Concept About Cholecystitis – This course is designed to understand the concept of community health nursing: nurses’ roles and interventions in family health, school health, occupational health, environmental health, elderly health care, gender issues, disaster management and principles and terminology of epidemiology. The aim of the course is to acquire knowledge and skills in community health nursing.
Concept About Cholecystitis
Cholecystitis is inflammation of the gallbladder. Symptoms include right upper abdominal pain, nausea, vomiting, and occasionally fever. Often gallbladder attacks (biliary colie) precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack.
Without appropriate treatment, recurrent episodes of cholecystitis are common. Complications of acute cholecystitis include gallstone pancreatitis, common bile duct stones, or inflammation of the common bile duct.
More than 90% of the time acute cholecystitis is from blockage of the cystic duct by a gallstone. Risk factors for gallstones include birth control pills, pregnancy, a family history of gallstones, obesity, diabetes, liver disease, or rapid weight loss.
Occasionally acute cholecystitis occur as a result of vasculitis, chemotherapy, or during recovery from major trauma or burns. Cholecystitis is suspected based on symptoms and laboratory testing. Abdominal ultrasound is then typically used to confirm the diagnosis.
Definition of Cholecystitis:
Cholecystitis is a sudden inflammation of the gallbladder that causes severe abdominal pain.
Or,
Cholecystitis is inflammation of the gallbladder, a small organ near the liver that plays a part in digesting food. Normally, fluid called bile passes out of the gallbladder on its way to the small intestine.
Or,
The term cholecystitis refers to inflammation of the gallbladder. It may develop acutely in association. with gallstones (acute cholecystitis) or, less often, without gallstones (acalculous cholecystitis).
Causes of Cholecystitis
A. In 90% of cases, acute cholecystitis is caused by gallstones in the gallbladder. Other causes include severe illness and (rarely) tumors of the gallbladder.
B. Acute cholecystitis occurs when bile becomes trapped in the gallbladder. The buildup of bile causes irritation and pressure in the gallbladder. This can lead to infection and a whole (perforation) in the organ.
C. Gallstones occur more often in women than men. Gallstones become more common with age in both sexes.
Management of Cholecystitis
Clinical features
A. Symptoms
a) Sudden onset of severe pain in the right hypochondrium or epigastrium, usually precipitated by heavy meal or fatty meal
b) Severe attacks of vomiting and pyrexia
c) There may be a previous history of gall stone disease
d) Aggravated by movement and relieved by analgesics
B. Sign
a) General examination:
- Patient is restless an toxic
- Rapid pulse
- High temperature (102-104°F)
- Tachycardia
- May be dehydrated due to vomiting
- Anxious appearance
b) Local sign
- Local tenderness in the right hypochondrium
- Murphys sign: Positive
- Boas sign: Area of hyperesthesia in the region of 9th to 11th rib posteriorly (right sided)
Investigation
- Blood for TC, DC, ESR, Hb%
- Blood urea, serum creatinine and blood sugar 2 hours after meal
- Urine for RME
- X-ray chest
- Plain X-ray abdomen A/P view
- Serum amylase
- ECG> 40 years
- Liver function test
- USG of hepatobiliary system and pancreas
- Radio isotope scanning (HIDA) – Most accurate test for acute cholecystitis
Treatment
A. Conservative treatment
- Complete bed rest
- Nothing per oral (NPO)
- Nasogastric suction
- Intravenous fluid and electrolyte
- Electrolyte replacement
- Analgesic: Anti spasmodic (Hyoscine-N-butyl bromide)
- Nutritional support
- Systemic Antibiotic (Metronidazole + Gentamycin/cephalosporin/amoxicillin)
- Anti-emetics: Stemetil
- Continuous monitoring: Vital sign, relief of pain, and state of hydration
- If burst, laparotomy and toileting then drain tube. After 6-8 weeks interval cholecystectomy
B. After complete recovery, advice for cholecystectomy.
Nursing Management of Cholecystitis.
Management of cholecystitis include the following:
Nursing Assessment
Integumentary system. Assess skin and mucous membranes.
Circulatory system. Assess peripheral pulses and capillary refill.
Bleeding. Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, petechiae, ecchymosis, hematemesis, or melena.
Gastrointestinal system. Assess for abdominal distension, frequent belching, guarding, and reluctance to move.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnosis for the patient may include:
- Acute pain related to the inflammatory process.
- Risk for imbalanced nutrition related to self-imposed dietary restrictions and pain.
Nursing Care Planning & Goals
The major goals for the patient include:
- Relieve pain and promote rest.
- Maintain fluid and electrolyte balance.
- Prevent complications.
- Provide information about disease process, prognosis, and treatment needs.
Nursing Interventions
Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications.
Pain assessment. Observe and document location, severity (0-10 scale), and character of pain.
Activity. Promote bed rest, allowing the patient to assume a position of comfort.
Diversion. Encourage use of relaxation techniques, and provide diversional activities. Communication. Make time to listen and to maintain frequent contact with the patient.
Calories. Calculate caloric intake to identify nutritional deficiencies or needs.
Food planning. Consult the patient about likes and dislikes, foods that cause distress, and preferred meal schedules.
Promote appetite. Provide a pleasant atmosphere at mealtime and remove noxious stimuli.
Laboratory studies. Monitor laboratory studies: BUN, pre-albumin, albumin, total protein, transferrin levels.
Evaluation
Expected patient outcomes are:
- pain relieved.
- Homeostasis achieved.
- Complications prevented/minimized.
- Disease process, prognosis, and therapeutic regimen understood.
Discharge and Home Care Guidelines
The focus of discharge instructions for patients with cholecystitis is education.
- Education. Patients with cholecystitis must be educated regarding causes of their disease, complications if left untreated, and medical and surgical options.
- Activity. Ambulate and increase activity as tolerated.
- Diet. Consult with the dietitian or nutritional support to establish individual nutritional needs.
Complication of Acute Cholicystitis
1. Perforation of the gallbladder
2. Abscess formation in the gallbladder
3. Development of an abnormal tube-like passage (fistula) from the gallbladder to the intestine, colon, or skin
4. Gangrene (gangrenous cholecystitis)
5. Pus in the gallbladder and abdominal cavity (empyema)
6. Inflammation of the bile ducts (cholangitis), liver (hepatitis), or pancreas (pancreatitis)
Chronic Cholecystitis
Management a Case of Chronic Cholecystitis:
Clinical features
A. Symptoms
a) Pain:
- Recurrent Pain
- Severe colicky pain in the right hypochondrium and or epigastrium may radiate to inferior angle of the scapula or to the tip of right shoulder.
- Continuous in nature
- Usually precipitate by fatty/heavy meal
- Aggravated by movement and relieved by analgesics
- May be associated with nausea, vomiting
b) Mild fever may be present
c) Flatulence dyspepsia
d) Fat intolerance
B. Signs:
a) General:
- Jaundice may be present
- Rise of temperature, obese
b) Local:
- On deep palpation, there may be mild tenderness on right hypochondrium
- Murphys sing (-ve) (may be positive in case of acute exacerbation of chronic cholecystitis)
- Boas’s sign (-ve) (may be positive in case of acute exacerbation of chronic cholecystitis)
Investigation:
a) For general assessment of patient condition
b) Blood for TC, DC, ESR, Hb%
c) Blood urea and serum creatinine
d) Blood sugar 2 hours after meal
e) Urine for RME
f) X-ray chest
g) ECG > 40 years
b) Liver function test
1) USG of hepato biliary system and pancreas (confirmatory)
Treatment: Cholexystectomy, if acute attack-conservative treatment followed by cholecystectomey
Pre-Operative Management of Calculus Cholecystitis:
- Reassure the patient physically & psychologically about operation.
- Provide correct information about operation/ surgery.
- Take history & collect all investigations report & prepared a preoperative file
- Check vital sign with height, weight & record all information on chart
- Patient should be kept on nothing by mouth (NPO) usually 6-8 hours before surgery
- Sedative as well as laxative should be given at night according to physician order.
- Enema given early in the morning if necessary
- All jewelries & false teeth, hearing aids etc. should be removed
- Shave & clean respective area for operation
- Check vital sign time & noted on chart
- Written consent/ informed consent must be collected from patient
- Ask the patient to empty the bladder before going to the operation table
- IV infusion should be given
- Catheter should be introduced
- Helps the patient to maintain personal hygiene
- If the patient female twisting hair 1/2 braids for long
- Administer pre anesthetic medication as per as doctors order
- Provide support to the patient & their relatives.
- Explain the surgical procedure to the patient
- Reduce fear about the upcoming surgery & recovery
- Send the patient to the OT with patient file
Postoperative Management
If the patient is restless, something is wrong.
Look out for the following in recovery:
- Airway obstruction
- Hypoxia
- Haemorrhage: internal or external
- Hypotension and/or hypertension
- Postoperative pain
- Shivering, hypothermia
- Vomiting, aspiration
- Falling on the floor
- Residual narcosis
The recovering patient is fit for the ward when:
- Awake, opens eyes
- Extubated
- Blood pressure and pulse are satisfactory
- Can lift head on command
- Not hypoxic
- Breathing quietly and comfortably
- Appropriate analgesia has been prescribed and is safely established
Nursing Responsibilities:
- The patient should be kept on nothing by mouth according to doctor’s order.
- IV fluid should be given according to doctor’s order.
- Maintain input and output chart.
- Maintain patency of NG tube. Notify physician if tube becomes dislodged
- Note character and amount of gastric drainage.
- Provide oral hygiene on a regular, frequent basis, including petroleum jelly for lips.
- Auscultate for resumption of bowel sounds and note passage of flatus.
- Monitor tolerance to fluid and food intake, noting abdominal distension, reports of increased pain,
- cramping, nausea and vomiting.
- Avoid milk and high-carbohydrate foods in the diet.
- Note admission weight and compare with subsequent readings.
- Administer IV fluids, TPN, and lipids as indicated.
- Monitor laboratory studies (Hb and Hct, electrolytes, and total protein, prealbumin).
- Progress diet as tolerated, advancing from clear liquid to bland diet with several small feedings.
- Administer medications as indicated:
✔ Anticholinergics: atropine, propantheline bromide (Pro-Banthine)
✔ Fat-soluble vitamin supplements, including vitamin B12, calcium
✔ Iron preparations
✔ Protein supplements
✔ Medium-chain triglycerides (MCT)
- Care of the surgical area
- Care of IV cannel
- Care of the bowel and bladder
- Patient and their family members assured and informed about patient condition.
Read more: