DISORDERS OF THE

GALLBLADDER
Geofry ouma
BSc.Nursing UoEm

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Introduction

 The gallbladder is a pear-shaped sac that is located in a depression of the

posterior surface of the liver. It is 7–10 cm (3–4 in.) long and typically hangs
from the anterior inferior margin of the liver.
 The parts of the gallbladder include the broad fundus, which projects
inferiorly beyond the inferior border of the liver; the body, the central
portion; and the neck, the tapered portion. The body and neck project
superiorly.
 The mucosa of the gallbladder consists of simple columnar epithelium
arranged in rugae resembling those of the stomach. The wall of the
gallbladder lacks a submucosa.

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 The middle, muscular coat of the wall consists of smooth muscle fibers.
Contraction of the smooth muscle fibers ejects the contents of the
gallbladder into the cystic duct.
 The gallbladder’s outer coat is the visceral peritoneum.
 The functions of the gallbladder are to store and concentrate the bile
produced by the liver (up to tenfold) until it is needed in the duodenum.
 In the concentration process, water and ions are absorbed by the gallbladder
mucosa. Bile aids in the digestion and absorption of fat.

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 Because neither lecithin nor bile salts are absorbed in the gallbladder, their
concentration increases along with that of cholesterol; in this way, the
solubility of cholesterol is maintained.
 Entrance of food into the intestine causes the gallbladder to contract and the
sphincter of the bile duct to relax, such that bile stored in the gallbladder
moves into the duodenum.
 The stimulus for gallbladder contraction is primarily hormonal.
 Products of food digestion, particularly lipids, stimulate the release of a
gastrointestinal hormone called cholecystokinin from the mucosa of the
duodenum.
 Cholecystokinin provides a strong stimulus for gallbladder contraction.

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 Pressure in the common duct largely is responsible for regulating passage of
bile into the intestine. Normally, the gallbladder regulates this pressure.
 It collects and stores bile as it relaxes and the pressure in the common bile
duct decreases, and it empties bile into the intestine as the gallbladder
contracts, producing an increase in common duct pressure.
 After gallbladder surgery, the pressure in the common duct changes, causing
the common duct to dilate. The sphincters in the common duct then regulate
the flow of bile.
 Two common disorders of the biliary system are cholelithiasis (i.e.,
gallstones) and inflammation of the gallbladder (cholecystitis) or common
bile duct (cholangitis). or stones in the common bile duct
(choledocholithiasis).
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Cholecystitis

 Cholecystitis (inflammation of the gallbladder which can be acute or

chronic) causes pain, tenderness, and rigidity of the upper right abdomen
that may radiate to the midsternal area or right shoulder and is associated
with nausea, vomiting, and the usual signs of an acute inflammation.
 An empyema of the gallbladder develops if the gallbladder becomes
filled with purulent fluid (pus).
 Calculous cholecystitis is the cause of more than 90% of cases of acute
cholecystitis (Feldman et al., 2015; Rakel & Rakel, 2015).
 In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile
remaining in the gallbladder initiates a chemical reaction; autolysis and
edema occur; and the blood vessels in the gallbladder are compressed,
compromising its vascular supply.
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 Gangrene of the gallbladder with perforation may result.
 Bacteria play a minor role in acute cholecystitis; however, secondary
infection of bile occurs in approximately 50% of cases.
 The organisms involved are generally enteric (normally live in the GI tract)
and include Escherichia coli, Klebsiella species, and Streptococcus.
Bacterial contamination is not believed to stimulate the actual onset of
acute cholecystitis.
 Acalculous cholecystitis describes acute gallbladder inflammation in the
absence of obstruction by gallstones.
 Acalculous cholecystitis occurs after major surgical procedures, orthopedic
procedures, severe trauma, or burns.

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 Other factors associated with this type of cholecystitis include torsion,
cystic duct obstruction, primary bacterial infections of the gallbladder, and
multiple blood transfusions.
 It is speculated that acalculous cholecystitis is caused by alterations in fluids
and electrolytes and alterations in regional blood flow in the visceral
circulation.
 Bile stasis (lack of gallbladder contraction) and increased viscosity of the
bile are also thought to play a role.
 The occurrence of acalculous cholecystitis with major surgical
procedures or trauma makes its diagnosis difficult

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 It has been theorized that obstruction of the cystic duct by a gallstone leads
to the release of phospholipase from the epithelium of the gallbladder. In
turn, this enzyme may hydrolyze lecithin and release lysolecithin, a
membrane-active toxin.
 At the same time, disruption of the normally protective mucous lining of the
epithelium renders the mucosal cells vulnerable to damage by the detergent
action of concentrated bile salts.
 Acute acalculous cholecystitis can rapidly progress to gangrene and
perforation because the process appears to involve a transmural infarction,
rather than inflammatory changes associated with stones.

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 Chronic cholecystitis results from repeated episodes of acute
cholecystitis or chronic irritation of the gallbladder by stones. It is
characterized by varying degrees of chronic inflammation.
 Gallstones almost always are present. Cholelithiasis with chronic
cholecystitis may be associated with acute exacerbations of gallbladder
inflammation, common duct stone, pancreatitis, and, rarely, carcinoma of
the gallbladder.

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Clinical Manifestations.

 People with acute cholecystitis usually experience an acute onset of

upper right quadrant or epigastric pain, frequently associated with mild
fever, anorexia, nausea, and vomiting.
 Whereas in biliary colic the cystic duct obstruction is transient, in acute
cholecystitis it is persistent.
 People with calculous cholecystitis usually, but not always, have experienced
previous episodes of biliary pain.
 People with acute cholecystitis usually have an elevated white blood cell count,
and many have mild elevations in AST, ALT, alkaline phosphatase, and bilirubin.
 The manifestations of chronic cholecystitis are more vague than those of
acute cholecystitis. There may be intolerance to fatty foods, belching, and
other indications of discomfort.
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Assessment and diagnosis

 ultrasonography can detect wall thickening, which indicates

inflammation. It also can rule out other causes of right upper quadrant
pain such as tumors.
 Cholescintigraphy, also called a gallbladder scan, relies on the ability of the
liver to extract a rapidly injected radionuclide, technetium-99m, bound
to one of several iminodiacetic acids, that is excreted into the bile ducts.
 Serial scanning images are obtained within several minutes of the injection of
the tracer and every 10 to 15 minutes during the next hour.
 Although CT is not as accurate as ultrasonography in detecting gallstones, it
can show thickening of the gallbladder wall or pericholecystic fluid associated
with acute cholecystitis.

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Treatment

 Gallbladder disease usually is treated by removing the gallbladder.

 The gallbladder stores and concentrates bile, and its removal usually does not
interfere with digestion.
 Laparoscopic cholecystectomy has become the treatment of choice for
symptomatic gallbladder disease.
 The procedure involves insertion of a laparoscope through a small incision
near the umbilicus, and surgical instruments are inserted through several
stab wounds in the upper abdomen.

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Cholelithiasis

 Calculi, or gallstones, usually form in the gallbladder from the solid

constituents of bile; they vary greatly in size, shape, and composition.
 Two primary factors contribute to the formation of gallstones: abnormalities
in the composition of bile (particularly increased cholesterol) and the stasis of
bile.
 The formation of cholesterol stones is associated with obesity and occurs
more frequently in women, especially women who have had multiple
pregnancies or who are taking oral contraceptives.
 All of these factors cause the liver to excrete more cholesterol into the bile.
Estrogen reduces the synthesis of bile acid in women.

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 Gallbladder sludge (thickened gallbladder mucoprotein with tiny trapped
cholesterol crystals) is thought to be a precursor of gallstones.
 Sludge frequently occurs with pregnancy, starvation, and rapid weight loss.
Drugs that lower serum cholesterol levels, such as clofibrate, also
cause increased cholesterol excretion into the bile.
 Malabsorption disorders stemming from ileal disease or intestinal bypass
surgery, for example, tend to interfere with the absorption of bile salts,
which are needed to maintain the solubility of cholesterol.
 Inflammation of the gallbladder alters the absorptive characteristics of the
mucosal layer, allowing excessive absorption of water and bile salts.

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Pathophysiology

 There are two major types of gallstones: those composed predominantly of

pigment and those composed primarily of cholesterol.
 Pigment stones probably form when unconjugated pigments in the bile
precipitate to form stones.
 The risk of developing such stones is increased in patients with cirrhosis,
hemolysis, and infections of the biliary tract. Pigment stones cannot be
dissolved and must be removed surgically.
 Cholesterol, which is a normal constituent of bile, is insoluble in water.
Its solubility depends on bile acids and lecithin (phospholipids) in bile.
 In gallstone-prone patients, there is decreased bile acid synthesis and
increased cholesterol synthesis in the liver, resulting in bile supersaturated
with cholesterol, which precipitates out of the bile to form stones.
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 The cholesterol-saturated bile predisposes to the formation of gallstones
and acts as an irritant that produces inflammatory changes in the mucosa of
the gallbladder.
 The incidence of stone formation increases with age as a result of increased
hepatic secretion of cholesterol and decreased bile acid synthesis.
 In addition, there is an increased risk because of malabsorption of bile salts
in patients with GI disease or T-tube fistula and in those who have undergone
ileal resection or bypass. The incidence is also greater in people with
diabetes.

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RISK FACTORS

 Cystic fibrosis
 Diabetes
 Frequent changes in weight
 Ileal resection or disease
 Low-dose estrogen therapy—carries a small increase in the risk of gallstones
 Obesity
 Rapid weight loss (leads to rapid development of gallstones and high risk of
symptomatic disease)
 Treatment with high-dose estrogen (e.g., in prostate cancer)
 Women, especially those who have had multiple pregnancies or who are of
Native American or U.S. southwestern Hispanic ethnicity
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Clinical Manifestations

Pain and Biliary Colic.

 If a gallstone obstructs the cystic duct, the gallbladder becomes
distended,
inflamed, and eventually infected (acute cholecystitis). The patient
develops a fever and may have a palpable abdominal mass.
 The patient may have biliary colic with excruciating upper right
abdominal pain that radiates to the back or right shoulder.
 Biliary colic is usually associated with nausea and vomiting, and it is
noticeable several hours after a heavy meal. The patient moves
about restlessly, unable to find a comfortable position. In some
patients, the pain is constant rather than colicky.
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 Such a bout of biliary colic is caused by contraction of the gallbladder, which
cannot release bile because of obstruction by the stone. When
distended, the fundus of the gallbladder comes in contact with the
abdominal wall in the region of the right 9th and 10th costal
cartilages.
 This produces marked tenderness in the right upper quadrant on deep
inspiration and prevents full inspiratory excursion.
 The pain of acute cholecystitis may be so severe that analgesic
medications are required. The use of morphine has traditionally been
avoided because of concern that it could cause spasm of the sphincter of
Oddi, and meperidine (Demerol) has been used instead.

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Jaundice

 Jaundice occurs in a few patients with gallbladder disease, usually with

obstruction of the common bile duct.
 The bile, which is no longer carried to the duodenum, is absorbed by the
blood and gives the skin and mucous membranes a yellow color.
 This is frequently accompanied by marked pruritus (itching) of the skin

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Changes in Urine and Stool Color

 The excretion of the bile pigments by the kidneys gives the urine a very dark
color. The feces, no longer colored with bile pigments, are grayish (like putty)
or clay colored.

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Vitamin Deficiency

 Obstruction of bile flow interferes with absorption of the fat-soluble

vitamins A, D, E, and K.
 Patients may exhibit deficiencies of these vitamins if biliary obstruction
has been prolonged.
 For example, a patient may have bleeding caused by vitamin K deficiency
(vitamin K is necessary for normal blood clotting).

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Assessment and Diagnostic Findings

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Abdominal X-Ray

 If gallbladder disease is suspected, an abdominal x-ray may be obtained to

exclude other causes of symptoms. However, only 10% to 15% of
gallstones are calcified sufficiently to be visible on such x-ray studies.

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Ultrasonography

 Ultrasonography is the diagnostic procedure of choice because it is rapid and

accurate and can be used in patients with liver dysfunction and
jaundice.
 It does not expose patients to ionizing radiation. The procedure is most
accurate if the patient fasts overnight so that the gallbladder is
distended.
 Ultrasonography can detect calculi in the gallbladder or a dilated
common bile duct with 90% accuracy

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Radionuclide Imaging or
Cholescintigraphy
 Cholescintigraphy is used successfully in the diagnosis of acute
cholecystitis or blockage of a bile duct.
 During this procedure, a radioactive agent is administered intravenously
(IV) which is taken up by the hepatocytes and excreted rapidly through
the biliary tract.
 The biliary tract is then scanned, and images of the gallbladder and
biliary tract are obtained.
 This test is more expensive than ultrasonography, takes longer to perform,
and exposes the patient to radiation.
 It is often used when ultrasonography is not conclusive, such as in acalculous
cholecystitis.

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Oral Cholecystography

 Oral cholecystography is used if ultrasound equipment is not available or if the

ultrasound results are inconclusive.
 This study may be performed to detect gallstones and to assess the ability of
the gallbladder to fill, concentrate its contents, contract, and empty.
 If the patient is not allergic to iodine or seafood, an iodide-containing contrast
agent that is excreted by the liver and concentrated in the gallbladder is given 10 to
12 hours before the x-ray study.
 The normal gallbladder fills with this radiopaque substance. If gallstones are
present, they appear as shadows on the x-ray image.
 Oral cholecystography may be used as part of the evaluation of patients who have
been treated with gallstone dissolution therapy (the use of medications to
break up/dissolve gallstones) or lithotripsy (disintegration of gallstones by shock
waves).
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Endoscopic Retrograde
Cholangiopancreatography
 ERCP permits direct visualization of structures that previously could be seen
only during laparotomy.
 This procedure examines the hepatobiliary system via a side-viewing flexible
fiberoptic endoscope inserted through the esophagus to the descending
duodenum.
 Multiple position changes are required to pass the endoscope during the
procedure, beginning in the left semiprone position.
 Fluoroscopy and multiple x-rays are used during ERCP to evaluate the presence
and location of ductal stones.
 Careful insertion of a catheter through the endoscope into the common
bile duct is the most important step in sphincterotomy (division of the
muscles of the biliary sphincter) for gallstone extraction via this technique.
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 ERCP is not recommended for the evaluation of suspected common bile duct
stones but can be used to treat confirmed choledocholithiasis before or
during laparoscopic cholecystectomy.


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Percutaneous Transhepatic
Cholangiography
 PTC is rarely used for diagnostic purposes alone due to the multitude of
other less invasive and reliable imaging studies.
 PTC is reserved for those patients in whom an ERCP may be unsafe due
to previous surgery involving the biliary tract.
 The use of PTC has mainly been replaced by ERCP and magnetic resonance
cholangiopancreatography (MRCP). PTC involves the injection of dye directly
into the biliary tract.
 Because of the relatively large concentration of dye that is introduced into
the biliary system, including the hepatic ducts within the liver, the entire
length of the common bile duct, the cystic duct, and the gallbladder
is outlined clearly.

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 This procedure can be carried out even in the presence of liver
dysfunction and jaundice. It is useful for (1) distinguishing jaundice caused
by liver disease (hepatocellular jaundice) from that caused by biliary
obstruction, (2) investigating the GI symptoms of a patient whose gallbladder
has been removed, (3) locating stones within the bile ducts, and (4)
diagnosing cancer involving the biliary system.
 This sterile procedure is performed under moderate sedation on a patient who
has been fasting; the patient also receives local anesthesia.
 Coagulation parameters and platelet count should be normal to minimize the
risk of bleeding.
 Broad-spectrum antibiotics are given during the procedure because of the
high prevalence of bacterial colonization from obstructed biliary systems .

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 After infiltration with a local anesthetic agent has occurred, a flexible needle is inserted
into the liver from the right side in the midclavicular line immediately beneath the
right costal margin.
 Successful entry of a duct is noted when bile is aspirated or on injection of a contrast
agent. Ultrasound can be used to guide puncture of the duct. Bile is aspirated, and
samples are sent for bacteriology and cytology.
 A water-soluble contrast agent is injected to fill the biliary system. The fluoroscopy
table is tilted and the patient is repositioned to allow x-rays to be taken in multiple
projections.
 Delayed x-ray views can identify abnormalities of more distant ducts and determine the
length of a stricture or multiple strictures.
 Before the needle is removed, as much dye and bile as possible are aspirated to forestall
subsequent leakage into the needle tract and eventually into the peritoneal cavity, thus
minimizing the risk of bile peritonitis.
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Medical Management

 The major objectives of medical therapy are to reduce the incidence

of acute episodes of gallbladder pain and cholecystitis by supportive
and dietary management and, if possible, to remove the cause of cholecystitis
by pharmacologic therapy, endoscopic procedures, or surgical
intervention.
 Removal of the gallbladder (cholecystectomy) through traditional surgical
approaches has largely been replaced by laparoscopic cholecystectomy
(removal of the gallbladder through a small incision through the
umbilicus).

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Nutritional and Supportive Therapy

 Approximately 80% of the patients with acute gallbladder inflammation

achieve remission with rest, IV fluids, nasogastric suction, analgesia, and
antibiotic agents. Unless the patient’s condition deteriorates, surgical
intervention is delayed just until the acute symptoms subside.
 At this time, the patient undergoes a laparoscopic cholecystectomy.
 The diet immediately after an episode is usually low-fat liquids. These can
include powdered supplements high in protein and carbohydrate stirred
into skim milk. Cooked fruits, rice or tapioca, lean meats, mashed potatoes,
non–gas-forming vegetables, bread, coffee, or tea may be added as
tolerated.
 The patient should avoid eggs, cream, pork, fried foods,cheese, rich
dressings, gas-forming vegetables, and alcohol.
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 It is important to remind the patient that fatty foods may induce an
episode of cholecystitis.
 Dietary management may be the major mode of therapy in patients who have
had only dietary intolerance to fatty foods and vague GI symptoms.

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Pharmacologic Therapy

 Ursodeoxycholic acid (UDCA [Urso, Actigall]) and chenodeoxycholic acid

(chenodiol or CDCA [Chenix]) have been used to dissolve small,
radiolucent gallstones composed primarily of cholesterol.
 UDCA has fewer side effects than chenodiol and can be given in smaller doses
to achieve the same effect.
 It acts by inhibiting the synthesis and secretion of cholesterol, thereby
desaturating bile.
 Treatment with UDCA can reduce the size of existing stones, dissolve small
stones, and prevent new stones from forming. Six to 12 months of therapy is
required in many patients to dissolve stones, and monitoring of the
patient for recurrence of symptoms or the occurrence of side effects
(e.g., GI symptoms, pruritus, headache) is required during this time.
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 The effective dose of medication depends on body weight. This method of
treatment is generally indicated for patients who refuse surgery or for whom
surgery is contraindicated. The success rate of this therapy is low as the
recurrence following it is high.
 Patients with significant, frequent symptoms, cystic duct occlusion, or
pigment stones are not candidates for pharmacologic therapy.
 Laparoscopic or open cholecystectomy is more appropriate for
symptomatic patients with acceptable operative risk.

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Nonsurgical Removal of Gallstones

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Dissolving Gallstones

 Several methods have been used to dissolve gallstones by infusion of a

solvent (mono-octanoin or methyl tertiary butyl ether [MTBE]) into the
gallbladder.
 The solvent can be infused through the following routes: through a tube
or catheter inserted percutaneously directly into the gallbladder, through a
tube or drain inserted through a T-tube tract to dissolve stones not
removed at the time of surgery, endoscopically with ERCP; or via a
transnasal biliary catheter (a rarely used procedure due to its lack of success,
potential side effects, and rates of recurrence rate of up to 50%.
 Laparoscopic cholecystectomy is the standard for management.
 Dissolution therapies are used for those patients who may not be
candidates for the procedure due to safety concerns regarding general
anesthesia.
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Stone Removal by Instrumentation

 Several nonsurgical methods are used to remove stones that were not
removed at the time of cholecystectomy or have become lodged in the
common bile duct.
 A catheter and instrument with a basket attached are threaded through the
T-tube tract or fistula formed at the time of T-tube insertion; the basket is
used to retrieve and remove the stones lodged in the common bile duct.
 A second procedure involves the use of ERCP endoscope.
 After the endoscope is inserted, a cutting instrument is passed through the
endoscope into the ampulla of Vater of the common bile duct.
 It may be used to cut the submucosal fibers, or papilla, of the sphincter of
Oddi, enlarging the opening, which may allow the lodged stones to pass
spontaneously into the duodenum.
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 Another instrument with a small basket or balloon at its tip may be inserted
through the endoscope to retrieve the stones.
 The patient is observed closely for bleeding, perforation, and the
development of pancreatitis (see later discussion) or sepsis.
 The ERCP procedure is particularly useful in diagnosis and treatment of
patients who have symptoms after biliary tract surgery, patients with intact
gallbladders, and patients for whom surgery is particularly hazardous.

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Intracorporeal Lithotripsy

 Stones in the gallbladder or common bile duct may be fragmented by

means of laser pulse technology.
 A laser pulse is directed under fluoroscopic guidance with the use of
devices that can distinguish between stones and tissue.
 The laser pulse produces rapid expansion and disintegration of plasma
on the stone surface, resulting in a mechanical shock wave.
 Electrohydraulic lithotripsy uses a probe with two electrodes that deliver
electric sparks in rapid pulses, creating expansion of the liquid environment
surrounding the gallstones.
 This results in pressure waves that cause stones to fragment.

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 This technique can be used percutaneously with a basket or balloon catheter
system or by direct visualization through an endoscope.
 Repeated procedures may be necessary because of stone size, local anatomy,
bleeding, or technical difficulty.
 A nasobiliary tube can be inserted to allow for biliary decompression and to
prevent stone impaction in the common bile duct.
 This approach allows time for improvement in the patient’s clinical condition
until gallstones are cleared endoscopically, percutaneously, or surgically.

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Extracorporeal Shock Wave Lithotripsy

 Extracorporeal shock wave therapy (lithotripsy or ESWL) has been used for
nonsurgical fragmentation of gallstones. Lithotripsy, which is a
noninvasive procedure, uses repeated shock waves directed at the
gallstones in the gallbladder or common bile duct to fragment the stones.
 The waves are transmitted to the body through a fluid-filled bag or by
immersing the patient in a water bath.
 After the stones are gradually broken up, the stone fragments can be
spontaneously passed from the gallbladder or common bile duct,
removed by endoscopy, or dissolved with oral bile acid or solvents.
 Because the procedure requires no incision and no hospitalization, patients
are usually treated as outpatients, but usually several sessions are
necessary.
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 This procedure has largely been replaced by laparoscopic cholecystectomy.
ESWL is used in some centers for a small percentage of suitable patients
(those with common bile duct stones who may not be surgical
candidates), sometimes in combination with dissolution therapy.

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Surgical Management

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Preoperative Measures

 Chest x-ray, electrocardiogram, and liver function tests may be performed in addition
to imaging studies of the gallbladder.
 Vitamin K may be given if the prothrombin level is low.
 Nutritional requirements are considered, and, if the nutritional status is suboptimal,
it may be necessary to provide IV glucose with protein supplements to aid wound
healing and help prevent liver damage.
 Patient education for gallbladder surgery is similar to that for any upper abdominal
laparotomy or laparoscopy.
 Instructions and explanations are given before surgery about turning and deep
breathing. Postoperative pneumonia and atelectasis can be avoided by deep-
breathing exercises, frequent turning, and early ambulation. The patient should
be informed that drainage tubes and a nasogastric tube and suction might be required
during the immediate postoperative period if an open cholecystectomy is performed.
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Laparoscopic Cholecystectomy

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 Laparoscopic cholecystectomy is the standard of therapy for symptomatic
gallstones.
 If the common bile duct is thought to be obstructed by a gallstone, an
ERCP with sphincterotomy may be performed to explore the duct before
laparoscopy.
 Before the procedure, the patient is educated that an open abdominal
procedure may be necessary, and general anesthesia is given.
 Laparoscopic cholecystectomy is performed through a small incision or
puncture made through the abdominal wall at the umbilicus.
 The abdominal cavity is insufflated with carbon dioxide (pneumoperitoneum)
to assist in inserting the laparoscope and to aid in visualizing the
abdominal structures.
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 The fiberoptic scope is inserted through the small umbilical incision. Several
additional punctures or small incisions are made in the abdominal wall to
introduce other surgical instruments into the operative field.
 A camera attached to the laparoscope permits the surgeon to view the
intraabdominal field and biliary system on a television monitor.
 After the cystic duct is dissected, the common bile duct can be visualized by
ultrasound or cholangiography to evaluate the anatomy and identify stones.
The cystic artery is dissected free and clipped.
 The gallbladder is separated from the hepatic bed and removed from the
abdominal cavity after bile and small stones are aspirated. Stone forceps
also can be used to remove or crush larger stones.

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 With the laparoscopic procedure, the patient does not experience the
paralytic ileus that occurs with open abdominal surgery and has less
postoperative abdominal pain.
 The patient is often discharged from the hospital on the same day of
surgery or within 1 or 2 days and resumes full activity and employment within 1
week after the procedure.
 Conversion to an open procedure occurs if there is inflammation in and
around the gallbladder, making safe dissection of the porta hepatis difficult.
 The porta hepatis is the fissure of the liver where the portal vein and the
hepatic artery enter and the hepatic ducts exit the liver.
 The most serious complication after laparoscopic cholecystectomy is a bile duct
injury, which may be identified and corrected at the time of the procedure.
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 Patients with a postoperative bile leak may not develop symptoms until
several days after the procedure, and some have an even more prolonged
period before injury to the bile duct becomes apparent.
 A bile leak may result in fluid collections, which can usually be managed
by endoscopic stent placement.
 Bile peritonitis, a rare complication, may result in serious illness or death.
 Because of the short length of hospital stay with uncomplicated
laparoscopic cholecystectomies, it is important to provide patient
education about managing postoperative pain and reporting signs and
symptoms of intra-abdominal complications, including loss of appetite,
vomiting, pain, distention of the abdomen, and temperature elevation.

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 Although recovery from laparoscopic cholecystectomy is rapid, patients
are drowsy afterward.
 The patient must have assistance at home during the first 24 to 48 hours.
 If pain occurs in the right shoulder or scapular area (from migration of the
carbon dioxide used to insufflate the abdominal cavity during the
procedure), the nurse may recommend a heating pad for 15 to 20 minutes
hourly.

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Cholecystectomy

 In cholecystectomy, the gallbladder is removed through an abdominal

incision (usually right subcostal) after the cystic duct and artery are
ligated.
 The procedure is performed for acute and chronic cholecystitis. In some
patients, a drain is placed close to the gallbladder bed and brought out
through a puncture wound if there is a bile leak.
 The drain type is chosen based on the surgeon’s preference. A small
leak should close spontaneously in a few days, with the drain
preventing accumulation of bile.
 Usually, only a small amount of serosanguineous fluid drains in the initial 24
hours after surgery; afterward, the drain is removed.

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 The drain is typically maintained if there is excess oozing or bile leakage.
 Insertion of a T-tube into the common bile duct during the open
procedure is now uncommon; it is used only in the setting of a complication
(i.e., retained common bile duct stone).
 Bile duct injury is a serious complication of cholecystectomy, but it
occurs less frequently than with the laparoscopic approach, which has largely
replaced traditional surgical cholecystectomy.

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Small-Incision Cholecystectomy

 Small-incision cholecystectomy is a surgical procedure in which the

gallbladder is removed through a small abdominal incision, as the name
implies.
 If needed, the surgical incision is extended to remove larger gallbladder
stones.
 Drains may or may not be used. The short length hospital stay has
been identified as a major advantage of this type of procedure
(Doherty, 2015; Goldman & Schafer, 2015).
 The procedure is controversial because it limits exposure to all involved
biliary structures.

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Choledochostomy

 Choledochostomy is reserved for the patient with acute cholecystitis who may
be too ill to undergo a surgical procedure.
 This procedure involves making an incision in the common duct, usually
for removal of stones.
 After the stones have been evacuated, a tube is usually inserted into the duct
for drainage of bile until edema subsides.
 This tube is connected to gravity drainage tubing; the patient is
monitored closely, and a laparoscopic cholecystectomy is planned for a
future date after acute inflammation has resolved.

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Surgical Cholecystostomy

 Cholecystostomy is performed when the patient’s condition precludes

more extensive surgery or when an acute inflammatory reaction is severe.
 The gallbladder is surgically opened, stones and the bile or the purulent
drainage are removed, and a drainage tube is secured with a purse-string
suture.
 The drainage tube is connected to a drainage system to prevent bile from
leaking around the tube or escaping into the peritoneal cavity.
 After recovery from the acute episode, the patient may return for
subsequent laparoscopic cholecystectomy.
 Despite its lower risk, surgical cholecystostomy has a high mortality rate
(reported to be as high as 10% to 30%) because of the underlying infectious
disease process.
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Percutaneous Cholecystostomy

 Percutaneous cholecystostomy has been used in the treatment and diagnosis of

acute cholecystitis in patients who are poor risks for any surgical procedure or
for general anesthesia.
 This at risk population may include patients with sepsis or severe cardiac, renal,
pulmonary, or liver failure.
 Under local anesthesia, a fine needle is inserted through the abdominal wall and liver
edge into the gallbladder under the guidance of ultrasound or computed tomography
(CT).
 Bile is aspirated to ensure adequate placement of the needle, and a catheter is
inserted into the gallbladder to decompress the biliary tract.
 Almost immediate relief of pain and resolution of signs and symptoms of sepsis and
cholecystitis have been reported with this procedure.
 Antibiotic agents are given before, during, and after the procedure.
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Cancer of the Gallbladder

 Cancer of the gallbladder is the fifth most common cancer of the gastrointestinal
tract.
 It is slightly more common in women and occurs more often in the seventh decade
of life.
 The onset of symptoms usually is insidious, and they resemble those of
cholecystitis.
 The diagnosis often is made unexpectedly at the time of gallbladder surgery.
 About 70% to 80% of people with gallbladder cancer have cholelithiasis.
 Because of its ability to produce chronic irritation of the gallbladder mucosa, it is
believed that cholelithiasis plays a role in the development of gallbladder cancer.
 The 5-year survival rate varies by stage of the carcinoma, ranging from stage 0 with
an 80% survival rate to stage IVB with a 2% survival rate.
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THE END THANK YOU
GEOFRY OUMA

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