Cholecystitis Flashcards
Cholecystitis
- inflammation of the gallbladder, most often caused by gallstones (cholelithiasis) obstructing the cystic and/or common bile ducts (bile normally flows from the gallbladder to the duodenum to help digest fats) causing bile to back up and the gallbladder to become inflamed.
- can be acute or chronic
- can obstruct the pancreatic duct causing pancreatitis
- can also cause the gallbladder to rupture with secondary peritonitis
Risk Factors for Cholecystitis
1) more common in women
2) high-fat diet
3) obesity (impaired fat metabolism, high cholesterol levels)
4) genetic predisposition
5) older than 60 years of age (more likely to develop gallstones)
6) individuals who have type 1 diabetes mellitus (high triglycerides)
7) low-calorie, liquid protein diets
8) rapid weight loss (increases cholesterol)
Signs & Symptoms of Cholecystitis
1) pain in the RUQ of the abdomen, often radiating to the right shoulder
2) pain with deep inspiration during right subcostal palpation (Murphy’s sign)
3) intense pain (increased HR, pallor, diaphoresis) caused by biliary colic with nausea and vomiting after ingestion of a large quantity of high-fat food
4) rebound tenderness (Blumberg’s sign)
5) Dyspepsia (indigestion), eructation (belching), and flatulence
6) fever
7) jaundice (yellow discoloration of the skin and mucous membranes), icterus (yellow discoloration of the sclerae), clay-colored stools, steatorrhea (fatty stools), dark urine, and pruritis (accumulation of bile salts in the skin) may be seen in client with chronic cholecystitis due to biliary obstruction
Laboratory and Diagnostic Tests
1) WBC count (elevated with infection)
2) direct, indirect, and total serum bilirubin (elevated if bile duct obstruction)
3) amylase and lipase (elevated if pancreatic involvement)
4) aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and alkaline phosphatase (elevated liver dysfunction) may indicated the common bile duct is obstructed
5) serum cholesterol (elevated above 200 mg/dL)
6) a RUQ ultrasound visualizes gall stones and a dilated common bile duct
7) an abdominal x-ray or CT scan can visualize calcified gallstones and an enlarged gallbladder
8) a hepatobiliary scan (HIDA) assesses the patency of the biliary duct system after an IV injection of contrast
9) an endoscopic retrograde cholangiopancreatography (ERCP) allows for direct visualization through use of endoscope that is inserted through esophagus and into common bile duct via duodenum (as sphincterotomy with gall stones removal may be done during this procedure)
Medications Used in Treatment of Cholecystitis
1) analgesics
- meperidine (Demerol) or hydromorphone (Dilaudid) are preferred over morphine (morphine sulfate may increase biliary spasms)
2) anticholinergics
- dicyclomine (Bentyl) decrease ductal tone and biliary spasms (monitor for constipation, urinary retention and confusion in older adults)
3) oral bile salts
- chenodiol (Chenix), ursodiol (Ursodeoxycholic Acid) can be used to gradually dissolve most small cholesterol-based gallstones
Therapeutic Procedures
1) extracorporeal shock wave lithotripsy (ESWL)
- shock waves are used to break up stones.
- may be used more on nonsurgical candidates who have small, cholesterol-based stones and are of normal weight
2) nursing actions:
- prepare client for immersion in water (fluid filled bag may be used instead of immersion)
- inform client that several procedures may be required to break up all stones
Surgical Interventions
1) cholecystectomy
- removal of gallbladder with a laparoscopic or an open approach (less common)
- client usually discharged within 24 hr if a laparoscopic approach is used.
- open approach requires 2-3 days hospitalization
Nursing Care Following Surgical Interventions
1) laparoscopic approach:
- provide immediate postoperative care
- discharge teaching regarding pain management, incision care, and follow-up appointments
2) open approach:
- provide immediate postoperative care
- a T-tube may be placed in the common bile duct. only required when there is exploration of the common bile duct intraoperatively. use of T-tubes has significantly decreased due to laparoscopic approach
Care of the T-tube
1) ***it is VERY important not to raise the drainage system above the level of the gallbladder
2) monitor and record drainage (initially bloody, then will be green-brown bile)
3) initially, the T-tube may drain more than 400 mL/day and then gradually decrease in amount. -report sudden increases in drainage or amounts exceeding 1,000 mL/day
4) empty drainage bag every 8 hr
5) if absence of drainage with symptoms of nausea and pain, check tubing (may indicate obstruction in the T-tube)
6) inspect surrounding skin for signs of infection or bile leakage
7) clamp tube 1-2 hr before and after meals as directed to assess the tolerance of food post cholecystectomy, and prior to removal
8) assess stools for color (stools will be clay-colored until biliary flow is reestablished)
Client Education Following Surgical Intervention
1) Laparoscopic approach:
- educate client regarding free air pain following surgery (under right clavicle, shoulder, scapula), and that ambulation is helpful for this type of pain
- educate client regarding pain control and incision care
- educate client regarding complications (infection, bile leak [pain, vomiting, abdominal distention])
- activities are often resumed in 1 wk
2) open approach:
- activity precautions for 4-6 wks
- T-tube usually left in 1-2 wks postoperatively
- report sudden increase in drainage, foul odor, pain, fever, or jaundice
- take showers instead of baths until T-tube is removed
- clamp 1-2 hr before and after meals as directed to prepare for removal
- color of stools should return to brown in 1 wk, and diarrhea is common
Dietary Counseling Post Cholecystectomy
1) encourage low-fat diet
- reduce dairy and avoid fried foods, chocolate, nuts, gravies
2) promote weight reduction
3) if an obstruction is present, fat-soluble vitamins and bile salts may be prescribed to enhance absorption and aid with digestion
4) avoid gas-forming foods (beans, cabbage, cauliflower, broccoli)
5) small, frequent meals may be tolerated
6) prepare for care of T-tube at home if indicated
