What is cholecystitis? 

Cholecystitis is a medical condition characterized by inflammation of the gallbladder. The gallbladder is a small organ located beneath the liver, and its primary function is to store bile produced by the liver. Bile aids in the digestion of fats in the small intestine.

Cholecystitis typically occurs when bile becomes trapped in the gallbladder, leading to irritation and inflammation of the gallbladder wall.

This obstruction is commonly caused by gallstones, which are solid deposits that form within the gallbladder. When gallstones block the flow of bile, the gallbladder becomes swollen and inflamed, resulting in cholecystitis.

Causes of cholecystitis

Gallstones or Biliary Sludge Obstruction

• Normally blockage of the cystic duct by gallstones or biliary sludge can impede the flow of bile from the gallbladder, leading to inflammation and irritation of the gallbladder wall.

Trauma, Extensive Burns, or Recent Surgery

• Physical trauma to the abdomen, extensive burns, or recent surgical procedures in the abdominal area can contribute to the development of cholecystitis by disrupting the normal function of the gallbladder.

Prolonged Total Parenteral Nutrition and Diabetes Mellitus

• Extended periods of total parenteral nutrition (TPN), as well as conditions such as diabetes mellitus, can predispose individuals to cholecystitis due to alterations in bile composition and motility.

Bacterial Infection

• Bacteria may enter the gallbladder through the bloodstream or lymphatic system, causing infection and subsequent inflammation of the gallbladder, a condition known as acute acalculous cholecystitis.

Chemical Irritants in the Bile

• Exposure to certain chemical irritants within the bile, such as bile acids or cholesterol, can irritate the gallbladder lining and trigger an inflammatory response.

Adhesions, Neoplasms, Anesthesia, and Narcotics

• Adhesions (scar tissue), neoplastic growths, anesthesia administration, and narcotic medications can all contribute to cholecystitis by impairing gallbladder function or causing mechanical obstruction of the bile ducts.

Inadequate blood supply

• Insufficient blood flow to the gallbladder, often due to vascular disorders or ischemic conditions, can lead to tissue damage and inflammation, contributing to the development of cholecystitis.

Causative Organisms (Bacterial Causes of Acute Cholecystitis)

Escherichia coli (E. coli)

• Escherichia coli is the most common bacterium associated with acute cholecystitis. It can enter the gallbladder through the bloodstream or via ascending infection from the gastrointestinal tract, leading to inflammation and infection.

Streptococci

• Streptococci bacteria, including various species such as Streptococcus viridans, may also play a role in causing acute cholecystitis. These organisms can enter the gallbladder and provoke an inflammatory response, contributing to the development of the condition.

Salmonella

• Salmonella bacteria, particularly certain serotypes such as Salmonella typhi and Salmonella paratyphi, have been implicated in cases of acute cholecystitis. Infection with Salmonella can result in gallbladder inflammation and subsequent clinical manifestations of cholecystitis.

Signs and Symptoms

Episodic or Vague Pain in the Right Upper Quadrant (RUQ) of the Abdomen:

• Patients with cholecystitis often experience recurrent or intermittent pain in the RUQ of the abdomen, which may radiate to the right shoulder. This pain is typically triggered or worsened by consuming high-fat or high-volume meals.

Anorexia:

• Patients with cholecystitis may exhibit a decreased appetite or aversion to food, leading to reduced intake or avoidance of meals.

Nausea and vomiting

• Nausea and vomiting are common symptoms associated with cholecystitis. Patients may experience feelings of queasiness or discomfort in the stomach, followed by episodes of vomiting.

Dyspepsia

• Dyspepsia, or indigestion, may occur in individuals with cholecystitis, manifesting as symptoms such as bloating, discomfort, or a sensation of fullness in the upper abdomen.

Mild to Moderate Fever

• Cholecystitis can lead to a mild to moderate elevation in body temperature, often accompanied by symptoms of fever such as chills or sweating.

Acute Abdominal Tenderness and Positive Murphy’s Sign

• A physical examination of the abdomen may reveal acute tenderness upon palpation of the RUQ, with the presence of a positive Murphy’s sign. This sign is characterized by a sudden increase in pain and temporary respiratory arrest when pressure is applied to the gallbladder area.

Nocturnal Pain

• Patients with cholecystitis may experience exacerbations of pain during the night, disrupting sleep and causing discomfort.

Jaundice

• In some cases, cholecystitis may lead to the development of jaundice, characterized by yellowing of the skin and sclera due to elevated levels of bilirubin in the bloodstream.

Clay-Colored Stool

• Cholecystitis can interfere with normal bile flow, resulting in pale or clay-colored stools. This change in stool coloration may be indicative of bile duct obstruction or dysfunction.

Medical Management

History

1. Presenting Symptoms: Ask about symptoms such as right upper quadrant abdominal pain, nausea, vomiting, anorexia, dyspepsia, fever, and jaundice.
2. Timing of Symptoms: Determine the onset, duration, frequency, and exacerbating factors of symptoms, including whether pain is associated with meals or occurs at night.
3. Medical History: Ask about any history of gallstones, biliary tract disorders, recent trauma or surgery, diabetes mellitus, or other relevant medical conditions.
4. Dietary Habits: Assess dietary patterns, particularly intake of high-fat or high-volume meals, which may exacerbate symptoms.
5. Medication History: Ask about the use of medications, especially lipid-lowering drugs or medications affecting bile composition.
6. Family History: Ask about a family history of gallstones or cholecystitis, as it may indicate a genetic predisposition.

Physical Examination

Abdominal Examination

• Palpate the abdomen for tenderness, focusing on the right upper quadrant (RUQ), where the gallbladder is located.
• Perform Murphy’s sign by palpating deeply in the RUQ while the patient takes a deep breath. Note any abrupt cessation of inspiration due to pain.
• Assess for guarding, rebound tenderness, or palpable masses suggestive of acute abdominal pathology.

Vital Signs

• Measure the temperature to evaluate for fever, which may indicate an inflammatory process.
• Assess heart rate and blood pressure, as well as respiratory rate, for signs of systemic involvement or complications.

Jaundice

• Inspect the skin and sclera for evidence of jaundice, characterized by yellow discoloration.

Other Signs

• Look for signs of dehydration, such as dry mucous membranes or poor skin turgor.
• Assess for pallor, diaphoresis, or signs of distress, which may indicate severe pain or complications.

Nocturnal Symptoms:

• Inquire about nocturnal pain or disturbances in sleep due to abdominal discomfort.

Investigations for cholecystitis:

Blood Tests

• Complete Blood Count (CBC): Assess for leukocytosis, which may indicate inflammation or infection.
• Liver Function Tests (LFTs): Measure levels of liver enzymes (e.g., alanine aminotransferase, aspartate aminotransferase) and bilirubin to evaluate liver function and detect biliary obstruction.
• Serum Amylase and Lipase: Evaluate pancreatic enzymes to rule out pancreatitis, a potential complication of cholecystitis.

Imaging Studies

• Abdominal ultrasound: This non-invasive imaging modality is the primary investigation for cholecystitis. It assesses gallbladder size, wall thickness, and the presence of gallstones or biliary sludge. Ultrasound can also detect complications such as gallbladder distension or pericholecystic fluid.
• Computed Tomography (CT) Scan: CT imaging may be performed to evaluate for complications such as perforation, abscess formation, or associated conditions like pancreatitis.
• Magnetic Resonance Cholangiopancreatography (MRCP): MRCP provides detailed images of the biliary tree and pancreatic ducts, aiding in the diagnosis of biliary obstruction or gallstone-related complications.

Hepatobiliary Scintigraphy (HIDA Scan)

• A HIDA scan involves the injection of a radioactive tracer that is taken up by hepatocytes and excreted into the bile. It evaluates gallbladder function and biliary patency, assisting in the diagnosis of acute cholecystitis or biliary dyskinesia.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

• ERCP may be performed in select cases to visualize the biliary tree and assess for biliary obstruction or gallstone-related complications. It also allows for therapeutic interventions such as stone extraction or stent placement.

Peritoneal Fluid Analysis

• If there is suspicion of gallbladder perforation or associated peritonitis, analysis of peritoneal fluid obtained via paracentesis may reveal signs of infection (e.g., elevated white blood cell count, culture positivity).

Other Tests

• In some cases, additional tests such as abdominal X-rays or upper gastrointestinal endoscopy may be indicated to evaluate for alternative diagnoses or associated conditions.

Medical Treatment

Anti-spasmodics

• Medications like atropine or probanthine may be prescribed to relieve smooth muscle spasms in the biliary tract, helping to alleviate pain associated with cholecystitis.

Intravenous (IV) Fluids

• IV fluids are administered to maintain hydration and electrolyte balance, especially in cases of vomiting or dehydration secondary to nausea and decreased oral intake.

Antibiotics

• Antibiotics are prescribed to treat bacterial infections associated with acute cholecystitis. Commonly used antibiotics include ampicillin or co-trimoxazole (Septrin), targeting gram-negative and anaerobic organisms.

Analgesia

• Pain management is essential in cholecystitis. Analgesic medications such as pethidine (meperidine) 100 mg may be given to alleviate severe pain and discomfort experienced by the patient.

Surgical Management

Cholecystectomy

• Surgery is indicated when medical treatment fails to resolve symptoms or in cases of recurrent cholecystitis. Cholecystectomy involves the surgical removal of the gallbladder, either through open surgery or laparoscopic techniques.
• This procedure aims to prevent further episodes of cholecystitis and associated complications.

Nursing Management

Aims

1. Pain Management: ensure the patient’s comfort by administering prescribed pain relief medications, applying heat therapy to the affected area, and implementing non-pharmacological pain management techniques.
2. Infection Control: Implement measures to prevent and manage infection, including strict adherence to aseptic techniques during procedures, proper wound care, and administering antibiotics as prescribed.
3. Patient Education: Provide a comprehensive education to the patient and their family about the condition, treatment options, dietary modifications, and signs of complications. Empowering the patient with knowledge can improve adherence to treatment and promote better outcomes.

Patient Assessment

• Conduct thorough physical assessments, including vital signs, pain assessment, abdominal examination, and monitoring for signs of complications. Assess the patient’s medical history, including any previous episodes of cholecystitis, comorbidities, and surgical history.

Observation

Pain Management

• When a patient experiences biliary colic, it’s essential to provide immediate relief. The patient should remain in bed, and if feasible, pethidine should be administered to alleviate the pain.
• In cases where pethidine is not available or feasible, antispasmodic medications like atropine, propantheline, or nitroglycerin can be administered.
• Morphine may also be considered to alleviate the painful reflex spasms triggered by the presence of a stone in a duct.
• In addition, local applications of heat to the upper abdomen can be applied to help ease discomfort.

Fluid and electrolyte balance

• Monitor fluid intake and output closely to ensure adequate hydration. Administer IV fluids as prescribed to maintain hydration and electrolyte balance.
• Monitor serum electrolyte levels and report any abnormalities promptly.

Nutritional Support

• During an episode of biliary colic, it’s crucial to withhold oral intake and instead administer prescribed intravenous fluids to maintain hydration.
• If vomiting and abdominal distention occur, a nasogastric tube may be inserted for suctioning to decompress the stomach. Local applications of heat to the upper abdomen may also be recommended for comfort.
• Following the acute episode and removal of the nasogastric tube, clear fluids are gradually introduced and advanced to a light, low-fat diet as tolerated.
• In addition, patients may receive a replacement of fat-soluble vitamins to support nutrition. Bile salts can be administered to facilitate digestion and the absorption of vitamins.
• For overweight patients, weight reduction strategies should be considered, along with adherence to a low-fat diet.
• Certain foods should be avoided, including dairy products such as whole milk, ice cream, and cheese, as well as fried foods, gravies, and nuts.

Psychological Support

• Provide emotional support and reassurance to alleviate anxiety and distress related to the diagnosis and treatment.
• Educate the patient about the condition, treatment options, and self-care strategies to promote empowerment and coping.

Hygiene and Comfort

• Assist with personal hygiene activities such as bathing and oral care to promote comfort and prevent infection.
• Ensure that a clean and comfortable environment for the patient, including clean linens and adequate ventilation by opening up near by windows.

Mobility and Activity

• Encourage early ambulation and movement within the patient’s tolerance level to prevent complications such as atelectasis or venous thromboembolism.
• Make sure provide support and assistance with mobility as needed, including the use of assistive devices or ambulation aids.

Medication Administration

• Administer prescribed medications accurately and on schedule, including antibiotics, anti-spasmodics, and analgesics. Monitor for potential adverse effects of medications and report any concerns to the healthcare provider.

Education and Discharge Planning

• Provide thorough education to the patient and family about the condition, treatment plan, and signs of complications to watch for at home.
• Collaborate with the healthcare team to develop a comprehensive discharge plan, including follow-up appointments, dietary recommendations, and activity restrictions.

Complications of Cholecystitis

1. Perforation: This refers to the rupture of the gallbladder, which can lead to the leakage of bile and other contents into the abdominal cavity, causing severe pain and inflammation.
2. Gallstones: Cholecystitis can exacerbate the formation and presence of gallstones, further obstructing the bile ducts and worsening symptoms.
3. Cholangitis: Infection may spread along the bile ducts, resulting in cholangitis. This condition is characterized by inflammation of the bile ducts, leading to symptoms such as jaundice and abdominal pain.
4. Empyema: Cholecystitis can lead to the accumulation of pus within the gallbladder, resulting in a condition known as empyema. This can cause severe pain and increase the risk of complications.
5. Gangrene: Severe cases of cholecystitis may result in tissue death (gangrene) of the gallbladder, which requires urgent medical intervention to prevent further complications.
6. Pancreatitis: Inflammation of the pancreas may occur as a complication of cholecystitis, leading to abdominal pain, nausea, and vomiting.
7. Peritonitis: Cholecystitis can cause inflammation of the lining of the abdomen (peritonitis), which may result in severe abdominal pain, tenderness, and fever. Prompt medical treatment is essential to prevent complications and ensure recovery.

Read more: Medical-Surgical Nursing

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