Cholecystitis With Cholelithiasis

 Cholecystitis with cholelithiasis is an acute or chronic inflammation of the gallbladder associated with obstruction by gallstone(s) of the cystic or common bile ducts. Common bile duct stones are either primary (formed in the bile ducts) or secondary (formed in and transported from the gallbladder). Although stones most often develop in (and obstruct) the common bile duct or the cystic duct, they have also been found in the hepatic, small bile, and pancreatic ducts. Stones (calculi) are made up of cholesterol, calcium bilirubinate, or a mixture caused by changes in the bile composition. Crystals can also form in the submucosa of the gallbladder causing widespread inflammation. Infection is thought to be a consequence rather than cause of cholecystitis.
Acute cholecystitis with cholelithiasis is usually treated by surgery, although several other treatment methods (fragmentation and dissolution of stones) are also used.

Care Setting

Severe acute attacks may require brief hospitalization on a medical unit. This plan of care deals with the acutely ill, hospitalized client.

Related Concerns

Fluid and electrolyte imbalances
Psychosocial aspects of care
Total nutritional support: parenteral/enteral feeding

Client Assessment Database
May report: Fatigue
May exhibit: Restlessness

May exhibit: Tachycardia, diaphoresis

May report: Change in color of urine and stools
May exhibit: Abdominal distention
Palpable mass in right upper quadrant (RUQ)
Dark, concentrated urine
Clay-colored stool, steatorrhea

May report: Anorexia, nausea/vomiting
Intolerance of fatty and “gas-forming” foods, recurrent regurgitation, heartburn, indigestion, flatulence, bloating (dyspepsia)
Belching (eructation)
May exhibit: Obesity, recent weight loss
Normal to hypoactive bowel sounds

May report: Severe epigastric and right upper abdominal pain, may radiate to mid-back, right shoulder/scapula, or to front of chest; often increases with movement
Midepigastric colicky pain associated with eating, especially after meals rich in fats
Episodes of pain severe/ongoing, starting suddenly, sometimes at night, with episodes of constant pain typically lasting 1–5 hr
Recurring episodes of similar pain
May exhibit: Rebound tenderness, muscle guarding, or abdominal rigidity when RUQ is palpated; positive Murphy’s sign

May exhibit: Increased respiratory rate
Splinted respiration marked by short, shallow breathing

May exhibit: Low-grade fever, high-grade fever and chills (septic complications)
Jaundice (not common), with dry, itching skin (purities)
Bleeding tendencies (vitamin K deficiency)

May report: Familial tendency for gallstones
Recent pregnancy/delivery; history of diabetes mellitus (DM), IBD, blood dyscrasias

Discharge plan
considerations: May require support with dietary changes/weight reduction
Refer to section at end of plan for postdischarge considerations.

Diagnostic Studies
Biliary ultrasound: Most common screening test, ultrasound is 90%–95% sensitive for cholecystitis and 98% sensitive and specific for simple cholelithiasis. Sonographic Murphy’s sign (pain with the probe is pushed directly on the gallbladder) is 86%–92% sensitive. Ultrasound also identifies abnormalities of surrounding tissues (e.g., dilated common bile duct or dilated intrahepatic ducts)

Oral cholecystography (OCG): Preferred method of visualizing general appearance and function of gallbladder, including presence of filling defects, structural defects, and/or stone in ducts/biliary tree. Can be done IV (IVC) when nausea/vomiting prevent oral intake, when the gallbladder cannot be visualized during OCG, or when symptoms persist following cholecystectomy. IVC may also be done perioperatively to assess structure and function of ducts, detect remaining stones after lithotripsy or cholecystectomy, and/or to detect surgical complications. Dye can also be injected via T-tube drain postoperatively.

Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the common bile duct through the duodenum.
Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes between gallbladder disease and cancer of the pancreas (when jaundice is present); supports the diagnosis of obstructive jaundice and reveals calculi in ducts.

Cholecystograms (for chronic cholecystitis): Reveals stones in the biliary system. Note: Contraindicated in acute cholecystitis because client is too ill to take the dye by mouth.

CT Hepatobiliary (HIDA, PIPIDA) scan: May be done to confirm diagnosis of cholecystitis, especially when barium studies are contraindicated. Scan may be combined with cholecystokinin injection to demonstrate abnormal gallbladder ejection.

Abdominal radiographs (multipositional): Radiopaque (calcified) gallstones present in 10%–15% of cases; calcification of the wall or enlargement of the gallbladder.
CBC: Moderate leukocytosis may be present (acute cholecystitis), but a normal WBC count does not rule out cholecystitis.

Serum bilirubin and amylase: Elevation may indicate common bile duct stone or presence of pancreatitis complicating cholelithiasis..

Serum liver enzymes—AST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase and 5-nucleotidase are markedly elevated in biliary obstruction.

Prothrombin levels: Reduced when obstruction to the flow of bile into the intestine decreases
absorption of vitamin K.

Nursing Priorities

1. Relieve pain and promote rest.
2. Maintain fluid and electrolyte balance.
3. Prevent complications.
4. Provide information about disease process, prognosis, and treatment needs.

Discharge Goals

1. Pain relieved.
2. Homeostasis achieved.
3. Complications prevented/minimized.
4. Disease process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge

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