Risk Factors Continued
Acute Acalculous Cholecystitis
Prevalence, Incidence and Prognosis
Acute Calculous Cholecystitis
- Critical Illness
- Major Surgery
- Severe Trauma/Burns
- Sepsis
- Long term total parenteral nutrition (TPN) - reduces flow of bile, increased risk for gallstones
- Prolonged Fasting
- female predominance
- 1% mortality/morbidity rate
Other related causes:
- Cardiac events (ie. MI)
- Sickle Cell Disease
- Salmonella Infections
- Diabetes Mellitus
- Pts w/ AIDS who have cytomegalovirus/cryptosporidiosis/microsporidiosis
- Immunocompromised pts
- Crohn’s Disease (poor reabsorption of bile salts from digestive tract)
- Cirrhosis
- Organ Transplantation
- Tumors in the bile duct
- Parasites
- Metabolic syndrome (obesity, low HDL (good) cholesterol, high triglycerides, high BP, high blood sugar)
- Genetics
Acute Calculous Cholecystitis
Pathophysiology:
Acute Acalculous Cholecystitis
Pathophysiology:
Acute Calculous Cholecystitis
Cystic duct obstruction (due to gallstones or sludge)
- Gallstones
- Low fiber, high fat and high cholesterol diet
- Obesity
- Rapid weight loss
- Old Age
- Female
- Pregnancy
- Diabetes
- Family History and Genetics
- Certain Ethnicities - (Natives, Hispanics/Latins, Africans, Chinese, Northern Europeans)
- Certain Drugs (ie. Narcotic/Opiate abuse (Hashemzehi, Esmaili-Motlagh, Moodi, & Balali-Mood, 2008), hormonal therapy ie. estrogen), Octreotide (Sandostatin), fibrates (cholesterol-lowering drugs) and thiazide diuretics
Gallbladder distension
Compromised blood flow & lymphatic drainage
Increased pressure in gallbladder
retained concentrated bile (toxic)
↓
bile stasis
↓
increased bile lithogenicity (formation of calculi)
↓
increased bile viscosity
↓
decreased/absences of cholecystokinin-induced gallbladder contraction
↓
gallbladder cannot empty
↓
gallbladder wall ischemia
↓
inflammation
↓
Necrosis
Mucosal ischemia
Inflammation
Necrosis
Etiology
Acute Calculous Cholecystitis
Acute Acalculous Cholecystitis
- Gallbladder stasis resulting in stagnant bile usually seen in critically ill
- No evidence of gallstones or cystic duct obstruction
Prevalence, Incidence and Prognosis
Acute Cholecystitis
Acute Acalculous Cholecystitis
- slightly higher in men
- 10-50% mortality rate
ACUTE CHOLECYSTITIS
By: John Paul Ilano and Meryl Pineda
Acute Cholecystitis
Complications
Manifestations of
Acute Cholecystitis
Both:
Lifespan Considerations
Symptom:
Acute Cholecystitis
Nursing Interventions/Teachings:
PAIN
- Extrabiliary abscess
- Biliary cirrhosis
- Fistulas
- Empyema (pus in gallbladder)
- Peritonitis
- Gangrenous cholecystitis (Gallbladder wall gangrene)
- Gallbladder Perforation
- Rupture of gallbladder
- Emphysematous cholecystitis (Gallbladder infection by gas- forming organisms)
- Cholangitis (bile duct inflammation)
Calculous:
- Small intestine blockage (abdomindal pain and bloating)
- Jaundice (common bile duct blockage → cholestasis)
- Pancreatitis
Older adults:
- symptoms: vague (loss of appetite, fatigue, vomit, may not develop fever)
- risk factors: 60 yrs and older with Crohn’s Disease
Children:
- risk factors: (spinal injury, history of abdominal surgery, sickle-cell anemia, impaired immune system, IV nutrition)
P (provokes): sharp pain when RUQ is pressed on, Breathing deeply may worsen the pain
Q (quality): sharp cramping or dull pain
R (Radiates): radiating to shoulder, scapula, epigastric region, right upper quadrant of abdomen(RUQ)
S (severity): subjective to pt. but usually excruciating
T (Time): Lasting more than 6-12 hrs, peaks at 15-60 mins then remains constant
- Pre-op:
- NPO, IV fluid and electrolyte therapy
- Patient teaching about process of cholecystectomy
- Answer questions to reduce anxiety
- Post-op:
- Monitoring for complications (e.g. bleeding)
- Monitoring VS
- Encourage walking and turning while in bed
- Encourage ROM and ambulation
- Encourage deep breathing, maintain adequate ventilation
- Maintain skin integrity
- Monitor for orientation, alertness, confusion/delirium
- Ensuring patient comfort (e.g. pain-free, PRN morphine administration, PRN antiemetics)
- Preparing patient for discharge
- Nutritional:
- liquids for the rest of the day and eat light meals for a few days
Assessment
Acute Cholecystitis
Manifestations of
Acute Cholecystitis
Acute Cholecystitis
Nursing Teachings:
Conservative Treatment of Acute Cholecystitis
Acute Cholecystitis Drug Therapy
- Obtain client’s height, weight, sex, age, race and ethnic group
- Food preferences, diet
- Allergies
- Take vital signs and perform proper head to toe assessment
- Daily activity or exercise routines (sedentary lifestyle)
- Medication history
- Identify pt concerns
- Teach:
- Education about anesthesia and postoperative care and process of cholecystectomy
- Walk, cough, deep breathing after surgery
- To avoid fatty foods and fluids
- Discuss healthy diet (fresh fruits, vegetables, whole grains
- Home care: (go home same day as surgery)
- Bandages come off the day after surgery
- Notify surgeon if there is; redness, swelling, bile-coloured drainage or pus from any incision, severe abdominal pain, nausea, vomiting, fever, chills
- Resume normal activities gradually
- Return to work within 1 week of surgery if no complications
- Resume normal diet; a low fat diet better tolerated for several weeks after surgery
- Keep NPO
- Focus is control on pain with pain relievers/analgesics
- Control of possible infection with Antibiotics
- Maintenance of fluid and electrolyte balance
- If nausea and vomiting are severe, NG tube, low suction, and gastric decompression
- Anticholinergics are administered to decrease secretion and counteract smooth muscle spasms
Common Signs:
- Nausea and Vomiting
- Fever w/ High WBC (leukocyte) count
- Tachycardia
- Abdominal tenderness in Right Upper Quadrant or epigastric region
- Abdominal Rigidity
- Indigestion
- Chills
- Diaphoresis
Uncommon Signs:
- Palpable gallbladder
- Jaundice - yellowing of skin and whites of the eyes
Diagnosis
Acute Cholecystitis
Antiemetics: to reduce nausea and vomiting and prevent fluid and electrolyte imbalances (Promethazine, Prochlorperazine)
Anticholinergics or Antispasmodics: to relax smooth muscle and decrease ductal tone (Atropine)
Fat soluble vitamins: A, D,E and K
Diagnostic Testing
Acute Cholecystitis
- Analgesics: to reduce pain and fever manifestations (Meperidine, Hydrocodone & Acetaminophen, Oxycodone & Acetaminophen)
- Antibiotics: to prevent bacterial infections
- Non-life threatening: Ampicillin/Sulbactam, Piperacillin/Tazobactam.
- Life threatening: Meropenem, Imipenem/Cilastatin.
- Alternatives: Combo of Metronidazole with a 3rd gen. Cephalosporin, ciprofloxacin, or aztreonam.
References
Invasive/Surgical Treatment of Acute Cholecystitis
- Blood tests (CBC, Bilirubin, Amylase and lipase)
- Past medical history and physical examination
- Liver enzyme measurements
- WBC count
- Serum bilirubin measurement
- Ultrasonography
- Higher rate of accurate diagnosis can be achieved using a triad of positive Murphy sign, elevated neutrophil count and an ultrasound showing cholelithiasis or cholecystitis (Hwang, marsh, & Doyle, 2014).
- 24-48 hours cholecystectomy
- Laparoscopic cholecystectomy (replaced open): should be done immediately after diagnosis because delaying surgery allows inflammation to become more intense, resulting in increased difficulty of the operation (Rattner, Ferguson, & Warshaw, 1993).
- Open cholecystectomy (if lap. choly. fails; associated with greater postoperative complications (pain and infection and incisional hernia)
- Abdominal Computed tomography (CT)
- detects complications of cholecystitis (e.g. pancreatitis or a tear in the gallbladder)
- Abdominal x-ray
- Oral cholecystogram
- Gallbladder radionuclide scan
- Endoscopic retrograde cholangiopancreatography (ERCP)
Hashemzehi, M., Esmaili-Motlagh M., Moodi, M., & Balali-Mood, M. (2008). Narcotic drug abuse and other risk factors in 100 operated patients for acute cholecystitis. Saudi Med, 29(5), 698-702. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18454217
Hwang, H., Marsh, I., & Doyle, J. (2014). Does ultrasonography accurately diagnose acute cholecystitis? Improving diagnostic accuracy based on a review at a regional hospital. Canadian Journl of Surgery, 57(3), 162-168. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035397/
Lewis, S., Heitkemper, M., Dirksen, S., Bucher, L., & Camera, I. (2014). Medical-Surgical nursing in Canada: Assessment and management of clinical problems. Toronto ON: Elsevier Mosby.
Rattner, D.W., Ferguson, C., & Warshaw A.L. (1993). Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis. Annals of Surgery 217(30), 233-236. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1242774/pdf/annsurg00073-0047.pdf
- Indications for surgery:
- acute cholecystitis confirmed and risk of surgery is small
- older adults, people with diabetes (higher risk for infections due to cholecystitis)
- suspected complication of abscess, gangrene, perforation
- acalculous cholecystitis
Diagnostic Testing
Acute Cholecystitis
Invasive/Surgical Treatment of Acute Cholecystitis
ACALCULOUS-SPECIFIC:
- abdominal ultrasonography (BEST WAY)
- detects fluid around gallbladder
- thickened wall
Acute Cholecystitis
Prevention:
- Can do calculous treatments
- Cholescintigraphy (useful when doctors suspect acute acalculous)
- Blood tests (liver function tests)
- cannot confirm diagnosis (results look normal or only slightly high unless bile duct blocked)
However.....
Endoscopic Gallbladder Stent Placement
- Blood tests (WBCs)
- increased WBCs indicate inflammation, abscess, gangrene, or perforation
- If high-risk surgical candidates (ie. end-stage liver disease) endoscopic gallbladder stent placement used as an effective palliative treatment. This involves placement of a double pigtail stent between the gallbladder and the duodenum during endoscopic retrograde cholangiopancreatography (ERCP)
- Maintain a Healthy diet - rich in fiber low in fat
- Do not skip meals
- If obese/overweight adopt a healthy regular exercise regime to lose weight
- Consuming Vitamin C - to help breakdown cholesterol in the bile
Abdominal CT Scan