Cholecystitis and Cholelithiasis

• Cholecystitis is the inflammation of the gallbladder, most often caused by gallstones (cholelithiasis) obstructing the cystic and/or common bile ducts.
• Cholelithiasis is the presence of stones in the gallbladder related to the precipitation of bile, calcium, or cholesterol.
• Bile, produced in the liver and stored in the gallbladder, aids in fat digestion.
• Cholecystitis can be acute or chronic, obstruct the pancreatic duct (causing pancreatitis), or cause the gallbladder to rupture (resulting in secondary peritonitis).

Health Promotion and Disease Prevention

• Consume a low-fat diet rich in HDL sources (seafood, nuts, olive oil) to promote gallbladder health.
• Participate in regular exercise and avoid smoking to reduce the risk of gallbladder issues.

Data Collection: Risk Factors

• Being female increases the risk of cholecystitis, as does estrogen therapy and the use of some oral contraceptives.
• Obesity, genetic predisposition, older age (decreased gallbladder contractility), type 2 diabetes mellitus (high triglycerides), Crohn’s disease, low-calorie diets, rapid weight loss (increases cholesterol), Native American or Mexican American ethnicity, and bariatric surgery increase the risk of cholecystitis.

Expected Findings

• Sharp pain in the right upper quadrant, often radiating to the right shoulder is to be expected.
• Intense pain with nausea and vomiting after high-fat food ingestion (biliary colic) is present.
• Dyspepsia, eructation (belching), and flatulence can be present.
• Clients can have a fever.

Physical Findings

• Jaundice (in sclera and skin), clay-colored stools, and steatorrhea (fatty stools) can be present.
• Older adult clients can have atypical presentations of cholecystitis such as absence of pain or fever.
• Delirium may be an initial manifestation in older adults, or they may have localized tenderness.

Laboratory Tests

• Increased WBC indicates inflammation.
• Increased direct, indirect, and total blood bilirubin can occur if a bile duct is obstructed.
• Increased amylase and lipase can occur with pancreatic involvement.
• Increased aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and alkaline phosphatase (ALP) (increased with liver dysfunction) can indicate the common bile duct is obstructed.

Diagnostic Procedures

• Ultrasound visualizes gallstones and a dilated common bile duct
• Abdominal x-ray or CT scan visualizes calcified gallstones and an enlarged gallbladder.
• Hepatobiliary scan (HIDA) determines the patency of the biliary duct system after an IV injection of contrast
• Endoscopic retrograde cholangiopancreatography (ERCP) allows for direct visualization using an endoscope that is inserted through the esophagus and into the common bile duct via the duodenum which also allows for the removal of gallstones.
• Magnetic resonance cholangiopancreatography combines the use of oral/IV contrast with an MRI to determine the cause of cholecystitis or cholelithiasis.

Patient-Centered Care: Nursing Care

• Administer analgesics as needed.
• Place the client in Fowler’s position to decrease pressure on the abdomen and decrease pain.

Medications

• Opioid analgesics like morphine sulfate or hydromorphone are preferred for acute biliary pain.
• Bile acid (chenodiol, ursodiol) gradually dissolves cholesterol-based gallstones.
  • Use caution in clients who have liver conditions or disorders with varices.
  • Report abdominal pain, diarrhea, or vomiting.
  • The medication is limited to 2 years of administration and requires a gallbladder ultrasound every 6 months during the first year to determine effectiveness.

Therapeutic Procedures: Extracorporeal Shock Wave Lithotripsy

• Shock waves break up stones.
  • Instruct and assist the client to lay on a fluid-filled pad for delivery of shock waves.
  • Administer analgesia.
  • Several procedures can be required to break up all stones
  • There can be pain intraprocedural due to gallbladder spasms or movement of the stones.

Cholecystectomy

• This is the Removal of the gallbladder with a laparoscopic, minimally invasive, or open approach
  • The client usually is discharged within 24 hr if a laparoscopic approach is used, but an open approach can require hospitalization for 2 to 4 days.

Nursing Actions for Cholecystectomy

• Laparoscopic approach: Provide immediate postoperative care.
• Minimally invasive approach: Natural orifice transluminal endoscopic surgery is performed through entry of the mouth, vagina, or rectum, eliminating visible incisions and decreasing the risk of complications for the client.
• Open approach: The provider can place a drain in the gallbladder or a T-tube in the common bile duct.
  • Monitor stools for color (stools clay-colored until biliary flow is reestablished).
  • Care of the drainage tube; Clients can have a drainage tube placed intraoperatively to prevent accumulation of fluid in the gallbladder bed.
    • Monitor and record drainage (initially serosanguineous stained with green-brown bile).
    • Antibiotics are often prescribed to decrease the risk for infection.
  • Care of the T-tube
    • Instruct client to report an absence of drainage with manifestations of nausea and pain (can indicate obstruction in the T-tube).
    • Inspect the surrounding skin for evidence of infection (redness, swelling, bile leakage, warmth).
    • Keep drainage tube below the level of the surgical area.
    • Monitor and record the color and amount of drainage.
    • Clamp the tube per protocol before and after meals.
    • Expect removal of the tube in 1 to 3 weeks.
    • Change wound dressing with caution to prevent accidental removal.

Client Education for Cholecystectomy

• Laparoscopic approach:
  • Ambulate frequently to minimize free air pain, common following laparoscopic surgery (under the right clavicle, shoulder, scapula).
  • Monitor the incision for evidence of infection.
  • Perform pain control.
  • Report indications of bile leak (pain, vomiting, abdominal distention) to the provider.
  • Resume activity gradually and as tolerated and resume the preoperative diet (low fat).
  • Remove bandages from surgical site the day after surgery and shower, but do not remove the adhesive surgical strips.
• Open approach:
  • Resume activity gradually. Avoid heavy lifting or strenuous activities.
  • Begin with clear liquids and advance to solid foods as peristalsis returns.
  • Report sudden increase in drainage, foul odor, pain, fever, or jaundice.
  • Take showers instead of baths until drainage tube is removed.
  • The color of stools should return to brown in about a week, and diarrhea is common
  • Wear loose fitting clothes
• Dietary counseling:
  • Adhere to a low-fat diet (reduce dairy products and avoid fried foods, chocolate, nuts, gravies).
  • The client can have increased tolerance of small, frequent meals.
  • Avoid gas-forming foods (beans, cabbage, cauliflower, broccoli).
  • Consider weight reduction.
  • Take fat-soluble vitamins or bile salts as prescribed to enhance absorption and aid with digestion.

Complications

• Obstruction of the bile duct can cause ischemia, gangrene, and a rupture of the gallbladder wall.
  • A rupture of the gallbladder wall can cause a local abscess or peritonitis (rigid, board-like abdomen, guarding), which requires surgical intervention and broad-spectrum antibiotics.
• Bile peritonitis can occur if adequate amounts of bile are not drained from the surgical site; this is a rare but potentially fatal complication.

Cholecystitis is gallbladder inflammation, often due to gallstones obstructing bile ducts. Cholelithiasis refers to stones in the gallbladder. Risk factors include being female, obesity, genetics and older age. Prevention includes a low-fat diet and exercise.