes of the nutrients folate,
magnesium, calcium, and vitamin C. On the other hand, wine and whole grain bread may decrease the
risk of gallstones.

The common mnemonic for gallstone risk factors refer to the "four Fs": fat (i.e., overweight), forty (an
age near or above 40), female, and fertile (pre-menopausal); a fifth F, fair is sometimes added to
indicate that the condition is more prevalent in Caucasians. The absence of these risk factors does not,
however, preclude the formation of gallstones.

Interestingly, a lack of melatonin could significantly contribute to gallbladder stones, as melatonin

both inhibits cholesterol secretion from the gallbladder, enhances the conversion of cholesterol to bile,
and is an antioxidant, capable of reducing oxidative stress to the gallbladder.

Symptoms

Gallstones usually remain asymptomatic initially. They start developing symptoms once the stones
reach a certain size (>8 mm). A main symptom of gallstones is commonly referred to as a gallstone
"attack", also known as biliary colic, in which a person will experience intense pain in the upper
abdominal region that steadily increases for approximately 30 minutes to several hours. A patient may
also experience pain in the back, ordinarily between the shoulder blades, or pain under the right
shoulder. In some cases, the pain develops in the lower region of the abdomen, nearer to the pelvis, but
this is less common. Nausea and vomiting may occur. Patients characteristically exhibit a positive
Murphy's sign, (the patient is instructed to breathe in while the gallbladder is deeply palpated). If the
gallbladder is inflamed, the patient will abruptly stop inhaling due to the pain, resulting in a positive
Murphy's sign.

These attacks are sharp and intensely painful, similar to that of a kidney stone attack. Often, attacks
occur after a particularly fatty meal and almost always happen at night. Other symptoms include
abdominal bloating, intolerance of fatty foods, belching, gas and indigestion. If the above symptoms
coincide with chills, low-grade fever, yellowing of the skin or eyes and/or clay-colored stool, a doctor
should be consulted immediately.

Some people who have gallstones are asymptomatic and do not feel any pain or discomfort. These
gallstones are called "silent stones" and do not affect the gallbladder or other internal organs. They do
not need treatment.
 Treatment
Medical options

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. Obstruction of the common bile duct with gallstones can sometimes be relieved by
endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde
cholangiopancreatography (ERCP). Gallstones can be broken up using a procedure called lithotripsy
(extracorporeal shock wave lithotripsy). This 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.

Surgical options

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 may
have no negative consequences in many people. However, there is a significant portion of the
population — between 5 and 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.[15] 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 they can all be removed.

Temporary Relief

Some patients have anecdotally reported that symptoms can be temporarily reduced by drinking
several glasses of water when experiencing gallstone pain. This approach will not eliminate the
gallstones or improve the patient's condition in the long term.
Oxygen therapy – is the administration of oxygen as a therapeutic modality. It is
prescribed by the physician, who specifies the concentration, method of delivery, and liter flow
per minute.

Benefits of Oxygen Therapy:

Additional Benefits of Oxygen Therapy:

 Increased clarity
 Relieves nausea
 Can prevent heart failure in people with severe lung disease
 Allows the bodies organs to carry out normal functions

Long-Term Benefits of Oxygen Therapy:

 Prolongs life by reducing heart strain

 Decreases shortness of breath
 Makes exercise more tolerable
 Results in fewer days of hospitalization
Oxygen Delivery Systems

1. Nasal Cannula

 Also called nasal prongs.

 Is the most common inexpensive device used to administer
oxygen.
 It is easy to apply and does not interfere with the client’s ability
to eat or talk.
 It delivers a relatively low concentration of oxygen which is
24% to 45% at flow rates of 2 to 6 liters per minute.

2. Face Mask

 It covers the client’s nose and mouth may be used for oxygen inhalation.
 Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape.

Types of Face Masks:

1. Simple Face Mask - Delivers oxygen concentrations from 40% to 60% at liter
flows of 5 to 8 liters per minute, respectively.
2. Partial Rebreather Mask – Delivers oxygen concentration of 60% to 90% at
liter flows of 6 to 10 liters per minute, respectively.
3. Non Rebreather Mask – Delivers the highest oxygen concentration possible
95% to 100% – by means other than intubation or mechanical ventilation, at liter
flows of 10 to 15 liters per minute.
4. Venturi Mask – Delivers oxygen concentrations varying from 24% to 40% or
50% at liter flows of 4 to 10 liters per minute.
3. Face Tent

 It can replace oxygen masks when masks are poorly

tolerated by clients.
 It provides varying concentrations of oxygen such as
30% to 50% concentration of oxygen at 4 to 8 liters per
minute.

4. Transtracheal Oxygen Delivery

 It may be used for oxygen-dependent clients.

 The client requires less oxygen (0.5 to 2 liters per minute) because all of
the low delivered enters the lungs.

Oxygen Therapy Safety Precautions:

1. For home oxygen use or when the facility permits smoking, teach family members and
roommates to smoke only outside or in provided smoking rooms away from the client.
2. Place cautionary signs reading “No Smoking: Oxygen in use” on the clients door, at the
foot or head of the bed, and on the oxygen equipment.
3. Instruct the client and visitors about the hazard of smoking with oxygen use.
4. Make sure that electric devices (such as razors, hearing aids, radios, televisions, and
hearing pads) are in good working order to prevent the occurrence of short-circuit sparks.
5. Avoids materials that generate static electricity, such as woolen blankets and synthetic
fabrics. Cotton blankets should be used , and client and caregivers should be advised to
wear cotton fabrics.
6. Avoid the use of volatile, flammable materials such as oils, greases, alcohol, ether, and
acetone (e.g. nail polish remover), near clients receiving oxygen.
7. Ground electric monitoring equipment, suction machines and portable diagnostic
machines.
8. Make known the location of the fire extinguishers, and make sure personnel are trained in
their use.