CHOLEYCYSTITIS

Key points  Cholecystitis is an inflammation of the gallbladder wall. The “attack” usually subsides in 2 to 3 days.  Bile is used for the digestion of fats. It is produced in the liver and stored in the gall bladder.  Cholecystitis can be acute or chronic, and it can also obstruct the pancreatic duct.  Cholecystitis is most often caused by gallstone (cholelithiasis) obstructing the cystic and/or common bile ducts (bile flow from gallbladder to duodenum);  cholecystitis without gallstones is rare and serious.

Key points  Calculi usually form in the gallbladder from solid constituents of bile and vary greatly in: size, shape, and composition.  There are two major types of gallstones:  pigment stones, which contain an excess of unconjugated pigments in the bile, and  cholesterol stones (the more common form), which result from bile supersaturated with cholesterol due to increased synthesis of cholesterol and decreased synthesis of bile acids that dissolve cholesterol.

Key points  Most clients with cholecystitis have gallstones (calculous cholecystitis). A gallstone obstructs bile outflow and bile in the gallbladder initiates a chemical reaction, resulting in edema, compromise of the vascular supply, and gangrene.  Cholecystitis (acalculous???) may occur after surgery, severe trauma, or burns, or with torsion, cystic duct obstruction, multiple blood transfusions, and primary bacterial infections of the gallbladder.  Infection causes pain, tenderness, and rigidity of the RUQ and is associated with N & V and the usual signs of inflammation. Purulent fluid indicates an empyema

Risk Factors  More common in females  Obesity (impaired fat metabolism, high cholesterol levels)  Multiparus  Older than 40 years of age (more likely to develop gallstones) 4Fs  High-fat diet  Pills; estrogen  Genetic predisposition  Individuals with type 1 diabetes mellitus (high triglycerides)  Low-calorie, liquid protein diets  Rapid weight loss (increases cholesterol)

Risk Factors  Risk factors for pigment stones include:  cirrhosis,  hemolysis, and  infections of the biliary tract.  These stones cannot be dissolved and must be removed surgically.

Triggering Factors  Trauma  Surgery  Coronary events  Diabetes  Fasting  Immobility  Hormone replacement therapy (HRT)  Pregnancy

Diagnostic Procedures and Nursing Interventions  RUQ US is the most diagnostic. Visualizes gallbladder edema.  Cholecystogram, cholangiogram; celiac axis arteriography  Abdominal x-ray (may visualize calcified gallstones)  WBCs elevations  Direct (normal is 0.1 to 0.3 mg/dL), indirect (0.2 to 0.8 mg/dL), and total (0.1 to 1.0 mg/dL) serum bilirubin levels (elevated if obstruction)  Aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) (elevated if liver dysfunction)  Serum cholesterol (elevated above 200 mg/dL)  Hepatobiliary scan (assesses patency of biliary duct system)

Therapeutic Procedures and Nursing Interventions  Medical Management  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,  remove the cause by pharmacotherapy, endoscopic procedures, or surgical intervention.

Therapeutic Procedures and Nursing Interventions  Cholecystectomy – with a laparoscopic or an open approach (when exploration of biliary ducts is indicated).  Postoperatively, clients may experience free air pain following laparoscopic surgery.  Ambulation is helpful.  Following an open approach, nursing care includes monitoring drainage from inserted Jackson-Pratt (JP) drains and T-tube.

Therapeutic Procedures and Nursing Interventions  Nonsurgical Removal of Gallstones  In addition to dissolving gallstones, they can be removed by other instrumentation (eg, catheter and instrument with a basket attached are threaded through the T-tube tract or fistula formed at the time of T-tube insertion, ERCP endoscope), intracorporeal lithotripsy (laser pulse), or extracorporeal shock wave therapy (lithotripsy or extracorporeal shock wave lithotripsy [ESWL]).

Assessments  May be silent, producing no pain and only mild GI symptoms  May be acute or chronic with epigastric distress (fullness, abdominal distention, and vague URQ); may follow a meal rich in fried or fatty foods  An attack of cholecystitis “gallbladder attack” is characterized by:  Sharp pain in the RUQ of the abdomen, often radiating to the RT shoulder.  Pain with deep inspiration during right subcostal palpation (Murphy’s sign).  Intense pain (tachycardia, pallor, diaphoresis) after ingestion of a large quantity of high-fat food.

Assessments  Rebound tenderness.  Nausea, anorexia, and vomiting.  Dyspepsia, eructation (belching), and flatulence.  Fever  Jaundice, clay-colored stools, dark urine, steatorrhea (fatty stools), and pruritus may be seen in clients with chronic cholecystitis (due to biliary obstruction).  Deficiencies of vitamins A, D, E, and K (fat-soluble vitamins)

NANDA Nursing Diagnoses  Acute pain  Impaired gas exchange  Risk for infection  Impaired skin integrity  Imbalanced nutrition, less than body requirements,  Deficient knowledge

Nursing Interventions  Achieve remission with rest, IV fluids, nasogastric suction, analgesia, and antibiotics.  Dietary Counseling  Encourage a low-fat diet (reduced dairy; avoid fried foods, eggs, cream, chocolate, cheese, rich dressings, nuts, and gravies).  high protein and carbohydrates  Promote weight reduction.  Fat-soluble vitamins and bile salts may be prescribed if obstruction is present to enhance absorption and aid digestion.  Avoid gas-forming foods (beans, cabbage, cauliflower, broccoli).  Smaller, more frequent meals may be tolerated better

Nursing Interventions  Administer analgesics as needed and prescribed Meperidine (Demerol) is generally preferred over morphine)  Antispasmodics and anticholinergics  Antiemetics  Postoperative Care  Support pain management.  Encourage splinting to reduce pain.  Encourage measures to reduce risk of respiratory complications  Monitor wound incision(s) and provide wound care.  Monitor and record T-tube drainage (initially bloody, then greenbrown bile).  Initially, may drain > 400 mL/day and then gradually decreases in amount.

Nursing Interventions  Report sudden increases in drainage or amounts exceeding 1,000 mL/day.  Inspect surrounding skin.  Maintain flow by gravity.  Clamp 1 to 2 hr ac and pc.  Monitor and document the client’s response to food.  Client Education  Activity precautions 4 to 6 weeks  Care of T-tube (up to 6 weeks postoperatively) – Report sudden increase in drainage or foul odor; Clamp 1 to 2 hr before and after meals.  Stool color should return to brown color in about a week.  Encourage a low-fat diet.

Surgical Terms  Laparoscopic cholecystectomy: performed through a small incision or puncture made through the abdominal wall in the umbilicus.  Cholecystectomy: Gallbladder is removed through an abdominal incision (usually right subcostal) after ligation of the cystic duct and artery.  Minicholecystectomy: Gallbladder is removed through a small incision.  Choledochostomy: incision into the common duct for stone removal.  Cholecystostomy (surgical or percutaneous): Gallbladder is opened, and the stone, bile, or purulent drainage is removed.

Complications and Nursing Implications  Obstruction of the bile duct can cause ischemia and a rupture of the gallbladder wall is possible.  Rupture of the gallbladder wall can cause a local abscess or peritonitis (rigid, board-like abdomen, guarding), which requires surgical intervention and administration of broad spectrum antibiotics.