GEJALA AKUT GEJALA KRONIS

TANDA :
1. Epigastrium kanan terasa nyeri dan
spasme

2. Usaha inspirasi dalam waktu

diraba pada kwadran kanan atas

3. Kandung empedu membesar dan TANDA:

nyeri 1. Biasanya tak tampak gambaran pada
abdomen
4. Ikterus ringan
2. Kadang terdapat nyeri di kwadran
kanan atas

GEJALA:
1. Rasa nyeri (kolik empedu), Tempat :
abdomen bagian atas (mid epigastrium),
Sifat : terpusat di epigastrium menyebar ke
arah skapula kanan
GEJALA:
1. Rasa nyeri (kolik empedu) yang 2. Nausea dan muntah

Menetap 3. Intoleransi dengan makanan berlemak

2. Mual dan muntah 4. Flatulensi

3. Febris (38,5C) 5. Eruktasi (bersendawa)

VI. Pemeriksaan penunjang

Tes laboratorium :

1. Leukosit : 12.000 15.000 /iu (N : 5000 10.000 iu).

2. Bilirubin : meningkat ringan, (N : < 0,4 mg/dl).

3. Amilase serum meningkat.( N: 17 115 unit/100ml).

4. Protrombin menurun, bila aliran dari empedu intestin menurun karena obstruksi sehingga
menyebabkan penurunan absorbsi vitamin K.(cara Kapilar : 2 6 mnt).

5. USG : menunjukkan adanya bendungan /hambatan , hal ini karena adanya batu empedu dan
distensi saluran empedu ( frekuensi sesuai dengan prosedur diagnostik)

6. Endoscopic Retrograde choledocho pancreaticography (ERCP), bertujuan untuk melihat

kandung empedu, tiga cabang saluran empedu melalui ductus duodenum.

7. PTC (perkutaneus transhepatik cholengiografi): Pemberian cairan kontras untuk menentukan

adanya batu dan cairan pankreas.

8. Cholecystogram (untuk Cholesistitis kronik) : menunjukkan adanya batu di sistim billiar.

9. CT Scan : menunjukkan gellbalder pada cysti, dilatasi pada saluran empedu, obstruksi/obstruksi
joundice.

10. Foto Abdomen :Gambaran radiopaque (perkapuran ) galstones, pengapuran pada saluran atau
pembesaran pada gallblader.

Daftar Pustaka :

1. Soeparman, Ilmu Penyakit Dalam, Jilid II, Balai Penerbit FKUI 1990, Jakarta, P: 586-588.

2. Sylvia Anderson Price, Patofisiologi Konsep Klinis Proses-Proses Penyakit. Alih Bahasa
AdiDharma, Edisi II.P: 329-330.

3. Marllyn E. Doengoes, Nursing Care Plan, Fa. Davis Company, Philadelpia, 1993.P: 523-536.

4. D.D.Ignatavicius dan M.V.Bayne, Medical Surgical Nursing, A Nursing Process Approach, W. B.

Saunders Company, Philadelpia, 1991.

5. Sutrisna Himawan, 1994, Pathologi (kumpulan kuliah), FKUI, Jakarta 250 251.

6. Mackenna & R. Kallander, 1990, Illustrated Physiologi, fifth edition, Churchill Livingstone,
Melborne : 74 76.
 Cholelithiasis

General

Cholelithiasis (or gallstones) represents one of the most common surgical problems
worldwide and is especially prevalent in most western countries. In the U.S. alone,
gallstones are present in 8-20% of the population by the age of 40 and are more
likely to develop in women than in men by a ratio of about 2-3 to 1. Mexican
Americans and American Indians also seem to have an increased risk for the
development of gallstones, and in all cultures, the incidence increases with
increasing age.

Gallstones come in three varieties. The first

and most common type (representing about
75% of cases) are cholesterol stones.
Normally, a delicate balance exists between
the levels of bile acids, phospholipids, and
cholesterol (see Admirand's Triangle at
right). When this balance is disrupted,
especially when there is supersaturation with cholesterol, there is predisposition for
the formation of lithogenic bile and the consequent development of cholesterol-
type gallstones. This is because when cholesterol supersaturates, it tends to
crystallize, and in the presence of enucleating factors, can be a nidus for stone
formation.

The second type of gallstone is of the pigmented variety. Pigmented stones arise
from the crystallization of calcium bilirubinate and occur in two types: black and
brown. Accounting for about 15-20% of all biliary stones, black stones tend to
occur in diseases associated with increased red blood cell destruction (hemolysis)
and abnormal metabolism of hemoglobin (liver disease). These stones typically
form in the sterile bile of the gallbladder.

Brown stones, on the other hand, are

associated with infected bile and are more
frequently found outside of the gallbladder
(intrahepatic or extrahepatic ducts). These
stones are associated with infection of the
gallbladder (especially with E.
Coli andKlebsiella). Other factors which
appear to predispose to the formation of
pigment stones include parasitic infections and a history of ileal resection.

The last type of gallstone encountered is of the mixed variety, containing a mixture
of cholesterol and pigment. Like the other two varieties, gallstones tend to form
when there is stasis of bile, impaired gallbladder motility, and an imbalance in the
bile content.

A commonly used pneumonic for remembering the risk factors for gallstone
formation are the 5 F's:

Fair, Fat, Fertile, Female, in

her Forties.

Gallbladder sludge is a common precursor to the development of gallstones.

Sludge represents crystallization within bile, without stone formation. The
formation of sludge commonly occurs when there is bile stasis and can be seen
during prolonged periods of total parenteral nutrition, starvation, and rapid weight
loss. While it can be a precursor to stones, gallbladder sludge can resolve on its
own (71% in one study).

Clinical Presentation

Gallstones tend to present themselves clinically in three different ways. The

majority (60-80%) remain asymptomatic throughout a patients' lifetime and only
manifest on imaging done for other reasons. The remaining 20-40% of gallstones
are either symptomatic or symptomatic with advanced
complications.

The most common presenting symptom is biliary colic

(intermittent pain below the right ribcage), which may
radiate to the back. The best definition of biliary colic,
however, is pain that is relatively severe in the RUQ or
epigastrium, that lasts 1-5 hours, often awakening the
patient from sleep. Nausea, with or without vomiting may
be present, flatulence (as well as belching and bloating) may be a symptom, and
certain foods (particularly those high in fat) typically provoke symptoms.
Unfortunately, however, RUQ pain is not always specific, and a detailed history of
pattern and characteristics of symptoms, as well as an ultrasound documenting
gallstones, is needed to make the diagnosis of symptomatic cholelithiasis.

On physical exam, discomfort may be elicited by deep palpation in the RUQ. A

positive Murphy sign (pain elicited on palpation of the RUQ while inspiring)
usually indicates more severe disease (cholecystitis). Typically, however, vital
signs and physical exam are usually normal in patients with cholelithiasis. Fever,
tachycardia, and hypotension should alert the physician to more advanced disease
(cholecystitis and cholangitis).

Treatment
For simple, asymptomatic gallstones, medical therapies are rarely used, as they
require long-term treatment (i.e. oral dissolution), cause complications, and
ultimately do not prevent recurrence. Dissolution agents such as ursodeoxycholate
are available for small, pure cholesterol stones located in a functioning gallbladder,
however, the recurrence rate is high (50-60%).

Removal of the gallbladder (cholecystectomy) is the treatment of choice for

symptomatic cholelithiasis in patients who are fit for operation. With the advent of
laparoscopic cholecystectomies, recovery and post-operative time have been
diminished markedly, and the procedure can be performed in the outpatient setting.

Other Complications of Cholelithiasis

Choledocholithiasis

Choledocholithiasis occurs as a result of either the primary formation of gallstones

in the common bile duct (CBD) or the passage of gallstones from the gallbladder
through the cystic duct into the CBD. Bile stasis, bactibilia, chemical imbalances,
pH imbalances, increased bilirubin excretion, and the formation of sludge are
among the principal factors leading to the formation of these stones.

Obstruction of the CBD by gallstones leads to symptoms and complications that

include pain, jaundice, cholangitis, pancreatitis, and sepsis.

Gallstone Pancreatitis

The most common cause of acute pancreatitis is gallstones passing into the bile
duct and temporarily lodging at the Sphincter of Oddi. The risk of a stone causing
pancreatitis is inversely proportional to its size. Occult microlithiasis is probably
responsible for many cases of idiopathic acute pancreatitis

Gallstone Ileus

In gallstone ileus, the formation of a fistula between a gangrenous gallbladder and

the bowel wall (typically the duodenum) allows gallstones to enter the intestinal
tract. Intestinal obstruction is usually caused when the gallstones are greater than
2.5cm in diameter. The most common site of impaction is in the distal ileum,
followed by jejunum and stomach. Presenting features may be non-specific, but
radiologic findings of Rogler's Classic Triad of (1) small bowel obstruction, (2)
pneumobilia, and (3) ectopic gallstones may occasionally be detected by plain
film radiographs or ultrasound.