CHOLECYSTITIS

JEMALYN MENDOZA, RN, MAN, PhD, MD

DISORDERS OF
GALLBLADDER

Cholecystitis
Cholelithiasis
Pathophysiology
Clinical manifestations
Assessment and diagnostic
findings
Medical management
 CHOLECYSTITIS

(inflammation of the gallbladder

which can be acute or chronic)
causes pain, tenderness, and rigidity
of the upper right abdomen that may
radiate to the midsternal area or
right shoulder and is associated with
nausea, vomiting, and the usual
signs of acute inflammation.
An empyema of the gallbladder
develops if the gallbladder becomes
filled with purulent fluid(pus).
 CALCULOUS CHOLECYSTITIS
- is the cause of more than 90% of cases of acute cholecystitis (Brunicardi, 2019; Cameron & Cameron, 2020).
- gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and
edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of
the gallbladder with perforation may result. Bacteria play a minor role in acute 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 (Feldman, Friedman, & Brandt, 2016; Goldman &
Schafer, 2019).
 ACALCULOUS CHOLECYSTITIS
Acalculous cholecystitis describes acute gallbladder inflammation in the absence of obstruction by gallstones.
Acalculous cholecystitis occurs after major surgical procedures, orthopedic procedures, severe trauma, or burns. Other
factors associated with this type of cholecystitis include torsion, cystic duct obstruction, primary bacterial infections of
the gallbladder, and multiple blood transfusions. It is speculated that acalculous cholecystitis is caused by alterations in
fluids and electrolytes and alterations in regional blood flow in the visceral circulation. Bile stasis (lack of gallbladder
contraction) and increased viscosity of the bile are also thought to play a role. The occurrence of acalculous cholecystitis
with major surgical procedures or trauma makes its diagnosis difficult.
CHOLELITHIASIS

Calculi, or gallstones, usually form in the

gallbladder from the solid constituents of
bile; they vary greatly in size, shape, and
composition (see Fig. 44-2). They are
uncommon in children and young adults but
become more prevalent with increasing age.
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. Cholelithiasis affects
approximately 50% of women by the age of
70 years (Littlefield & Lenahan, 2019).
ADDITIONAL CONTENT
Subtitle
1 type
st
◼ Composition ◼ predominantly of pigment
◼ Process ◼ Pigment stones probably form
when unconjugated pigments in the
◼ Percentage of case bile precipitate to form stones
◼ Risk factors ◼ these stones account for about 10%
to 25% of cases in the United States
◼ cirrhosis, hemolysis, and infections
of the biliary tract. Pigment stones
cannot be dissolved and must be
removed surgically
2nd type
◼ Cholesterol
◼ Cholesterol, which is a normal constituent of bile, is
insoluble in water. Its solubility depends on bile acids
and lecithin (phospholipids) in bile (Hammer &
McPhee, 2019). In gallstoneprone patients, there is
decreased bile acid synthesis and increased cholesterol
synthesis in the liver, resulting in bile supersaturated
with cholesterol, which
◼ precipitates out of the bile to form stonesaccount for
most of the remaining 75% of cases of gallbladder
disease in the United States.
 RISK FACTORS
• Cystic fibrosis
• Diabetes
• Frequent changes in weight
• Ileal resection or disease
• Low-dose estrogen therapy—carries a small
increase in the risk of gallstones
• Obesity
• Rapid weight loss (leads to rapid development
of gallstones and high risk of symptomatic
disease)
• Treatment with high-dose estrogen
• Women, especially those who have had
multiple pregnancies or who
• are of Native American or U.S. southwestern
Hispanic ethnicity
CLINICAL MANIFESTATIONS

Gallstones may be silent, producing no pain and only mild

GI symptoms. Such stones may be detected incidentally
during surgery or evaluation for unrelated problems.

The symptoms may be acute or chronic. Epigastric distress,

such as fullness, abdominal distention, and vague pain in
the right upper quadrant of the abdomen, may occur. This
distress may follow a meal rich in fried or fatty foods.
ASSESSMENT AND DIAGNOSTIC FINDINGS

Endoscopic Retrograde
Abdominal X-Ray Ultrasonography Radionuclide Imaging
Oral Cholecystography Cholangiopancreato
or Cholescintigraphy
-graphy
CLINICAL MANIFESTATIONS

Pain and Biliary Colic Jaundice Changes in Urine and Vitamin Deficiency
Stool Color
If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute
cholecystitis). The patient develops a fever and may have a palpable abdominal mass. The patient may have biliary colic with
excruciating upper right abdominal pain that radiates to the back or right shoulder and is usually associated with nausea and
vomiting, and it is noticeable several hours after a heavy meal.

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.

The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile
pigments, are grayish (like putty) or clay colored.

Obstruction of bile flow interferes with absorption of the fat-soluble vitamins A, D, E, and K. Patients may exhibit
deficiencies of these vitamins if biliary obstruction has been prolonged.
MEDICAL
Approximately 80% of the patients with acute gallbladder
MANAGEMENT inflammation achieve remission with rest, IV fluids,
nasogastric suction, analgesia, and antibiotic agents.

Nutritional and Supportive Therapy

Low-fat liquids: powdered supplements high in protein and

carbohydrates stirred into skim milk.
Cooked fruits, rice or tapioca, lean meats, mashed potatoes,
non–gas-forming vegetables, bread, coffee, or tea may be
added as tolerated.
MEDICAL
Pharmacologic Therapy
MANAGEMENT
Ursodeoxycholic acid (UDCA) and chenodeoxycholic acid
(chenodiol or CDCA) have been used to dissolve small,
radiolucent gallstones composed primarily of cholesterol
(Goldman & Shafer, 2019). UDCA has fewer side effects than
chenodiol and can be given in smaller doses to achieve the
same effect.

Patients with frequent symptoms, cystic duct occlusion, or

pigment stones are not candidates for pharmacologic therapy.
Laparoscopic or open cholecystectomy is more appropriate for
symptomatic patients with acceptable operative risk (Goldman
& Shafer, 2019).
MEDICAL
Nonsurgical Removal of Gallstones
MANAGEMENT
Dissolving Gallstones
Stone Removal by Instrumentation
Intracorporeal Lithotripsy
Extracorporeal Shock Wave Lithotripsy
 Surgical Management
MEDICAL Preoperative Measures
MANAGEMENT Laparoscopic Cholecystectomy
Cholecystectomy
Choledochostomy
Percutaneous Cholecystostomy
Endoscopic Ultrasound