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Risk Factors

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

Risk Factors

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

Etiology

Acute Calculous Cholecystitis

Acute Acalculous Cholecystitis

  • Gallstones
  • Biliary Sludge
  • 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

Two Types:

  • Calculous
  • Acalculous
  • 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

Acalculous:

  • Death

  • 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

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