Nursing Articles: Cholecystitis

Cholecystitis is inflammation of the gallbladder. Most cases are caused by gallstones. If you have cholecystitis you will normally be admitted to hospital for treatment with painkillers, fluids, (and sometimes antibiotics) directly into a vein. The inflammation may settle down with treatment. However, removal of the gallbladder is usually advised to prevent further bouts of cholecystitis

Bile is a fluid made in the liver. Bile contains various substances, including bile pigments, bile salts, cholesterol and lecithin. Bile is passed into tiny tubes called bile ducts. The bile ducts join together (like the branches of a tree) to form the main bile duct. Bile constantly drips down the bile ducts, into the main bile duct, and then into the gut.

The gallbladder lies under the liver on the right side of the upper abdomen. It is like a pouch which comes off the main bile duct and fills with bile. It is a 'reservoir' which stores bile. The gallbladder contracts (squeezes) when we eat. This empties the stored bile back into the main bile duct. The bile passes along the remainder of the bile duct into the duodenum (the first part of the gut after the stomach).

Bile helps to digest food, particularly fatty foods.

Symptoms

Symptoms tend to develop quite quickly, over a few hours or so. They include:
Pain in the upper abdomen is the main symptom. It is usually worse on the right side under the ribs. The pain may radiate (travel) to the back or to the right shoulder. The pain tends to be worse if you breathe in deeply.
You may also develop nausea (feeling sick), vomiting and a fever (high temperature).

Causes

Most cases of cholecystitis are caused by gallstones

Gallstones occur when bile, which is normally fluid, forms stones. Gallstones commonly contain lumps of cholesterol-like (fatty) material that has solidified and hardened. Sometimes bile pigments or calcium deposits form gallstones. Sometimes just a few small stones are formed; sometimes a great many. Occasionally, just one large stone is formed. About 1 in 3 women, and 1 in 6 men, form gallstones at some stage in their life. They become more common with increasing age.

Most people with gallstones do not have any symptoms or problems, and do not know they have them. Commonly, the stones simply stay in the gallbladder and cause no harm. However, in some people, gallstones can cause problems.

Cholecystitis is one problem that can occur with gallstones. About 19 in 20 cases of cholecystitis are thought to be caused by gallstones. What seems to happen is that a gallstone becomes stuck in the cystic duct (this is the tube that drains bile out from the gallbladder into the bile duct). Bile then builds up in the gallbladder, which becomes stretched (distended). Because of this, the walls of the gallbladder become inflamed. In some cases the inflamed gallbladder becomes infected. An infected gallbladder is more prone to lead to complications

Other causes of cholecystitis are uncommon

No gallstones are found in about 1 in 20 cases of cholecystitis. In many of these cases it is unclear as to why the gallbladder became inflamed and/or infected.

Diagnosis

An ultrasound scan is commonly done to clarify the diagnosis. This is a painless test which uses sound waves to scan the abdomen. An ultrasound scan can usually detect gallstones, and also if the wall of the gallbladder is thickened (as occurs with cholecystitis). If the diagnosis is in doubt then other more detailed scans may be done.

Treatment

You will normally be admitted to hospital. Usually, you will not be allowed to eat or drink (to rest the gallbladder), and you will be given fluids and painkillers directly into a vein through a 'drip'. With this initial treatment the gallstone that caused the blockage often falls back into the gallbladder, and the inflammation and symptoms often settle down. If the doctor suspects that the gallbladder has become infected, you will also be given antibiotics directly into a vein through the 'drip'.

The gallbladder will usually be removed by an operation. The operation is often done within a few days of being admitted to hospital. Sometimes the operation is delayed for several weeks until the inflammation has settled. Different techniques to remove the gallbladder may be used depending on various factors.

Keyhole surgery is now the most common way to remove a gallbladder. The medical term for this operation is laparoscopic cholecystectomy. It is called keyhole surgery as only small cuts are needed in the abdomen with small scars remaining afterwards. The operation is done with the aid of a special telescope that is pushed into the abdomen through one small cut. This allows the surgeon to see the gallbladder. Instruments pushed through another small cut are used to cut out and remove the gallbladder. Keyhole surgery is not suitable for all people.
Some people need a traditional operation to remove the gallbladder. This is called cholecystectomy. In this operation a larger cut is needed to get at the gallbladder.

Complications

If treatment is delayed or not available, in some cases the gallbladder becomes severely infected and even gangrenous. This can lead to blood poisoning (septicaemia), which is very serious and can be life-threatening. Other possible complications include: the gallbladder may perforate (burst), or a fistula (channel) may form between the gallbladder and gut as a result of continued inflammation.

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.

Acute cholecystitis with cholelithiasis is usually treated by surgery, although several other treatment methods (fragmentation and dissolution of stones) are also used.

NURSING DIAGNOSIS: acute Pain

May be related to
Biologic injuring agents: obstruction/ductal spasm, inflammatory process, tissue ischemia/necrosis
Possibly evidenced by
Reports of pain, biliary colic (waves of pain)
Facial mask of pain; guarding behavior
Autonomic responses (changes in BP, pulse)
Self-focusing; narrowed focus
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
Pain Control (NOC)
Report pain is relieved/controlled.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

NURSING DIAGNOSIS: risk for deficient Fluid Volume

Risk factors may include
Excessive losses through gastric suction; vomiting, distention, and gastric hypermotility
Medically restricted intake
Altered clotting process
Possibly evidenced by
[Not applicable; presence of signs and symptoms and establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
Hydration (NOC)
Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, absence of vomiting.

NURSING DIAGNOSIS: risk for imbalanced Nutrition: less than body requirements

Risk factors may include
Self-imposed or prescribed dietary restrictions, nausea/vomiting, dyspepsia, pain
Loss of nutrients; impaired fat digestion due to obstruction of bile flow
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
Nutritional Status (NOC)
Report relief of nausea/vomiting.
Demonstrate progression toward desired weight gain or maintain weight as individually appropriate.

NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs

May be related to
Lack of knowledge/recall
Information misinterpretation
Unfamiliarity with information resources
Possibly evidenced by
Questions; request for information
Statement of misconception
Inaccurate follow-through of instruction
Development of preventable complications
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
Knowledge: Illness Care (NOC)
Verbalize understanding of disease process, prognosis, potential complications.
Verbalize understanding of therapeutic needs.
Initiate necessary lifestyle changes and participate in treatment regimen.