treatment, diagnostic

1. CHOLECYSTITIS

2. INTRODUCTION
Cholecystitis is the acute or chronic inflammation
of the gallbladder. It normally happens because a
gallstone gets stuck at the opening of the
gallbladder. It can lead to fever, pain, nausea, and
severe complications.

3. Anatomy and physiology of gall bladder
The gallbladder is a hollow organ that sits beneath the liver and stores bile
made in the liver. In adults, the gallbladder measures approximately eight
centimetres (3.1 in) in length and four centimetres (1.6 in) in diameter when
fully distended.
The gallbladder is divided into three sections:
 Fundus.
 Body.
 Neck.

4.  BILE FLOW:

5. CLASSIFICATION
1.Calculous cholecystitis
2.Acalculous cholecystitis
3.Acute cholecystitis
4.Chronic cholecystitis

6. 1.Calculous cholecystitis: In calculous cholecystitis, a gallbladder stone
obstructs bile outflow.
2.Acalculous cholecystitis: Acute inflammation in the absence of
obstruction by gallstones.
3.Acute cholecystitis: This inflammation often causes severe pain in the mid
or right upper abdomen. Pain can also spread between the shoulder blades. In
severe cases, the gallbladder may tear or burst and release bile into the
abdomen, causing severe pain. This can be a life-threatening situation that
requires immediate attention.
4.Chronic cholecystitis: Recurrent bouts of mild swelling and
irritation/inflammation will often damage the wall of the gallbladder causing it
to thicken, shrink and lose proper function.

7. Pathophysiology
 Obstruction. Calculous cholecystitis occurs when a gallbladder stone
obstructs the bile outflow.
 Chemical reaction. Bile remaining in the gallbladder initiates a
chemical reaction; autolysis and oedema occur.
 Compression. Blood vessels in the gallbladder compressed,
compromising its vascular supply.

8. Statistics and Incidences
 Although not all occurrences of cholecystitis are related cholelithiasis,
more than 90% of patients with acute cholecystitis have gallstones.
 The acute form is most common during middle age.
 The chronic form usually occurs among elderly patients.

9. Causes
 Gallbladder stone. Most often, cholecystitis is the result of hard particles
that develop in your gallbladder (gallstones). Gallstones can block the
tube (cystic duct) through which bile flows when it leaves the gallbladder.
Bile builds up, causing inflammation.
 Bacteria. Bacteria plays a minor role in cholecystitis; E. coli, Klebsiella,
Streptococcus, and Clostridium species.
 Alterations in fluids and electrolytes. Acalculous cholecystitis is
speculated to be caused by alterations in fluids and electrolytes.
 Bile stasis. Bile stasis or the lack of gallbladder contraction also play a
role in the development of cholecystitis.

10. CONTD…
•Tumor. A tumor may prevent bile from draining out of gallbladder properly,
causing bile buildup that can lead to cholecystitis.
•Infection. AIDS and certain viral infections can trigger gallbladder inflammation.
•Blood vessel problems. A very severe illness can damage blood vessels and
decrease blood flow to the gallbladder, leading to cholecystitis.

12. Sign and symptoms:

13. CONTD…
 Murphy sign: A Murphy sign is a “catch” in the breath elicited by gently pressing on the right upper quadrant and
asking the patient to take a deep breath. Patient will have pain during inhalation.
 Boas sign: Boas' or Boas sign is hyperesthesia (increased or altered sensitivity) below the right scapula can be a
symptom in acute cholecystitis (inflammation of the gallbladder). Originally this sign referred to point tenderness
in the region to the right of the 9th to 11th thoracic vertebrae.
 Mirrizi syndrome: defined as common hepatic duct obstruction caused by extrinsic compression from an impacted stone in
the cystic duct or infundibulum of the gallbladder . Patients with Mirizzi syndrome can present with jaundice, fever, and right
upper quadrant pain.
 Charcot's cholangitis triad: is the combination of jaundice; fever, usually with rigors; and right upper
quadrant abdominal pain. It occurs as a result of ascending cholangitis (an infection of the bile duct in the liver).
 Courvoisier's law (or courvoisier syndrome, or courvoisier's sign or courvoisier-terrier's sign): states that in
the presence of a palpable enlarged gallbladder which is non-tender and accompanied with mild painless jaundice, the cause is
unlikely to be gallstones.
 Reynolds pentad: collection of signs and symptoms suggesting the diagnosis obstructive ascending cholangitis, a
serious infection of the biliary system. It is a combination of Charcot's triad (right upper quadrant pain,
jaundice, and fever) with shock (low blood pressure, tachycardia) and an altered mental status.

15. Complications
Cholecystitis can progress to gallbladder complications, such as:
 Empyema. An empyema of the bladder develops if the gallbladder becomes filled with
purulent fluid.
 Gangrene. Gangrene develops because the tissues do not receive enough oxygen and
nourishment at all.
 Cholangitis. The infection progresses as it reaches the bile duct.
• Infection within the gallbladder. If bile builds up within gallbladder, causing
cholecystitis, the bile may become infected.
• Torn gallbladder. A tear (perforation) in gallbladder may result from gallbladder swelling,
infection or death of tissue.

16. Assessment and Diagnostic Findings
 Biliary ultrasound: Reveals calculi, with gallbladder and/or bile duct distension (frequently the initial diagnostic procedure).
 Oral cholecystography (OCG): Preferred method of visualizing general appearance and function of gallbladder, including
presence of filling defects, structural defects, and/or stone in ducts/biliary tree. Can be done IV (IVC) when nausea/vomiting
prevent oral intake, when the gallbladder cannot be visualized during OCG, or when symptoms persist following
cholecystectomy. IVC may also be done perioperatively to assess structure and function of ducts, detect remaining stones after
lithotripsy or cholecystectomy, and/or to detect surgical complications. Dye can also be injected via T-tube drain
postoperatively.
 Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the common bile duct
through the duodenum. Assess the retroperitoneal organs gallbladder, bile duct and pancreas.
 Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes between gallbladder disease
and cancer of the pancreas (when jaundice is present); supports the diagnosis of obstructive jaundice and reveals calculi in
ducts.
 Cholecystograms (for chronic cholecystitis): Reveals stones in the biliary system. Note: Contraindicated in acute
cholecystitis because patient is too ill to take the dye by mouth.

17. CONTD…
 Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile ducts, and distinguish between
obstructive/nonobstructive jaundice.
 Hepatobiliary (HIDA, PIPIDA) scan: May be done to confirm diagnosis of cholecystitis, especially when
barium studies are contraindicated. Scan may be combined with cholecystokinin injection to demonstrate
abnormal gallbladder ejection. Done to evaluate the health and function of gall bladder.
 Abdominal x-ray films (multilocational): Radiopaque (calcified) gallstones present in 10%–15% of cases;
calcification of the wall or enlargement of the gallbladder.
 CBC: leucocytosis.
 Serum bilirubin and amylase: Elevated.

18. CONTD…
 Serum liver enzymes—AST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase
and 5-nucleotidase are markedly elevated in biliary obstruction.
 Prothrombin levels: Reduced when obstruction to the flow of bile into the intestine
decrease’s absorption of vitamin K.
 Ultrasonography. Ultrasound is the preferred initial imaging test for the diagnosis of
acute cholecystitis; scintigraphy is the preferred alternative.
 CT scan. CT scan is a secondary imaging test that can identify extra-biliary disorders
and acute complications of cholecystitis.

19. Contd…
 MRI. Magnetic resonance imaging is also a possible secondary choice for confirming a
diagnosis of acute cholecystitis.
 Oral cholecystography. Preferred method of visualizing general appearance and function
of the gallbladder.
 Cholecystogram. Cholecystography reveals stones in the biliary system.
 Abdominal x-ray. Radiopaque or calcified gallstones present in 10% to 15% of cases.

20. Management:
Management may involve controlling the signs and symptoms and the inflammation of
the gallbladder.
 Fasting. The patient may not be allowed to drink or eat at first in order to take the
stress off the inflamed gallbladder; IV fluids are prescribed to provide temporary food
for the cells.
 Supportive medical care. This may include restoration pf hemodynamic
stability and antibiotic coverage for gram-negative enteric flora.
 Gallbladder stimulation. Daily stimulation of gallbladder contraction with IV
cholecystokinin may help prevent the formation of gallbladder sludge in patients
receiving TPN.

21. Pharmacologic Therapy:
The following medications may be useful in patients with cholecystitis:
 Antibiotic therapy. Levofloxacin and Metronidazole for prophylactic
antibiotic coverage against the most common organisms.
 Promethazine or Prochlorperazine may control nausea and prevent fluid
and electrolyte disorders.
 Oxycodone or Acetaminophen may control inflammatory signs and
symptoms and reduce pain.

22. Surgical Management
Because cholecystitis frequently recurs, most people with the condition eventually require gallbladder removal.
 Cholecystectomy. Cholecystectomy is most commonly performed by using a laparoscope and removing the
gallbladder.

23. DRAINAGE DEVICE USED AFTER CHOLECYSTECTOMY:

24.  Endoscopic retrograde cholangiopancreatography (ERCP). ERCP is a procedure that
enables your physician to examine the pancreatic and bile ducts. A bendable, lighted tube
(endoscope) about the thickness of index finger is placed through mouth and into stomach
and first part of the small intestine (duodenum).
 Choledocholithotomy: Removal of stones present in the bile duct. After surgery T-Tube
used for drainage of bile from bile duct, drainage up to 14 days.

28. Biliary stent:

29. POST CHOLECYSTECTOMY SYNDROME:
 Complication of cholecystectomy develops after 2 years.
Characteristic by severe indigestion and repeated episodes of
nausea , vomiting, diarrhea, and constipation.
 Advice patient for low fat and carbohydrate diet.

30. Nursing Management:
Management of cholecystitis include the following:
Nursing Assessment:
 Integumentary system. Assess skin and mucous membranes.
 Circulatory system. Assess peripheral pulses and capillary refill.
 Bleeding. Assess for unusual bleeding: oozing from injection sites,
epistaxis, bleeding gums, petechiae, ecchymosis, hematemesis, or
melena.
 Gastrointestinal system. Assess for abdominal distension, frequent
belching, guarding, and reluctance to move.

31. Nursing Diagnosis
1. Nursing Diagnosis Acute Pain related to: biological trauma obstruction / spasm tract
inflammatory processes, ischemia / tissue necrosis
Evidenced by:
 Complaints of pain, colic biliary (pain frequency).
 Facial expressions as pain, a cautious attitude.
 Autonomic responses (changes in blood pressure, pulse).
 Focus on self-limited.
2. Risk for Deficient Fluid Volume related to:
 Increase in gastric fluid loss: vomiting, gastric distention and hipermolity.
 Treatment has the effect of reducing the fluid.
 The freezing process

32. 3. Nursing Diagnosis Imbalanced Nutrition Less Than Body Requirements related
to:
 Imposed on themselves and given limited food, nausea, vomiting, dyspepsia, pain.
 Loss of nutrients, affect digestion due to disturbance / narrowing of the bile duct.
4. Nursing Diagnosis Deficient Knowledge: about prognosis and treatment needs
related to:
 Re asking about information.
 Lack of knowledge/recall
 Information misinterpretation
 Unfamiliarity with information resources

33. Nursing Goals
The major goals for the patient include:
 Relieve pain and promote rest.
 Maintain fluid and electrolyte balance.
 Maintain nutritional balance.
 Provide information about disease process, prognosis, and treatment
needs.

34. Nursing Intervention:
1.Releive pain and promote rest
 Observe and document location, severity [0-10], and character of pain [steady,
intermittent, colicky].
 Note response to medication, and report to physician if pain is not being relieved.
 Provide bed rest, allowing patient to assume position of comfort.
 Use soft or cotton linens; calamine lotion, oil bath; cool or moist compresses as
indicated.
 Encourage use of relaxation techniques. Provide diversional activities.
 Maintain NPO status, insert and/or maintain NG suction as indicated.

35. 2. Maintain fluid and electrolyte balance.
 Maintain accurate record of intake and output, noting less than intake, increased urine
specific gravity. Assess skin and mucous membrane, peripheral pulses and capillary refill.
 Monitor for signs and symptoms of increased or continued nausea or vomiting, abdominal
cramps, weakness, twitching, seizures, irregular heart rate, paraesthesia, hypoactive or absent
bowel sounds, depressed respirations.
 Eliminate noxious sites or smells from environment
 Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.
 Use small gauge needle for injections and apply firm pressure for longer than usual after
venepuncture.
 Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums,
ecchymosis, petechiae, hematemesis or melena.
 Keep patient NPO as necessary
 Insert NG tube, connect to suction, and maintain patency as indicated.

36. 3 Maintain nutritional balance.
 Calculate calorie intake. Keep comments about appetite to its minimum.
 Weigh as indicated.
 Consult with patient about likes and dislikes, foods that causes distress, and preferred meal
schedule.
 Provide a pleasant atmosphere at mealtime; remove noxious stimuli.
 Provide oral hygiene before meal
 Offer effervescent drinks with meals, if tolerated.
 Assess for abdominal distension, frequent belching, guarding, reluctance to move.
 Ambulate and increase activity as tolerated.
 Ambulate and increase activity as tolerated
 Consult with dietitian or nutritional support team as indicated.
 Begin low-fat liquid diet after NG tube is removed.
 Administer bile salts: Bilron, Zanchol, dehydrocholic acid (Decholin), as indicated.
 Provide parenteral and/or enteral feedings as needed.

37. 4. Provide information about disease process, prognosis, and treatment needs.
 Explain reasons for test procedures and preparations as needed.
 Review disease process and prognosis. Discuss hospitalization and prospective treatment
as indicated. Encourage questions, expression of concern.
 Review drug regimen and possible side effects.
 Review signs and symptoms requiring medical intervention: recurrent fever; persistent
nausea and vomiting, or pain; jaundice of skin or eyes, itching; dark urine; clay-coloured
stools; blood in urine, stools, vomitus; or bleeding from mucous membranes.
 Suggest patient limit gum chewing, sucking on straw and hard candy, or smoking.
 Recommend use of soft toothbrush, electric razor.

38. Discharge and Home Care Guidelines
The focus of discharge instructions for patients with cholecystitis is education.
 Education. Patients with cholecystitis must be educated regarding causes of their
disease, complications if left untreated, and medical and surgical options.
 Activity. Ambulate and increase activity as tolerated.
 Diet. One big meal can throw off the system and produce a spasm in the gallbladder
and bile ducts. Stick to a low-fat diet with lean proteins, such as poultry or fish. Avoid
fatty meats, fried food, and any high-fat foods, including whole milk products.

39. RESEARCH FINDINGS
 Acute Cholecystitis in Elderly Patients after Hip Fracture: a Nationwide
Cohort Study:
Abstract
Background
Because acute cholecystitis in elderly hip fracture is not easily distinguishable from other gastrointestinal symptoms
and involves atypical clinical behaviors, it may not be diagnosed in the early stage. However, the exact incidences
could not be reported. We utilized data from a nationwide claims database and attempted to assess the incidence of
acute cholecystitis in elderly hip fracture patients and how cholecystitis affects mortality rates after hip fracture.
Methods
Study subjects were from the Korean National Health Insurance Service-Senior cohort. From a population of
approximately 5.5 million Korean enrollees > 60 years of age in 2002, a total of 588,147 participants were randomly
selected using 10% simple random sampling. The subjects included in this study were those who were over 65 years
old and underwent surgery for hip fractures.

40. Results
A total of 15,210 patients were enrolled in the cohort as hip fracture patients. There were 7,888 cases (51.9%) of
femoral neck fracture and 7,443 (48.9%) cases of hemiarthroplasty. Thirty-six patients developed acute cholecystitis
within 30 days after the index date (30-day cumulative incidence, 0.24%). Four of the 36 acute cholecystitis patients
(11.1%) died within 30 days versus 2.92% of patients without acute cholecystitis. In the multivariate-adjusted Poisson
regression model, hip fracture patients with incident acute cholecystitis were 4.35 (adjusted risk ratio 4.35; 95%
confidence interval, 1.66–11.37; P = 0.003) times more likely to die within 30 days than those without acute
cholecystitis.
Conclusion
Incidence of acute cholecystitis in elderly patients after hip fracture within 30 days after the index date was 0.24%.
Acute cholecystitis in elderly hip fracture patients dramatically increases the 30-day mortality rate by 4.35-fold.
Therefore, early disease detection and management are crucial for patients.

41.  H pylori exist in the gallbladder mucosa of patients with chronic
cholecystitis
AIM: To study whether H pylori locate in the gallbladder mucosa of patients with chronic
cholecystitis.
METHODS: Using Worthy-Starry (W-S) silver stain and immunohistochemistry stain with anti-H
pylori antibodies, we screened paraffin specimens in 524 cases of cholecystitis. H pylori urease gene
A (HPUA) and H pylori urease gene B (HPUB) were analysed by polymerase chain reaction (PCR)
in the fresh tissue specimens from 81 cases of cholecystitis.
RESULTS: H pylori-like bacteria were found in 13.55% of the gallbladders of the cholecystitis
patients using W-S stain. Meanwhile, bacteria positive for H pylori antibodies were also found in
7.1% of the gallbladders of patients with cholecystitis by immunohistochemistry. Of 81 gallbladders,
11 were positive for both HPUA and HPUB, 4 were positive for HPUA only and 7 were positive for
HPUB only.
CONCLUSION: H pylori exist in the gallbladders of patients with chronic cholecystitis.