CHOLECYSTITIS – Etiology, Risk Factors, Signs and Symptoms, Diagnostic Evaluations and Management
DEFINITION
Cholecystitis is inflammation of the gallbladder
ETIOLOGY
- Gallstones: the vast majority of cholecystitis cases are the result of gallstones that block the cystic duct, causing bile to build up and resulting in gallbladder inflammation
- Tumor: a tumor may prevent bile from draining out of gallbladder properly, causing bile buildup that can lead to cholecystitis
- Bile duct blockage: kinking or scarring of the bile ducts can cause blockages that lead to cholecystitis
RISK FACTORS
- Gallstones: most cases of cholecystitis are linked to gallstones
- Sex: women have a greater risk of gallstones than men do. This makes women more likely to develop cholecystitis
- Age: older people are at high risk of gallstones
SIGNS AND SYMPTOMS
- Severe, steady pain in the upper righ part of abdomen
- Pain that radiates from abdomen to right shoulder or back
- Tenderness over abdomen when it is touched
- Sweating
- Nausea
- Vomiting
- Fever
- Chills
- Abdominal bloating
COMPLICATIONS
- Enlarged gallbladder: if gallbladder becomes inflamed due to bile buildup, it may stretch and swell beyond its normal size, which can cause pain and increase the risk of a tear (perforation) in gallbladder, as well as infection and tissue death
- Infection within the gallbladder: if bile builds up within gallbladder, causing cholecystitis, the bile may become infected
- Gangrene: untreated cholecystitis can cause tissue in the gallbladder to die (gangrene), which, in turn, can lead to a tear in the gallbladder
- Perforation: a tear (perforation) in gallbladder may be caused by an enlarged or infected gallbladder that occurs as a result of cholecystitis
DIAGNOSTIC EVALUATION
- Blood tests: blood tests are done to look for signs of an infection or of gallbladder problems
- Imaging tests: imaging tests, such as abdominal ultrasound or a computerized tomography (CT) scan can be used to create pictures of gallbladder that may reveal signs of cholecystitis
- HIDA: a hepatobiliary iminodiacetic acid (HIDA) scan tracks the production and flow of bile from liver to small intestine and shows if bile is blocked at any point along the way.
MANAGEMENT
- Antibiotics: to treat the infection
- Analgesics: to help control pain until the inflammation in gallbladder is relieved
Surgical Interventions
- Cholecystectomy
- Laparoscopic laser cholecystectomy
- Cholecystectomy
- Choledochotomy (incision of common bile duct)
- Choledocholithotomy (incision of common bile duct and removal of gallstones)
NURSING MANAGEMENT
Nursing Assessment
- Obtain history and demographic data that may indicate risk factors for biliary disease
- Assess mental status through interview and interaction with patient
- Perform abdominal examination for ascites
- Assess the client’s bowel elimination pattern, noting the number of stools and their color and also the presence of blood
- Assess the client’s abdomen for bowel sounds and the location of pain
- Assess the complete nutritional status of diseased patient
- Observe for any bleeding
- Monitor for temperature and WBC counts for indicating inflammation of infection
- Assess the emotional status, coping skills, verbal and nonverbal behaviors
Nursing Diagnosis
- Risk for injury related to medication during retrograde endoscopy for stone removal
- Knowledge deficit related to oral dissolution agents
- Pain related to stone obstruction
- Fluid volume deficit related to nausea and vomiting
- Activity intolerance related to fatigue, general discomfort
- Anxiety-related inflammatory disease of gallbladder
- Imbalanced nutrition less than body requirement related to pain
- Ineffective coping related to feeling of rejection
- Risk for injury related to medication during retrograde endoscopy for stone removal
Interventions
- Assess for signs and symptoms of GI bleeding, e.g. check all secretions for frank or occult blood. Observe color and consistency of stools, NG drainage, or vomitus
- Observe for presence of petechiae, ecchymosis, bleeding from one or more sites
- Monitor pulse, BP (and CVP, if available)
- Note changes in mentation and level of consciousness
- Avoid rectal temperature, be gentle with GI tube insertions
- Encourage use of soft toothbrush, electric razor, avoiding straining for stool, forceful nose blowing, and so forth
- Use small needles for injections. Apply pressure to small bleeding and venipuncture sites for longer than usual
- Recommend avoidance of aspirin-containing products
- Knowledge deficit related to oral dissolution agents
Interventions
- Inform patient of altered effects of medications with cholecystitis and the importance of using only drugs prescribed or cleared by a health care provider who is familiar with patient’s history
- Assist patient in identifying the support person
- Emphasize the importance of good nutrition. Recommend avoidance of high-protein and salty foods, onions and strong cheeses. Provide written dietary instructions.
- Discuss sodium and salt substitute restrictions and necessity of reading labels on food and OTC drugs
- Encourage scheduling activities with adequate rest periods
- Promote diversional activities that are enjoyable to the patient
- Recommend avoidance of persons with infections, especially upper respiratory tract infection
- Identify environmental dangers, e.g. carbon tetrachloride-type cleaning agents, exposure to hepatitis
- Pain related to stone obstruction
Intervention
- Assess the pain location, severity and characteristics
- Administer medications or monitor patient-controlled analgesia
- Assist in attaining position of comfort and maintain bed rest
- Fluid volume deficit related to nausea and vomiting
Interventions
- Administer IV fluids and electrolytes as prescribed
- Administer antiemetic as prescribed to reduce vomiting
- Maintain nasogastric decompression until nausea and vomiting subside
- Begin food and fluids as tolerated by the client
- Observe and record amount of T tube drainage, if applicable
- Activity intolerance related to fatigue, general discomfort
Interventions
- Encouraging alternating periods of rests and ambulation
- Maintain some periods of rest
- Encourage and assist with gradually increasing periods of exercise
- Imbalanced nutrition less than body requirement related to pain
Interventions
- Encourage a diet that is low in residue fiber and fat and high in calories, protein and carbohydrates with vitamin and mineral supplements
- Monitor weight daily
- Provide small frequent feeding to prevent distension
- Have the patient participate in meal planning to encourage compliance and increased knowledge
- Prepare the patient for elementary diet
- Restart oral fluid intake gradually. Offer clear liquids hourly; avoid cold fluids
- Ineffective coping related to feeling of rejection
Intervention
- Assess the level of fear and note nonverbal communication
- Ask the patient’s usual coping pattern
- Assure patient he/she will be closely monitored
- Allow patient to verbalize fear of dying
- Provide diversional materials, such as newspapers, music and television
- Offer family support
COMPLICATIONS
- Acute cholangitis: acute cholecystitis is a condition indicated by a sudden attack of pain in the upper abdomen that lasts more than 12 hours
- Acute biliary pancreatitis: pancreatitis is a potentially serious disorder that occasionally develops in people with gallstones
- Gallstone ileus
- Obstructive jaundice or cholestasis
- Gallbladder cancer
