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cholecystitis

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John Anderson

on 16 April 2015

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Transcript of cholecystitis

By John Anderson, RN, MSN
CHOLECYSTITIS AND CHOLELITHIASIS





Cholecystitis is an inflammation of the gallbladder
Cholecystitis is most often caused by gallstones (cholelithiasis) obstructing the cystic and or common bile ducts causing bile to back up and the gall bladder to become inflamed. Surgery is not recommended until signs and symptoms subside
Bile flows from the gallbladder to the duodenum

OVERVIEW






Cholelithiasis is the presence of stones in the gall bladder related to either the precipitation or bile or cholesterol into stones
Bile is used for the digestion of fats
Bile is produced in the liver and stored in the gall bladder

OVERVIEW




Cholecystitis can be acute or chronic, and can obstruct the pancreatic duct, causing pancreatitis
It can also cause the gall bladder to rupture, resulting in secondary peritonitis

OVERVIEW













Consume a low-fat diet rich in HDL sources (seafood, nuts, olive oil)

Participate in a regular exercise program

Do not smoke


HEALTH PROMOTION AND DISEASE PREVENTION

ASSESSMENT




More common in females

Hormone therapy and use of some oral contraceptives

High-fat diet
Obesity (impaired fat metabolism, high cholesterol)
Genetic predisposition



RISK FACTORS




Older than 60 years of age (decreased contractility, more likely to develop gallstones)
Individuals who have type 1 diabetes mellitus (high triglycerides)
Low-calorie, liquid protein diet
Rapid weight loss (increases cholesterol)

RISK FACTORS




Sharp pain in the right upper quadrant
Often radiating to the right shoulder
Pain with deep inspiration during right subcostal palpation (Murphy’s sign)
Intense pain (increased heart rate, pallor, diaphoresis) with nausea and vomiting
after ingestion of high-fat food caused by biliary colic

SUBJECTIVE DATA




Rebound tenderness (Blumberg’s sign)
Blumberg’s sign performed by the provider only
Dyspepsia (indigestion), eructation (belching), and flatulence
Fever

SUBJECTIVE DATA

OBJECTIVE DATA




WBC increased with left shift indicates inflammation( increase in new white cells)
Direct, indirect, and total serum bilirubin (increased if duct obstructed) = cholelithiasis
Bilirubin that reacts with the diazo reagent without the addition of alcohol is called “direct” or conjugated while the form that reacts only in the presence of alcohol is called “indirect” or unconjugated.
Indirect+direct= Total Bilirubin

LABORATORY TESTS

LABORATORY TEST


Bilirubin type

Bilirubin level

Total bilirubin 0.0-1.4mg/dl

Direct bilirubin 0.0- 0.3mg/dl

indirect bilirbun 0.2-1.2mg/dl





Amylase and lipase will increased with pancreatic involvement
Aspartate aminotransferase (AST), lactate dehydrogenase (LDH),
and alkaline phosphatase (ALP) will increased with liver dysfunction
May indicate the common bile duct is obstructed
Serum cholesterol will be greater than 200 mg/dl

LABORATORY TESTS





Ultrasound visualizes gall stones and a dilated common bile duct. Client will be NPO
An abdominal x-ray or CT can visualize calcified gallstone and an enlarged gall bladder
A hepatobiliary scan (HIDA) assesses the patency of the biliary duct system after an IV injection of contrast

DIAGNOSTIC PROCEDURE




An endoscopic retrograde cholangiopancreatography (ERCP) allows for direct visualization using an endoscope that is inserted through the esophagus and into the common bile duct via the duodenum
A sphincterotomy with gall stones removal may be done during this procedure
This procedure is done with moderate sedation not general anesthesia

DIAGNOSTIC PROCEDURE




The client is observed closely for bleeding, perforation
and the development of pancreatitis or sepsis

NURSING ACTIONS




A percutaneous transheptic cholangiography (PTC) involves the direct injection of contrast into the biliary tract through the use of a flexible needle

The gallbladder and ducts can be visualized

DIAGNOSTIC PROCEDURE

PATIENT-CENTERED CARE




Administer analgesics PRN


Analgesics: Morphine sulfate and Hydromorphone (dilaudid) are preferred over meperidine (Demerol), which can cause seizures, especially in older adults

MEDICATIONS




Bile Acid: chenodiol (chenix), ursodiol (ursodeoxycholic acid)
Bile acid gradually dissolves cholesterol-based stones, with few adverse effects

Nursing consideration-Use caution in clients who have liver conditions or disorders

MEDICATIONS




Extracorporeal shock wave lithotripsy (ESWL)– shock wave are used to break up stones. This may be used more on nonsurgical candidates of normal weight who have small, cholesterol-based stones
Clients with acute cholecystitis will need cholecystectomy

THERAPEUTIC PROCEDURE



NURSING ACTIONS
Instruct and assist client to lay on fluid-filled bag for delivery of shock waves
Administer analgesia as prescribed
CLIENT EDUCATION
Inform the client that several procedures may be required to break up all stones


THERAPEUTIC PROCEDURE



Cholecystectomy-removal of the gallbladder with laparoscopic or open approach
The client usually is discharged within 24 hours if a laparoscopic approach is used
An open approach requires the client to be hospitalized for 2-3 days

SURGICAL INTERVENTIONS



Open Cholecystectomy surgery has been replaced by laparoscopic Cholecystectomy. As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after open Cholecystectomy. Both approaches allow for removal of the entire gallbladder and must be done under general anesthetic in an operating room

Laparoscopic Cholecystectomy




Laparoscopic approach- provide immediate postoperative care
Natural orifice transluminal endoscopic surgery (NOTES) –Surgery is performed through entry of mouth, vagina, or rectum.
This approach decreases the risk of complication for the client

NURSING ACTIONS



OPEN CHOLECYSTECTOMY
A T-TUBE MAY BE PLACED IN THE COMMON BiLE DUCT. THIS IS ONLY REQUIRED WHEN THERE IS EXPLORATION OF THE COMMON BILE DUCT INTRAOPERATIVELY
THE USE OF T-TUBES HAS SIGNIFICANTLY DECREASED DUE TO THE LAPARSCOPIC APPROACH

NURSING ACTIONS




Monitor and record drainage (initially bloody, then green-brown bile)
Expect more than 400ml of drainage in 24 hours initially, with gradual decrease in amount
Instruct client to report an absence of drainage with manifestations of nausea and pain (may indicate obstruction in the T-tube)

CARE OF THE T-TUBE




Inspect the surrounding skin for evidence of infection or bile leakage
Maintain flow by gravity and do not raise drainage bag above level of gallbladder
Empty the drainage bag every 8 hours
Assess stool for color (stools clay-colored until biliary flow is reestablished)

CARE OF THE T-TUBE




Clamp the tube 1 to 2 hours before and after meals to assess tolerance to food post cholecystectomy, and prior to removal
Monitor for bile peritonitis (pain, fever, jaundice)
Monitor and document response to food

CARE OF THE T-TUBE




Educate the client regarding pain control

Report indication of bile leak (pain, vomiting, abdominal distention) to the provider

Activates are often resumed in 1 week

CLIENT EDUCATION




Laparoscopic or NOTES approach
Ambulate frequently to minimize free air pain, common following laparoscopic surgery (under the right clavicle, shoulder, scapula)
Heat can be applied to the shoulder if the client has pain from migration of CO2
Monitor incision for evidence of infection or wound dehiscence (laparoscopic approach) could lead to intra-abdominal complications


CLIENT EDUCATION




Educate the client regarding pain control

Report indication of bile leak (pain, vomiting, abdominal distention) to the provider

Activates are often resumed in 1 week

CLIENT EDUCATION




Resume activity gradually. Avoid heavy lifting for 4 to 6 weeks
Report sudden increase in drainage, foul odor, pain,fever, or jaundice
The T-tube is usually left in 1 to 2 weeks postoperatively

OPEN APPROACH




Take showers instead of baths until T-tube is removed
Clamp T-tube 1 to 2 hours before and after meals to prepare for removal
The color of stools should return to brown in about a week, and diarrhea is common

OPEN APPROACH




Encourage a low-fat diet (reduce dairy products and avoid fried foods, chocolate, nuts, gravies)
Small, frequent meals may be more easily tolerated
Avoid gas-forming foods(beans, cabbage, cauliflower, broccoli)
Promote weight reduction
Take fat-soluble vit or bile salts to enhance absorption and aid with digestion


DIETARY COUNSELING

COMPLICATIONS




This can cause ischemia, gangrene, and a rapture of the gallbladder wall
A rupture of the gallbladder wall can cause a local abscess or peritonitis (rigid, board-like abdomen, guarding)
Will requires a surgical intervention and administration of broad spectrum antibiotics

OBSTRUCTION OF THE BILE DUCT




This can occur if adequate amount of bile are not drained from the surgical site
This is rare complication, but it may be fatal
NURSING ACTIONS
Monitor for pain, fever, and jaundice
Report to the provider immediately

BILE PERITONITIS




Manifestations of gallbladder disease can continue after surgery
Client will report pain and nausea just like before surgery
Manifestation can recur immediately or years later

POSTCHOLECYSTECTOMY SYNDROME (PCS)




Assess pain and report finding
Instruct client that further diagnostic evaluation may be necessary

NURSING ACTIONS

Glucagon- Hormone, made in islets of Langerhand, stimulates the conversion of glycogen to sugar. Given when C6 H12 O4 is low.

Somatostatin- Hormone, is made to inhibit the release of growth hormone.

Amylase- breaks down starches into carbohydrate WNL is 56-190

Trypsin-breaks down proteins

Lipase- breaks down fats WNL is 0-110

Insulin- made in islets of Langerhans and respons to increase levels of glucose in the blood
REVIEW OF ANATOMY & PHYSIOLOGY
Gallbladder- stores and secretes bile and emulsifies fats
http://education-portal.com/academy/lesson/carbohydrate-digestion-and-absorption-process-end-products.html#lesson
GALL STONES
PIGMENT STONES-SMALL AND DARK MADE OF BILIRUBIN AND CALCIUM SALTS AND ARE FOUND IN BILE. LESS THEN 20% CHOLESTEROL

CHOLESTEROL STONES-LIGHT YELLOW TO DARK GREEN OR BROWN AND OVAL, BETWEEN 2 AND 3 CM LONG EACH HAVING A DARK CENTRAL SPOT. MUST BE AT LEAST 80% CHOLESTEROL BY WEIGHT

Chronic


severe abdominal pains that may feel sharp or dull
•abdominal cramping and bloating
•pain that spreads to your back or below your right shoulder blade
•fever and chills
•nausea and vomiting
•loose, light-colored stools
•jaundice (when the skin and whites of your eyes turn yellow)
•itching

Acute

stool the color of clay
vomiting
nausea
fever
yellowing of the whites of the eyes and skin
attacks of pain, typically after a meal
chills
abdominal bloating



Physical Assessment Finding
Jaundice, clay-colored stools, steatorrhea (fatty stools), dark urine, and pruritus (accumulation of bile salts in the skin) in clients who have chronic cholecystitis (due to biliary obstruction)
Older adult clients who have diabetes mellitus may have atypical presentation of cholecystitis (absence of pain or fever)



ERCP involves the insertion of a tube into the pancreatic and common bile ducts during an endoscopy. the test is not performed if the client's bilirubin is greater than 5mg/dl
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