CHOLECYSTITIS
Cholecystitis is the inflammation of the gall bladder, may be acute or chronic.
Incidence Client's who are overweigly, especially those with sedentary lifestyles/and certain ethnic groups/including Chinese, Jews/Italians have a higher rate of the disease
Causes
- Gallstone obstruction.
- Kinking or twisting of bile ducts.
- Conditions that alter GB's ability to fill or empty trauma, reduced blood supply to the GB/prolonged immobility, chronic dieting, adhesions, prolonged anesthesia and narcotic abuse.
- Risk Factors: Obesity, sedentary life styles, ethnic groups Chinese, Jews and Italians, clients with cholelithiasis and diabetes at the same time
Pathophysiology
Gallstone obstruction
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Acute cholecystitis
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2ยบ bacterial infection may occur and progress to empyema (purulent effusion of the GB)
Repeated attacks of cholecystitis, calculi or chronic irritation
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Chronic cholecystitis
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GB becomes thickened, rigid and fibrotic and functions poorly.
Clinical Manifestations
- Acute cholecystitis Biliary colic pain persists > 4 hours and increases with movement, including respirations!
- Nausea, vomiting, low-grade fever and jaundice [(with stones or inflammation in the common bile duct)].
- Right upper quadrant guarding and Murphy's sign (inability to take a deep inspiration when examiner's fingers are pressed below the hepatic margin) [when palpating the right subcostal area, ask client to take a deep breath, then the client experiences extreme tenderness and stops brerthing on inspiration].
- Chronic cholecystitis heart burn, flatulence and indigestion. Repeated attacks of symptoms-resemble acute cholecystitis.
Diagnostic Evaluation
- History, physical examination [sudden onset of right upper quadrant tenderness, fever and leucocytosis-highly suggestive acute cholecystitis).
- Biochemistry slight elevation in Serum bilirubin. amino-transferase and alkaline phosphate.
- USG scan - Biliary unltrasonography, Cholelithiasis, Focal tenderness Over GB
- Thickening of GB wall (>3cm)
- Distension of GB lumen (> 5 cm)
- Oral cholecystography
- Hepatobiliary (HIDA) scan may visualize stones or inflammation [ERCP or PTC-visualize location of stones and obstruction].
- Elevated conjugated bilirubin because of obstruction.
Medical Management
Supportive management with IVF, NG suction persistent vomiting is present, pain management morphine, pentazocine and diclofenac and antibiotics against organisms found in bile. Eg. Cephalosporin D.O.C.
Surgical Management
Cholecystectomy open or closed (laparoscopic approach)
Complications
Empyema in the GB hydrops or mucocele, gangrene. Gangrene may lead to perforation resulting in peritonitis, fistula formation, pancreatitis, limy bile and porcelain GB. Other complication-chronic cholecystitis and cholangitis
Nursing Management
1. Administer pain medications as ordered eg. Meperidine - DOC
2. Assess pain location severity and characteristics.
3. Assist is attaining a comfortable position.
4. If vomiting continues, NG decompression to relieve distension and vomiting
5. Administer IVF and e as prescribed.
6. Administer antiemetics as prescribed - decrease nausea and vomiting.
7. Provide a low-fat diet and smaller more frequent meals to help prevent attacks of biliary colic.
8. After surgery:
- be alert for signs of bleeding, infection or atelectasis. [Evaluate the incision site for bleeding]. Serosanguineous and bile drainage is common during the 1" 24-48 hours if patient has a wound drain.
- Monitor I/O
- Monitor NG tube drainage for colour, amount ad consistency.
- When peristalsis resumes, remove the NG tube and begin a clear liquid diet.
- Encourage leg exercises every hour.
- Encourage coughing and deep breathing every hour.
- Provide elastic stockings to support leg muscles and promote venous blood flow, thus preventing stasis and clot formation. Check for positive Homan's sign. (Pain on dorsiflexion of the ankle) or calf tenderness signs of phlebitis and thrombophlebitis.
- Evaluate location, duration and character of any pain.
- Explain the procedures that will be performed before, during and after surgery
- Advise the patient against heavy lifting or straining for 6 weeks.
