Cholecystitis and Cholelithiasis PDF

Gallbladder Disorders Gallbladder Overview Gallbladder - Collects, concentrates and stores bile. ○ Located underneath the liver ○ Bile comes from the liver ○ Bile essential for fat breakdown ○ GB releases bile into duodenum (first part of the small intestine) Bile - a bitter greenish-brown alkaline...

Gallbladder Disorders Gallbladder Overview Gallbladder - Collects, concentrates and stores bile. ○ Located underneath the liver ○ Bile comes from the liver ○ Bile essential for fat breakdown ○ GB releases bile into duodenum (first part of the small intestine) Bile - a bitter greenish-brown alkaline fluid that aids digestion ○ Secreted by the liver and stored in the gallbladder. Bilirubin - the primary pigment in bile ○ Normally conjugated and excreted by liver and the biliary system ○ Higher than normal levels = indicates liver, bile duct, other problems. Cholecystitis Questions to Ask Patient/Significant Other ○ Are you taking any medications? ○ Has this pain occurred before? ○ What have you taken for it? ○ If so, what triggers this pain? ○ Do you have a feeling of gas? ○ Bloating in the abdomen? ○ Have you had a fever? ○ What color are your stools? ○ Color of urine? ○ Skin color? Cholecystitis/ Cholelithiasis Cholecystitis - Acute/Chronic. Inflammatory condition of the gallbladder. ○ Types: Calculous Cholecystitis (Cholelithiasis) - irritation and inflammation result in gall stones that obstruct cystic duct, gall bladder neck, or common bile duct. Acalculous Cholecystitis - irritation without gallstones ○ Concepts Affected: Pain Nutrition IT pH GI | GI IBS ○ Acute vs. Chronic Cholecystitis: Acute Cholecystitis with Cholelithiasis - Trapped bile reabsorbed and irritates gallbladder wall. Complications: IT pH GI ○ Ischemia and infection → due to reabsorbed bile, edema, impaired circulation and distention of gallbladder ○ Tissue sloughing with necrosis and gangrene within gallbladder itself Necrosis - entire process of irreversible cell death Gangrene - tissue death due to a form of interrupted blood supply ○ Peritonitis → If perforation is large Peritonitis - Inflammation of the peritoneum (lining of belly or abdomen) ○ Hyperlipidemia, rapid weight loss ○ Gall bladder can rupture ○ Jaundice (Icterus) Chronic Cholecystitis - Chronic inflammation due to repeated episodes of duct obstruction GI IBS Complications: ○ Gallbladder becomes fibrotic and atrophied (wasted away) ○ Jaundice (Icterus) ○ Itching/burning of skin → due to excessive buildup of bile salts in skin ○ Bile flow blockage → prevents bilirubin from going to large intestine forming urobilinogen (makes stools brown) ○ Steatorrhea - Oily, smelly stools, which often float due to an increase in fat excretion in the stools. Management: ○ Emphasis on weight loss and avoidance of fatty foods. ○ Fatty foods = Fast food, fried food, pizza, hamburgers, butter, cream (ice cream) Signs and symptoms ○ Jaundice → indicates blockage in biliary ducts ○ Clay colored stools ○ Fever ○ Anorexia, nausea or vomiting ○ Dyspepsia, eructation, flatulence Dyspepsia - indigestion Eructation (Belch) - burp. ○ Episodic or vague pain that can radiate to right shoulder ○ Steatorrhea - Oily, smelly stools, which often float due to an increase in fat excretion in the stools. → Most common with chronic disease. ○ Pain triggered by a high fat or high volume meal ○ Blumberg sign - Rebound tenderness. Pain occurs upon removal of pressure rather than application of pressure to the abdomen. Risk Factors Cholecystitis Risk Factors Women of all ages (calculi increase with aging) Women on hormone replacement Obesity ○ High fat diet (rapid wt. loss/fasting) ○ Increased cholesterol/lipids ○ On statins (cholesterol-lowering drugs) Native American, Caucasian, Mexican American Family Hx/ Genetic factors Gallstone Risk Factors Women (Female Gender) Oral contraceptive pill use Obesity ○ High fat diet ○ Rapid weight loss Low fiber diet Age above 40 years Blood disorders (sickle cell anemia, leukemia) Pregnancy Diabetes mellitus Secondary Prevention: XL SUB ○ Ultrasound → BEST INITIAL DIAGNOSTIC TEST ○ X-Ray / CT scan → looks for gallstones/enlargement of organ ○ Bloodwork → to see level of inflammation. CBC → looks for an increase in WBCs. ESR (Sed Rate) - measures inflammation. > 20 mm/hr (indicates inflammation) Abnormal ESR = ○ Liver Enzymes - elevation indicates abnormalities in liver function if there is a biliary obstruction Alk phosphatase → elevated in cholecystitis AST (aminotransferase) → elevated in cholecystitis LDH (lactate dehydrogenase) → elevated in cholecystitis Serum bilirubin → elevated in cholecystitis Tertiary Prevention (Non-Surgical) ○ Pain Management Avoid fatty foods/large meals Antiemetic drugs - for nausea and vomiting. Ketorolac - potent NSAID for mild-moderate pain Opioid analgesia if acute biliary pain ○ Oral Bile Acid Dissolution or Gallstone Stabilizing Meds Ursodiol & Chenodiol long-term Ursodiol - Cholesterol medication that can dissolve gallstones when they cannot be removed by surgery. Can also treat primary biliary cirrhosis (PBC), a liver disorder. ○ Need periodic surveillance (ultrasounds), blood work ○ ○ Extracorporeal Shock Wave Lithotripsy (ESWL) - Shock waves are targeted to break up the stones Pain may occur as stones may move or gallbladder has spasms Ursodeoxycholic Acid [Ursodiol] = given afterwards to dissolve stone fragments Can also have pain This procedure is only for patients with normal weight, good gallbladder function, and cholesterol-based stones (Surgical) Percutaneous Transhepatic Biliary Catheter - Using CT or guided ultrasound, a catheter is inserted surgically to open a blocked duct. Internal drain - all bile enters the duodenum External drain - some of bile empties into drainage bag ○ Should be positioned below the catheter insertion site so that it drains by gravity. ○ Reduction of bile drainage → indicates drain not working. Laparoscopic Cholecystectomy - inserting a tiny video camera and special tools through several small incisions to see inside your abdomen and remove the gallbladder FM CUP Benefits: ○ Faster patient recovery ○ Minimally invasive ○ Complications uncommon ○ Usually same day surgery ○ Post-op pain is less severe Problems: ○ May have discomfort from CO2 retention in the abdomen CO2 buildup can be presented as shoulder pain Traditional (Open) Cholecystectomy - surgeon cuts open your abdomen below your ribs on your right side to reveal your liver and gallbladder. Used if: ○ The laparoscopic cholecystectomy failed ○ Obese patients or severe obstruction & need to explore ducts Problems: ○ A lot of pain after Nursing Care for Post Cholecystectomy ○ Deep breathing ○ Medications: Pain meds PRN Antiemetics IV antibiotics Anti-inflammatory drugs ○ NPO until fully awake → clear fluids to solids → monitor I&O ○ Promote ambulation ○ Measure and describe drainage Usually serosanguinous and bile for first 24 hours after surgery Patient Education Promote a Post-Cholecystectomy Diet: ○ Well balanced meals ○ Weight loss if appropriate ○ Avoid fatty foods (fast food, fried food, butter, cream) ○ Monitor for Post Cholecystectomy Syndrome. Post-Cholecystectomy Syndrome Post-Cholecystectomy Syndrome - Weeks, months after surgery patients can experience abdominal pain, diarrhea, and flatulence. Causes: ○ Often the result of large intake of fatty food. ○ Bile leaking into the stomach ○ Stones left in bile ducts ○ Other problems with the biliary system. ○ Often it goes away by itself, but needs to be reported to doctor and investigated Treatment: ○ Small meals, low fat diet ○ Avoid fatty foods ○ Weight reduction