Cholecystitis is the inflammation of the gallbladder.

Gallbladder stores bile

containing waste and fats that is needed to be excreted from the body.
Symptoms include right upper abdominal pain, nausea and vomiting, and
occasionally fever. There are 2 classifications of cholecystitis: (1) Calculous
cholecystitis gallstones obstruct bile outflow. (2) Alcalculous cholecystitis acute
inflammation in the absence of obstruction by gallstones. Without appropriate
treatment recurrent episodes of cholecystitis are common. Acute cholecystitis
may be complicated by gallstone pancreatitis, common bile duct stones, and
inflammation of the common bile duct.
More than 90% of the time, acute cholecystitis is from blockage of the bile
duct by gallstones. Risk factors for gallstone include:

Birth control pills- Both estrogen and progesterone have been shown to play
an important role in the formation of gallstones. Estrogen has been shown
to increase cholesterol production in the liver, with excess amounts
precipitating in bile and leading to the formation of gallstones.
Progesterone has been shown to decrease gall-bladder motility, which
impedes bile flow and leads to gallstone formation.
Pregnancy - Gallstones are more common during pregnancy due to
decreased gallbladder motility and increased cholesterol saturation of bile.
In pregnant women with biliary colic, supportive care will lead to resolution
of symptoms in most cases, but the symptoms frequently recur later in
pregnancy.
Family history of gallstone- Having a family member or close relative with
gallstones may increase the risk of gallstones. Up to one-third of cases of
painful gallstones may be related to genetic factors. Defects in transport
proteins involved in biliary lipid secretion appear to predispose certain
people to gallstone disease, but this alone many not be sufficient to create
gallstones. Studies indicate that the disease is complex and may result from
the interaction between genetics and environment. Some studies suggest
immune and inflammatory mediators may play key roles.
Obesity liver over-produces cholesterol, which is delivered into the bile
and causes it to become supersaturated.
Diabetes- People with diabetes are at higher risk for gallstones and have a
higher-than-average risk for acalculous disease (without stones).
Gallbladder disease may progress more rapidly in patients with diabetes,
who tend to suffer worse infections. In theory, drugs designed to improve
insulin resistance should reduce the incidence of gallstones. However, this
may not always occur. Researchers were surprised when animal studies
 showed that the type 2 diabetes drug pioglitazone (Actos) caused
gallbladder volume to increase, indicating that its function may be
compromised. This may raise the risk of gallstone formation.
Liver disease - alcoholic
Rapid weight loss- Rapid weight loss or cycling (dieting and then putting
weight back on) further increases cholesterol production in the liver, with
resulting supersaturation and risk for gallstones.

It occurs as a result of vasculitis (inflammation of the blood/lymph vessels),

chemotherapy or during recovery from major trauma or burns. Abdominal
ultrasound is typically used to confirm diagnosis.

Signs and Symptoms

Most people with cholecystitis do not have symptoms. When gallstone

intermittently lodged in cystic ducts they suffer from biliary colic abdominal pain
in the RUQ or epigastrium that is usually episodic after eating greasy/fatty foods
and leads to N & V. People who suffer from cholecystitis most commonly initially
have symptoms of biliary content before developing cholecystitis.

Pathophysiology
Blockage of the cystic ducts by gallstones
Bile stasis in gallbladder

Bile formation/ Cholelithiasis (production of gallstones) or

Autolysis (breakdown of all cells/tissue by self-producing enzyme)
+ Secondary bacterial infection

Cholecystitis (inflammation of the gallbladder)

(When bile from the liver becomes concentrated that it forms gallstone)

Edema, obstruction

Fatty food intake causes gallbladder contraction

Pain (gallbladder forced to process food that you eat)

Pathophysiology

Calculous and acalculous cholecystitis have different origins.

Obstruction. Calculous cholecystitis occurs when a gallbladder stone

obstructs the bileoutflow.
Chemical reaction. Bile remaining in the gallbladder initiates a
chemical reaction; autolysis and edema occur.
Compression. Blood vessels in the gallbladder compressed,
compromising its vascular supply.

Statistics and Incidences

Cholecystitis account for most patients requiring gallbladder surgery.

Although not all occurrences of cholecystitis are related cholelithiasis,

more than 90% of patients with acute cholecystitis have gallstones.
The acute form is most common during middle age.
The chronic form usually occurs among elderly patients.

Causes

The causes of cholecystitis include:

Gallbladder stone. Cholecystitis is usually associated with gallstone

impacted in the cystic duct.
Bacteria. Bacteria plays a minor role in cholecystitis; however,
secondary infection of bile occurs in approximately 50% of cases.
Alterations in fluids and electrolytes. Acalculous cholecystitis is
speculated to be caused by alterations in fluids and electrolytes.
Bile stasis. Bile stasis or the lack of gallbladder contraction also play a
role in the development of cholecystitis.

Clinical Manifestations

Cholecystitis causes a series of signs and symptoms:

Pain. Right upper quadrant pain occurs with cholecystitis.

 Leukocytosis. An increase in the WBC occurs because of the bodys
attempt to ward off pathogens.
Fever. Fever occurs in response to the infection inside the body.
Palpable gallbladder. The gallbladder becomes edematous
as infection progresses.
Sepsis. Infection reaches the bloodstream and the body
undergoes sepsis.

Complications

Cholecystitis can progress to gallbladder complications, such as:

Empyema. An empyema of the bladder develops if the gallbladder

becomes filled with purulent fluid.
Gangrene. Gangrene develops because the tissues do not receive
enough oxygen and nourishment at all.
Cholangitis. The infection progresses as it reaches the bile duct.

Assessment and Diagnostic Findings

Studies used in the diagnosis of cholecystitis include:

Biliary ultrasound: Reveals calculi, with gallbladder and/or bile

duct distension (frequently the initial diagnostic procedure).
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
patient is too ill to take the dye by mouth.
Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile
ducts, and distinguish between obstructive/nonobstructive jaundice.
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 x-ray films (multipositional): Radiopaque
(calcified) gallstones present in 10%15% of cases; calcification of the
wall or enlargement of the gallbladder.
Chest x-ray: Rule out respiratory causes of referred pain.
CBC: Moderate leukocytosis (acute).
Serum bilirubin and amylase: Elevated.
Serum liver enzymesAST; 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 intestinedecreases absorption of vitamin K.
Ultrasonography. Ultrasound is the preferred initial imaging test for
the diagnosis of acute cholecystitis; scintigraphy is the preferred
alternative.
CT scan. CT scan is a secondary imaging test that can identify extra-
biliary disorders and acute complications of cholecystitis.
MRI. Magnetic resonance imaging is also a possible secondary choice
for confirming a diagnosis of acute cholecystitis.
Oral cholecystography. Preferred method of visualizing general
appearance and function of the gallbladder.
Cholecystogram. Cholecystography reveals stones in the biliary
system.
Abdominal xray. Radiopaque or calcified gallstones present in 10% to
15% of cases.

Medical Management

Management may involve controlling the signs and symptoms and the
inflammation of the gallbladder.
 Fasting. The patient may not be allowed to drink or eat at first in order
to take the stress off the inflamed gallbladder; IV fluids are prescribed
to provide temporary food for the cells.
Supportive medical care. This may include restoration
pf hemodynamic stabilityand antibiotic coverage for gram-negative
enteric flora.
Gallbladder stimulation. Daily stimulation of gallbladder contraction
with IV cholecystokinin may help prevent the formation of gallbladder
sludge in patients receiving TPN.

Pharmacologic Therapy

The following medications may be useful in patients with cholecystitis:

Antibiotic therapy. Levofloxacin and Metronidazole for

prophylactic antibiotic coverage against the most common organisms.
Promethazine or Prochlorperazine may control nausea and prevent
fluid and electrolyte disorders.
Oxycodone or Acetaminophen may control inflammatory signs and
symptoms and reduce pain.

Surgical Management

Because cholecystitis frequently recurs, most people with the condition eventually
require gallbladder removal.

Cholecystectomy. Cholecystectomy is most commonly performed by

using a laparoscope and removing the gallbladder.
Endoscopic retrograde cholangiopancreatography (ERCP). ERCP
visualizes the biliary tree by cannulation of the common bile duct
through the duodenum.

Nursing Management

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, bleedinggums, 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

Main Article: 4 Cholecystitis and Cholelithiasis Nursing Care Plans

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 bedrest, 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.

Documentation Guidelines

The focus of documentation should include:

Clients description of response to pain.

Specifics of pain inventory.
Expectations of pain management.
Acceptable level of pain.
Prior medication use.
Caloric intake.
Individual cultural or religious restrictions, personal preferences.
Availability and use of resources.
 Plan of care.
Teaching plan.
Response to interventions, teaching, and actions performed.
Attainment or progress toward desired outcomes.
Modifications to plan of care.