Cholecystitis (Gallbladder Inflammation)

Introduction

Cholecystitis is a medical condition characterised by inflammation of the gallbladder, a small, pear-shaped organ located beneath the liver in the right upper part of the abdomen. The gallbladder’s primary function is to store and concentrate bile, a digestive fluid produced by the liver, and release it into the small intestine to aid in the digestion of fats.

Types of Cholecystitis

Cholecystitis can be broadly classified into two main types:

• Acute Cholecystitis: This is a sudden inflammation of the gallbladder, often caused by the obstruction of the cystic duct (which drains bile from the gallbladder) by gallstones. It presents with severe symptoms and requires prompt medical attention.
• Chronic Cholecystitis: This refers to long-standing inflammation, usually resulting from repeated episodes of acute cholecystitis. Over time, the gallbladder wall becomes thickened and less functional.

Causes and Risk Factors

The most common cause of cholecystitis is the presence of gallstones (cholelithiasis) that block the cystic duct, leading to bile accumulation and subsequent inflammation. Other causes include:

• Acalculous Cholecystitis: Inflammation without gallstones, often seen in critically ill patients or after major surgery, trauma, or infections.
• Infections: Bacterial infections (such as Escherichia coli, Klebsiella, or Enterococcus) can contribute to the development of cholecystitis.
• Tumours: Rarely, tumours can block the bile ducts, leading to inflammation.
• Other risk factors: Obesity, rapid weight loss, pregnancy, diabetes mellitus, and certain genetic factors.

Symptoms

Patients with cholecystitis typically present with the following symptoms:

• Severe pain in the right upper abdomen, which may radiate to the right shoulder or back
• Pain that worsens after eating fatty or greasy foods
• Fever and chills
• Nausea and vomiting
• Tenderness over the right upper abdomen (Murphy’s sign)
• Jaundice (yellowing of the skin and eyes) in some cases

Diagnosis

Diagnosis of cholecystitis is based on a combination of clinical evaluation, laboratory tests, and imaging studies:

• Physical examination: Reveals tenderness in the right upper quadrant of the abdomen.
• Blood tests: May show raised white blood cell count (leukocytosis), elevated liver enzymes, and markers of inflammation (such as C-reactive protein).
• Ultrasound: The most common imaging test, which can detect gallstones, gallbladder wall thickening, and fluid around the gallbladder.
• Other imaging: CT scan, MRI, or HIDA scan may be used in certain situations.

Complications

If left untreated, cholecystitis can result in serious complications, such as:

• Gallbladder rupture (perforation): Can lead to peritonitis, a life-threatening infection of the abdominal cavity.
• Abscess formation: Localised collection of pus within or around the gallbladder.
• Gangrene: Death of gallbladder tissue due to lack of blood supply.
• Cholangitis: Infection spreads to the bile ducts.
• Biliary fistula: Abnormal connection between the gallbladder and other organs.

Treatment

Treatment approaches depend on the severity and type of cholecystitis:

• Hospital admission: Most patients require admission for monitoring and supportive care.
• Fasting (NPO): Patients are asked not to eat or drink to rest the digestive system.
• Intravenous fluids and electrolytes: To maintain hydration and balance.
• Pain relief and antibiotics: To control infection and manage pain.
• Laparoscopic cholecystectomy: Surgical removal of the gallbladder is the definitive treatment, especially for acute cases caused by gallstones. This is typically performed as a minimally invasive procedure.
• Non-surgical management: In patients who cannot undergo surgery, drainage of the gallbladder (percutaneous cholecystostomy) may be considered.

Prevention

While not all cases of cholecystitis can be prevented, certain lifestyle modifications can reduce the risk:

• Maintaining a healthy weight
• Eating a balanced diet rich in fibre and low in unhealthy fats
• Regular physical activity
• Avoiding rapid weight loss
• Managing chronic conditions like diabetes

Nursing Care of Patients with Cholecystitis (Gallbladder Inflammation)

Nurses play a vital role in the assessment, care, and recovery of patients with cholecystitis. Effective nursing management can reduce complications, promote comfort, and hasten recovery.

Nursing Assessment

A comprehensive nursing assessment sets the foundation for an effective care plan and should include:

• Detailed patient history including onset, duration, and characteristics of pain, dietary triggers, and associated symptoms
• Physical examination for tenderness, guarding, and signs of peritonitis
• Vital signs monitoring for fever, tachycardia, and hypotension (may indicate complications such as sepsis or perforation)
• Observation for signs of jaundice or changes in urine/stool color
• Assessment of hydration status and nutritional intake
• Review of laboratory and imaging results (CBC, liver function tests, abdominal ultrasound, etc.)

Nursing Diagnoses

Common nursing diagnoses for patients with cholecystitis include:

• Acute pain related to inflammation of the gallbladder
• Nausea related to impaired digestion and inflammation
• Risk for infection related to biliary stasis or perforation
• Imbalanced nutrition: Less than body requirements due to anorexia or dietary restrictions
• Deficient knowledge regarding disease process and self-care

Goals of Nursing Care

• Alleviate pain and discomfort
• Reduce inflammation and prevent complications
• Maintain adequate nutrition and hydration
• Monitor for and prevent infectious complications
• Educate the patient and family regarding disease management and prevention

Nursing Interventions

Pain Management

• Administer prescribed analgesics (e.g., NSAIDs, opioids) as indicated, and assess pain relief regularly
• Encourage rest and provide a quiet environment, minimizing stimuli
• Position patient for comfort (semi-Fowler’s or right lateral position may reduce pain)
• Monitor for changes in pain intensity, which may signal complications

Management of Nausea and Gastrointestinal Symptoms

• Administer antiemetics as prescribed to control nausea and vomiting
• Advise patient to avoid foods that exacerbate symptoms, particularly fatty or spicy foods
• Provide small, frequent meals if oral intake is tolerated
• Monitor for signs of dehydration due to vomiting, and maintain IV fluids as ordered

Infection Prevention and Monitoring

• Monitor temperature and other vital signs regularly for early detection of infection
• Practice and teach proper hand hygiene to prevent cross-contamination
• Administer antibiotics as prescribed and monitor for therapeutic response
• Observe for signs of sepsis or abscess formation (increasing pain, high fever, tachycardia, confusion)

Nutritional Support

• Initially, keep patient NPO (nothing by mouth) to rest the gastrointestinal tract in acute cases
• Once symptoms improve, slowly advance diet from clear liquids to low-fat, well-balanced meals
• Monitor for tolerance to oral intake and signs of malnutrition
• Consult dietitians as needed for individualized nutrition planning

Hydration and Fluid Balance

• Monitor intake and output accurately to assess fluid balance
• Administer IV fluids as prescribed to prevent dehydration
• Assess for signs of fluid overload, especially in patients with comorbid cardiac or renal conditions

Education and Discharge Planning

• Educate patient and family about the disease process, treatment plan, and necessity of follow-up care
• Instruct on dietary modifications—emphasize a low-fat, high-fiber diet to prevent recurrence
• Review signs and symptoms that warrant immediate medical attention (severe pain, persistent vomiting, jaundice, high fever)
• Discuss the importance of medication compliance and potential side effects
• Encourage gradual resumption of activities as tolerated and stress the importance of rest

Special Considerations for Surgical Patients

Cholecystectomy (surgical removal of the gallbladder) is the definitive treatment for many cases of cholecystitis, especially if recurrent or complicated. Nursing care for surgical patients includes:

Preoperative Care

• Prepare patient physically and emotionally for surgery; address anxieties and answer questions
• Ensure necessary lab results, consent forms, and preoperative checklists are complete
• Maintain NPO status and administer preoperative medications as ordered

Postoperative Care

• Monitor vital signs frequently for early detection of complications
• Assess surgical site for bleeding, infection, or bile leakage
• Encourage early ambulation to promote circulation and prevent respiratory complications
• Gradually reintroduce oral intake following physician’s protocol
• Provide thorough discharge instructions including wound care, activity restrictions, and dietary guidelines

Monitoring and Preventing Complications

Nurses must remain vigilant for complications associated with cholecystitis, which include:

• Peritonitis
• Gallbladder perforation
• Abscess formation
• Biliary fistula
• Sepsis

Early recognition and intervention are critical to prevent morbidity and mortality.

Psychosocial Support

Patients with cholecystitis may experience anxiety, fear, or frustration due to pain, dietary restrictions, or the prospect of surgery. Nurses should provide empathetic support, encourage expression of feelings, and involve family members in the care process when appropriate.

Patient and Family Education

Thorough education can empower patients and families, reduce anxiety, and promote adherence to treatment plans.

• Explain the importance of following dietary restrictions and the rationale behind them
• Advise on lifestyle modifications including maintaining a healthy weight and regular physical activity
• Discuss the potential need for ongoing monitoring or additional interventions
• Provide resources for additional support, such as nutritional counseling or support groups

REFERENCES

1. Jones MW, Genova R, O’Rourke MC. Acute Cholecystitis. https://www.ncbi.nlm.nih.gov/books/NBK459171/. 2022 Oct 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
2. Jones MW, Gnanapandithan K, Panneerselvam D, et al. Chronic Cholecystitis. https://www.ncbi.nlm.nih.gov/books/NBK470236/. 2022 Oct 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
3. Merck Manual Consumer Version. Cholecystitis. https://www.merckmanuals.com/home/liver-and-gallbladder-disorders/gallbladder-and-bile-duct-disorders/cholecystitis.
4. Kurihara H. et al. Acute cholecystitis: Which flow-chart for the most appropriate management? Digestive and Liver Disease. 2023; doi:10.1016/j.dld.2023.02.005.
5. Merck Manual Professional Version. Chronic Cholecystitis. https://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/chronic-cholecystitis?query=Cholecystitis.
6. Hudson JL, et al. Endoscopic approaches to cholecystitis. American Journal of Gastroenterology. 2023; doi:10.14309/ajg.0000000000002351.
7. AskMayoExpert. Biliary stone disease. Mayo Clinic; 2023.
8. National Organization for Rare Disorders (U.S.). Acute Cholecystitis. https://rarediseases.org/rare-diseases/cholecystitis/.

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