Cholecystitis
Cholelithiasis affects approximately 50% of
Inflammation of the gallbladder that may occur
as an acute or chronic process
Caused by gallstones results of hard particles
that develop in the gallbladder.
Gallstones develop because of an imbalance in
the chemical make-up of bile inside the
gallbladder.
Types
1. Acute inflammation is associated with
gallstones (cholelithiasis).
Cholethiasis is the presence of one or more
calculi or gallstones in the gallbladder, they
form from the solid constituent of bile and they
vary greatly in size, shape and composition.
Examples of cholesterol gallstones (left) made
up of a coalescence of multiple small stones and
pigment gallstones (right) composed of calcium
bilirubinate.
Level of cholesterol in bile becomes to high and
excess form into stones. Too much cholesterol,
bilirubin, not enough bile salts. Bile salt hep
with the digestion of fats.
Pigment stone associated with bacterial
infection or parasitic infestation of the biliary
system. Deconjugation of bilirubin. Consist of
calcium salts of bilirubin, phosphate carbonate
(cholesterol stones are yellow-green and made
of hardened cholesterol while pigment stone
are dark in color and are made of bilirubin.
They are uncommon in children and young
adults but become more prevalent with
increasing age. Women get gallstones more
often than men and more commonly after age
40. It is estimated that the prevalence of
gallstones ranges from 5% to 20% in women
between the ages of 20 and 55 years and from
25% to 30% in women older than 50 years.
women by the age of 70 years (Littlefield &
Lenahan, 2019).
2. Chronic cholecystitis results when inefficient
bile emptying and gallbladder muscle wall
disease cause a fibrotic and contracted
gallbladder.
3. Acalculous cholecystitis occurs in the absence
of gallstones and is caused by bacterial invasion
via the lymphatic or vascular system. Bacteria
responsible are salmonella, Escherichia coli,
Klebsiella species, and Streptococcus. It can
also occur after major surgical procedures,
orthopedic procedures, severe trauma, or
burns. Other factors associated with this type of
cholecystitis include torsion (twisting or
wrenching of the body by the exertion of
forces), cystic duct obstruction, primary
bacterial infections of the gallbladder, and
multiple blood transfusions. The usual finding of
imaging studies is a distended acalculous
gallbladder with thickened walls about 3-4mm
with or without pericholecystic fluid.
Signs and Symptoms
1. Nausea and vomiting
2. Indigestion
3. Belching
4. Flatulence
5. Epigastric pain that radiates to the scapula 2
to 4 hours after eating fatty foods and may
persist for 4 to 6 hours
6. pain, tenderness, and rigidity of the upper
right abdomen that may radiate to the
midsternal area or right shoulder. pain of acute
cholecystitis may be so severe that analgesic
medications are required. The use of morphine
has traditionally been avoided because of
concern that it could cause spasm of the
sphincter of Oddi. This is controversial,
because morphine is the preferred analgesic
agent for management of acute pain.
Furthermore, all opioids stimulate the
sphincter of Oddi to some degree.
7. Guarding – muscle spasm
8. Mass palpated in the right upper quadrant,
9. Murphy’s sign (cannot take a deep breath
when the examiner’s fingers are passed below
the hepatic margin because of pain)
10. Elevated temperature
11. Tachycardia
12. Signs of dehydration
For Biliary obstruction
1. Jaundice, occurs in a few patients with
gallbladder disease, usually with obstruction of
the common bile duct. The bile, which is no
longer carried to the duodenum, is absorbed by
the blood and gives the skin and mucous
membranes a yellow color. This is frequently
accompanied by marked pruritus (itching) of the
skin.
2. Dark orange and foamy urine, The excretion
of the bile pigments by the kidneys gives the
urine a very dark color.
3. Steatorrhea and clay-colored feces, as it is no
longer colored with bile pigment.
4. Pruritus, due to jaundice
PATHOPHYSIOLOGY
Calculous and acalculous cholecystitis have
different origins.
Calculous – develop when the main opening to
the gallbladder called the cystic duct gets
blocked by a gallstone
Acalculous – severe trauma, surgery, anorexia
that causes the bile to become stagnant
Obstruction. Calculous cholecystitis occurs
when a gallbladder stone obstructs the bile
outflow.
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
Causes
Gallbladder stone. Cholecystitis is usually
associated with gallstone impacted in the cystic
duct. There are two major types of gallstones:
those composed predominantly of pigment and
those composed primarily of cholesterol.
Pigment stones probably form when
unconjugated pigments in the bile precipitate to
form stones. Cholesterol, which is a normal
constituent of bile, is insoluble in water. Its
solubility depends on bile acids and lecithin
(phospholipids) in bile. In gallstone prone
patients, there is decreased bile acid synthesis
and increased cholesterol synthesis in the liver,
resulting in bile supersaturated with
cholesterol, which recipitates out of the bile to
form stones.
Bacteria. Bacteria plays a minor role in
cholecystitis; however, secondary infection of
bile occurs in approximately 50% of cases. The
organisms involved are generally enteric
(normally live in the GI tract) and include
Escherichia coli, Klebsiella species, and
Streptococcus. Bacterial contamination is not
believed to stimulate the actual onset of acute
cholecystitis
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.
Diagnostic procedures
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.
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.
Nursing Implications
Although the complication rate after this
procedure is low, the nurse must closely
observe the patient for symptoms of bleeding,
peritonitis, and sepsis. The nurse assesses the
patient for pain and indications of these
complications and reports them promptly to
the primary provider, takes measures to
reassure the patient, and ensures patient
comfort. Antibiotic agents are often prescribed
to minimize the risk of sepsis and septic shock.
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.
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.
Ultrasonography-Ultrasonography is the
diagnostic procedure of choice because it is
rapid and accurate and can be used in patients
with liver dysfunction and jaundice. The
procedure is most accurate if the patient fasts
overnight so that the gallbladder is distended.
Ultrasonography can detect calculi in the
gallbladder or a dilated CBD with 90%
accuracy.
Radionuclide Imaging or Cholescintigraphy
Cholescintigraphy is used successfully in the
diagnosis of acute cholecystitisor blockage of a
bile duct. During this procedure, a radioactive
agent is administered intravenously (IV), which
is taken up by the hepatocytes and excreted
rapidly through the biliary tract. The biliary
tract is then scanned, and images of the
gallbladder and biliary tract are obtained. This
test is more expensive than ultrasonography,
takes longer to perform, and exposes the
patient to radiation. It is often used when
ultrasonography is not conclusive, such as in
acalculous cholecystitis.
monitors the patient for side effects of any
medications received during the procedure.
Chest x-ray: Rule out respiratory causes of
referred pain.
CBC: Moderate leukocytosis (acute).
Serum bilirubin and amylase: Elevated.

Endoscopic retrograde Serum liver enzymes—AST; ALT; ALP; LDH:

cholangiopancreatography. A fiberoptic Slight elevation; alkaline phosphatase and 5-
duodenoscope, with side-viewing apparatus, is nucleotidase are markedly elevated in biliary
inserted into the duodenum. The ampulla of obstruction
Vater is catheterized, and the biliary tree is Prothrombin levels: Reduced when obstruction
injected with contrast agent. The pancreatic to the flow of bile into the intestine
ductal system is also assessed, if indicated. This decreases absorption of vitamin K.
procedure is of special value in visualizing
neoplasms of the ampulla area and extracting a
biopsy specimen.
Management
NURSING IMPLICATION. Before ERCP, the Medical Management
patient is educated about the procedure and
Fasting. The patient may not be allowed to
their role in it. This preparation can allay anxiety
drink or eat at first in order to take the stress off
and facilitate the insertion of the endoscope
the inflamed gallbladder; IV fluids are
without damage to the GI tract structures,
prescribed to provide temporary food for the
including the biliary tree. The patient takes
cells. The diet immediately after an episode is
nothing by mouth for several hours before the
usually low-fat liquids. These can include
procedure. The procedure requires intravenous
powdered supplements high in protein and
(IV) sedation and monitored anesthesia care. In
carbohydrate stirred into skim milk. Cooked
some cases general anesthesia is required, and
fruits, rice or tapioca, lean meats, mashed
the sedated patient is monitored closely during
potatoes, non–gas-forming vegetables, bread,
and after the procedure (Brunicardi, 2019). It
coffee, or tea may be added as tolerated. The
may be necessary to administer medications,
patient should avoid eggs, cream, pork, fried
such as glucagon or anticholinergic agents, to
foods, cheese, rich dressings, gas forming
make cannulation easier by decreasing
vegetables, and alcohol. It is important to
duodenal peristalsis. The nurse observes closely
remind the patient that fatty foods may induce
for signs of respiratory and CNS depression,
an episode of cholecystitis. Dietary
hypotension, oversedation, and vomiting (if
management may be the major mode of
glucagon is given). During ERCP, the nurse
therapy in patients who have had only dietary
monitors IV fluids, administers medications, and
intolerance to fatty foods and vague GI
positions the patient. After the procedure, the
symptoms.
nurse monitors the patient’s condition,
observing vital signs and assessing for signs of Supportive medical care. This may include
perforation or infection. The nurse also restoration pf hemodynamic stability and
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.

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.
Surgery
Cholecystectomy. Removal of the gallbladder.
Cholecystectomy is most commonly performed
by using a laparoscope and removing the
gallbladder. In cholecystectomy, the gallbladder
is removed through an abdominal incision
(usually right subcostal) after the cystic duct and
artery are ligated. The procedure is performed
for acute and chronic cholecystitis.
Laparoscopic Cholecystectomy
Laparoscopic cholecystectomy is the standard
of therapy for symptomatic gallstones.
Laparoscopic cholecystectomy is performed
through a small incision or puncture made
through the abdominal wall at the umbilicus.
In laparoscopic cholecystectomy (A), the
surgeon makes four small incisions (less than
one half inch each) in the abdomen and inserts
a laparoscope with a miniature camera through
the umbilical incision (B). The camera apparatus
displays the gallbladder and adjacent tissues on
a screen, allowing the surgeon to visualize the
sections of the organ for removal.
Small-Incision Cholecystectomy
Small-incision cholecystectomy is a surgical
procedure in which the gallbladder is removed
through a small abdominal incision, as the name
implies. If needed, the surgical incision is
extended to remove larger gallbladder stones.
Drains may or may not be used. The short
length hospital stay has been identified as a
major advantage of this type of procedure
Choledochostomy
Choledochostomy is reserved for the patient
with acute cholecystitis who may be too ill to
undergo a surgical procedure. This procedure
involves making an incision in the common
duct, usually for removal of stones. After the
stones have been evacuated, a tube is usually
inserted into the duct for drainage of bile until
edema subsides. This tube is connected to
gravity drainage tubing; the patient is
monitored closely, and a laparoscopic
cholecystectomy is planned for a future date
after acute inflammation has resolved.
Cholecystostomy is performed when the
patient’s condition precludes more extensive
surgery or when an acute inflammatory reaction
is severe. The gallbladder is surgically opened,
stones and the bile or the purulent drainage are
removed, and a drainage tube is secured with a
purse-string suture. The drainage tube is
connected to a drainage system to prevent bile
from leaking around the tube or escaping into
the peritoneal cavity
Nonsurgical Removal of Gallstones
Dissolving Gallstones
Several methods have been used to dissolve
gallstones by infusion of a solvent (mono-
octanoin or methyl tertiary butyl ether [MTBE])
into the gallbladder. The solvent can be infused
through the following routes: through a tube or
catheter inserted percutaneously directly into
the gallbladder;
through a tube or drain inserted through a T-
tube tract to dissolve stones not removed at the
time of surgery, endoscopically with ERCP; or
via a transnasal biliary catheter, a rarely used
procedure due to its lack of success, potential
side effects, and recurrence rates of up to 50%
Stone Removal by Instrumentation
Several methods are used to remove stones
that were not removed at the time of
cholecystectomy or have become lodged in the
CBD (see Fig. A,B). A catheter and instrument
with a basket attached are threaded through
the T-tube tract or fistula formed at the time of
T-tube insertion; the basket is used to retrieve
and remove the stones lodged in the common
bile duct. A second procedure involves the use
of the ERCP endoscope (see Fig. C). After the
endoscope is inserted, a cutting instrument is
passed through the endoscope into the ampulla
of Vater of the common bile duct. It may be
used to cut the submucosal fibers, or papilla, of
the sphincter of Oddi, enlarging the opening,
which may allow the lodged stones to pass
spontaneously into the duodenum. Another
instrument with a small basket or balloon at its
tip may be inserted through the endoscope to
retrieve the stones (see Fig. D–F). The patient is
observed closely for bleeding, perforation, and
the development of pancreatitis (see later
discussion) or sepsis. The ERCP procedure is
particularly useful in diagnosis and treatment of
patients who have symptoms after biliary tract
surgery, patients with intact gallbladders, and
patients for whom surgery is particularly
hazardous.
Intracorporeal Lithotripsy
Stones in the gallbladder or CBD may be
fragmented by means of laser pulse technology.
A laser pulse is directed under fluoroscopic
guidance with the use of devices that can
distinguish between stones and tissue. The laser
pulse produces rapid expansion and
disintegration of plasma on the stone surface,
resulting in a mechanical shock wave.
Electrohydraulic lithotripsy uses a probe with
two electrodes that deliver electric sparks in
rapid pulses, creating expansion of the liquid
environment surrounding the gallstones. This
results in pressure waves that cause stones to
fragment. This technique can be used
percutaneously with a basket or balloon
catheter system or by direct visualization
through an endoscope. Repeated procedures
may be necessary because of stone size, local
anatomy, bleeding, or technical difficulty. A
nasobiliary tube can be inserted to allow for
biliary decompression and to prevent stone
impaction in the common bile duct. This
approach allows time for improvement in the
patient’s clinical condition until gallstones are
cleared endoscopically, percutaneously, or
surgically.
Extracorporeal Shock Wave Lithotripsy
Extracorporeal shock wave lithotripsy (ESWL)
has been used for nonsurgical fragmentation of
gallstones. ESWL is a noninvasive procedure
that uses repeated shock waves directed at the
gallstones in the gallbladder or CBD to fragment
the stones. The waves are transmitted to the
body through a fluidfilled bag or by immersing
the patient in a water bath. After the stones are
gradually broken up, the stone fragments can
be spontaneously passed from the gallbladder
or common bile duct, removed by endoscopy,
or dissolved with oral bile acid or solvents.
Because the procedure requires no incision and
no hospitalization, patients are usually treated
as outpatients, but usually several sessions are
necessary. This procedure has largely been
replaced by laparoscopic cholecystectomy.
ESWL is used in some centers for a small
percentage of suitable patients (those with CBD
stones who may not be surgical candidates),
sometimes in combination with dissolution
therapy
(Feldman et al., 2016; Kellerman & Rakel, 2018).
Complications
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
Surgical Management
Surgical treatment of gallbladder disease and
gallstones is carried out to relieve persistent
symptoms, to remove the cause of biliary colic,
and to treat acute cholecystitis. Surgery may
be delayed until the patient’s symptoms have
subsided, or it may be performed as an
emergency procedure, if necessitated by the
patient’s condition.
Nursing Management
Preoperative
1. Maintain NPO status during nausea and
vomiting episodes.
2. Maintain nasogastric decompression as
prescribed for severe vomiting.
3. Administer antiemetics as prescribed for
nausea and vomiting.
4. Administer analgesics as prescribed to relieve
pain and reduce spasm.
5. Administer antispasmodics (anticholinergics)
as prescribed to relax smooth muscle.
6. Instruct the client with chronic cholecystitis
to eat small, low-fat meals.
7. Instruct the client to avoid gas-forming foods.
8. Prepare the client for nonsurgical and surgical
procedures as prescribed.
Postoperative interventions
a. Monitor for respiratory complications caused
by pain at the incisional site.
b. Encourage coughing and deep breathing.
c. Encourage early ambulation.
d. Instruct the client about splinting the
abdomen to prevent discomfort during
coughing.
e.Administer antiemetics as prescribed for
nausea and vomiting.
f. Administer analgesics as prescribed for pain
relief.
g. Maintain NPO status and nasogastric tube
suction as prescribed.
h. Advance diet from clear liquids to solids
when prescribed and as tolerated by the client.
I. Maintain and monitor drainage from the T-
tube, if present
Goal: relief of pain, adequate ventilation, intact
skin and improved biliary drainage, optimal
nutritional intake, absence of complications,
and understanding of self-care routines.