11/10/2022

Lecture #5
First semester

cholecystitis and cholelithiasis

:by
lecturer
Dr. Sadiq Salam H. AL-Salih

Al-Mustaqbal University College

Nursing Department
2nd Class
Adult Nursing

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Cholecystitis
Definition:
It is inflammation of the gallbladder (may be acute or chronic).
1. Acute cholecystitis is an acute infection of the gallbladder .
➢calculus cholecystitis most cases are caused by gallstone obstruction of the
cystic duct, causing edema, inflammation, and bacterial invasion.
➢A calculus cholecystitis is acute gallbladder inflammation in the absence of
obstruction by gallstones.

2. Chronic cholecystitis occurs when the gallbladder becomes thickened, rigid,

and fibrotic and functions poorly .
➢Results from repeated attacks of cholecystitis, presence of calculi, or
chronic irritation.

Incidence & Risk Factors

➢ Acute cholecystitis can affect any age group.
➢ Chronic cholecystitis primarily affects middle aged and obese older
women.
➢ Incidence of chronic cholecystitis has a female to male ratio of 4:1.
➢ A higher incidence of cholecystitis is seen among individuals with a
sedentary life style.

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In acute cholecystitis the risk factors are following:

1. Gall stone.
2. Sepsis due to invasion by bacteria (usually Escherichia coli, salmonella or
streptococcus) via lymphatic or vascular route.
3. Multiple child birth.
4. Prolonged dehydration.
5. Prolonged immobility.
In chronic cholecystitis the risk factors are following:
1. Cholelithiasis.
2. Obesity.
3. Acute cholecystitis

Cholelithiasis
Definition:
Is the presence of stones in the gallbladder. Gallstone formation takes
place in the gallbladder, the common bile duct, and the duodenum.
Types of gallstones:
a.Cholesterol gallstones contain at least 50% cholesterol by
weight.
b.Pigmented gallstones are made up of bile pigments and are
caused by increased production and execration of bilirubin or
stasis of bile such as cirrhosis, hemolysis, and infection of the
biliary tree.

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Risk Factors:
a.Women are 4 times risk more than men to develop cholesterol
stones, usually above 40 & obese,
(4 F's: female, fatty, fertile, forty).
a.The incidence of stone formation rises in users of oral
contraceptives, estrogen.
b.The incidence increases with age as a result of increased hepatic
secretion of cholesterol and decreased bile acid synthesis.
c. People with diabetes.

Pathophysiology

Stones occur when cholesterol

supersaturates the bile in the
gallbladder and precipitates
out of the bile. The
cholesterol-saturated bile
predisposes to the formation of
gallstones and acts as an
irritant, producing
inflammatory changes in the
gallbladder .

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Clinical Manifestations
1. Biliary colic can be caused by the presence of gallstones .
a) Steady, severe aching pain or sensation of pressure in the epigastrium or right upper
quadrant, which may radiate to the right scapular area or right shoulder.
b) Epigastric distress as fullness and abdominal distention epically after a fatty meal.
c) Begins suddenly and persists for 1 to 3 hours until the stone falls back into the gallbladder
or is passed through the cystic duct .
2. Acute cholecystitis causes biliary colic pain that persists more than 4 hours and increases
with movement, including respirations .

Cont.
a) Also causes nausea and vomiting, low-grade fever, and jaundice (with stones or
inflammation in the common bile duct.(
b) Right upper quadrant guarding and Murphy’s sign (inability to take a deep inspiration
when examiner’s fingers are pressed below the hepatic margin) are present .
3 - Chronic cholecystitis causes
a. Heartburn, flatulence, and eructation because of gas accumulation resulting from
impaired fat digestion
b.Jaundice from obstruction of the common bile duct, the bile is absorbed by the
blood and gives the skin and mucous membrane a yellow color causing marked
itching.
c. Clay colored stools.
d. Steattorrhea ( presence of fat in the stool)

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Diagnostic Evaluation
1.Oral cholecystography, ultrasonography,
may visualize stones or inflammation .
2.ERCP (Endoscopic retrograde
Cholangiopancreatography)to visualize location of stones and
obstruction .
3.Elevated conjugated bilirubin due to obstruction .

Clinical Management

B- Non Pharmacological interventions:

1.A low fat diet to decrease stimulation of the gall bladder.
2.Weight reduction, including prescribed diet and exercise program.
3.Intravenous fluids for patient given nothing per mouth.
4.Monitoring of serum bilirubin.
5.Assessment of abdominal guarding and rigidity two reliable
indicators of peritoneal irritation.

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C- Pharmacological Interventions
a.Anticholinergics such as propantheline bromide( Pro-
Banthine) to relax smooth muscles and prevent Biliary
contraction.
b.Narcotic analgesics such as Mepridine to relive and decrease
incidence of spasms.
c.Antiemetics to provide relief from nausea and vomiting.
d.chenodeoxycholic acid (CDCA), ursodeoxycholic acid
(Actigall), to decrease the size of existing cholesterol stones or
dissolve small ones .

D- Surgical management
a. Cholecystectomy, open or laparoscopic .
b. Intraoperative cholangiography and choledochoscopy for common bile duct
exploration .
c. Placement of a T-tube in the common bile duct to decompress the biliary
tree and allow access into the biliary tree postoperatively.
d. Extracorporeal shock wave lithotripsy; is a non invasive procedure that
use high energy or high pressure sound waves to break gall stones into small
fragments so that they can pas through the common bile duct into the
duodenum

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Complications
1)Cholangitis
2)Necrosis, empyema, or perforation of the gallbladder
3)Biliary fistula through the duodenum
4)Gallstone ileus
5)Adenocarcinoma of the gallbladder

Nursing Assessment
1)Obtain history and demographic data that may indicate risk factors
for biliary disease.
2)Assess patient’s pain for location, description, intensity, relieving
and exacerbating factors.
3) Assess for signs of dehydration: dry mucous membranes, poor
skin turgor, and low urine output with elevated specific gravity .
4) Monitor temperature and white blood count for indications of
infection or perforation.

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Nursing Diagnosis
A. Pain related to biliary colic or stone obstruction.
B. Fluid Volume Deficit related to nausea and vomiting and
decreased intake.

Nursing Interventions
A.Relieving Pain
1. Assess pain location, severity, and characteristics.
2. Administer medications or monitor patient-controlled analgesia
to control pain .
3. Assist in attaining position of comfort; maintain bed rest during
acute illness .

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B. Restoring Normal Fluid Volume

1. Administer IV fluids and electrolytes as prescribed .
2. Administer antiemetics as prescribed to decrease nausea
and vomiting .
3. Maintain nasogastric decompression until nausea and
vomiting subside .
4. Begin food and fluids as tolerated, after acute symptoms
subside or postoperatively .
5. Observe and record amount of T-tube drainage, if
applicable .

Evaluation

A. Patient verbalizes reduced pain level

B. Tolerating oral fluids, urine output adequate

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Thanks
For Listening

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