03.02 Nursing Care and Pathophysiology for Cholecystitis
Pathophysiology: Inflammation of the gallbladder. The gallbladder holds bile, that is released into the small intestine. When the bile duct between the gallbladder and small intestine is blocked, the bile becomes trapped and causes the inflammation.
- Acute or chronic inflammation of the gallbladder.
- Cholelithiasis (gallstones)
- Duct obstruction
- Gallbladder stores and secretes bile into the duodenum to aid in digestion of fats
- Uncorrected can lead to liver damage
- RUQ pain
- Occurs 2-4 hours after high fat meals
- Lasts 1-3 hours
- Murphy’s Sign
- Pain with expiration while examiners hand is placed below the costal margin on right side at midclavicular line.
- Patient then asked to inspire if patient is unable to inspire due to pain, test is positive.
- Rebound tenderness over RUQ
- Decrease GB stimulation
- Nasogastric decompression
- Avoid gas forming foods
- Removal of gallbladder
- Monitor for pain and infection at incision site
- Abdominal splinting when coughing
- Clear liquids post-op, advance as tolerated/ordered
- T-tube drainage
- Maintain patency of duct
- High Fowler’s position
- Report drainage >500mL
- GI/Liver Metabolism
- Avoid high-fat foods
- May experience loose stools
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In this lesson we’re going to talk about Cholecystitis. Let’s break down this word. We know that -itis means inflammation. In the GU section I mentioned that Cysto always means some sort of bladder, and any time you see chole, you’re gonna think gallbladder.
So cholecystitis is inflammation of the gallbladder. Remember from anatomy that the purpose of the gallbladder is to store and secrete bile into the duodenum. Bile, specifically, helps in the digestion of fats. Patients with cholecystitis are going to have difficulty digesting and processing high fat meals. The most common cause is gallstones or cholelithiasis, which is crystallized bile salts. You can see here in this ultrasound that there’s thickening around the outside, that’s the inflammation, and there are little stones on the inside. These stones cause a lot of irritation and can even block the bile duct. There’s also a couple of autoimmune conditions that can cause recurrent cholecystitis. So, it can be acute or chronic depending on the cause.
Patients will report nausea and vomiting, but those are pretty general symptoms, right? So it’s important that we get more details. We’ll see that they have severe right upper quadrant pain. It tends to be worse about 2-4 hours after a high fat meal – that’s about when the food is making its way through the duodenum. And the pain will last for a few hours. So when we’re doing our initial assessment, we have to do a full detailed pain assessment. When did it start, how long does it last, was it associated with anything like eating? All of these questions help us to get a bigger picture so we can know what we’re looking at. We’ll also see something called Murphy’s sign. This is specific to gallbladder and liver damage, so it again helps us to know what we’re dealing with. What you’ll do is press your hand or fingers up under their ribs on the right upper quadrant and ask them to take a deep breath. If the pain is so bad that they can’t even breathe in fully, that’s a positive murphy’s sign. And lastly, we also see rebound tenderness. If you remember from the appendicitis lesson, this is when you press on their right upper quadrant and then release and the pain is actually worse with the release than with the initial pressure.
So how do we manage cholecystitis? Well the first thing we want to do is decrease the amount of gallbladder stimulation. There’s a couple things we can do. One is make the patient NPO – if no food is coming in, then we won’t be stimulating it. But also, we can place an NG tube to decompress the stomach – this means that not even stomach acid will be making its way into the duodenum so now there’s very very little stimulation of the gallbladder. If they ARE eating, we encourage low-fat, non-gas-forming foods. We’ll also give analgesics and antiemetics for their symptoms. Ultimately, the most common course of treatment for cholecystitis, especially acute cholecystitis, is a cholecystectomy – or removal of the gallbladder altogether. Since the liver is where the bile is MADE, they’ll still be able to secrete bile, except it won’t be well regulated, it will just kind of constantly drip into the duodenum. So patients still need to eat low-fat diets. Immediately after the surgery, which is usually laparoscopic (you may hear it called a “lap choley”), we want to monitor for pain and signs of infection. We also encourage the patients to use a pillow to split their abdomen when coughing – this can prevent wound dehiscence and decreases the pain. Then we’ll also see patients left with what’s called a T-tube drain. What they do is insert this T-tube here into the common bile duct, and it will come out the abdomen into a drainage bag. This will help to drain off any wound drainage, but also any excess bile secretion. Sometimes it takes the body a week or two to adjust and decrease the amount of bile being produced. That excess bile can actually build up and put pressure in the duct and bust the sutures. If that leaks out the patient is at risk for peritonitis. So we insert this drain for about 2 weeks to help relieve that pressure and keep the duct patent. However, if the output is >500 mL in one day, report that to the surgeons because that’s too high.
So our top priority nursing concepts for a patient with cholecystitis are nutrition, because they’ll have difficulty with digestion and may be NPO, comfort, because this is quite painful, and GI/Liver metabolism because if we don’t address this, it can cause a backup and cause damage to the liver. Make sure you check out the care plan attached to this lesson to see more detailed nursing interventions and rationales.
So, let’s recap. Cholecystitis is inflammation of the gallbladder, usually caused by gallstones, and it can make it difficult for the patient to digest their food appropriately. They’ll experience significant RUQ pain that is worse after a high-fat meal, and we’ll see a positive Murphy’s Sign. We want to decrease stimulation of the gallbladder by keeping the patient NPO or placing an NG Tube, or if the patient is eating, it needs to be a low-fat diet. Eventually, the best treatment for cholecystitis is to remove the gallbladder altogether with a cholecystectomy. And, they’ll have a T-tube drain to keep the duct patent while they heal.
So that’s it for cholecystitis, make sure you check out all the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!