Cholelithiasis ( Cholecystitis) : Symptoms, Causes, Complications and Treatment by Nursesnote

CHOLELITHIASIS AND CHOLECYSTITIS

 In cholelithiasis, calculi (gallstones) usually from in the gallbladder from solid constituents of bile and vary greatly in size, shape, and composition. There are two major types of unconjugated pigments in the bile, and cholesterol stones (the more common form) , which result from bile supersaturated with cholesterol due to increased synthesis of cholesterol and decreased synthesis of bile acids that dissolve cholesterol. Risk factors for pigments stones include cirrhosis, hemolysis, and infections of the biliary tract. These stones cannot be dissolved and must be removed surgically. Risk factors for cholesterol stones include gender (women are two to three times more likely to develop cholesterol stones); use of oral contraceptives, estrogens, and clofibrate; age (usually older than 40 years); multiparous status; and obesity. There is also an increased risk related to diabetes, GI tract disease, T tube fistula, and ileal resection or bypass. 

Cholecystitis, an acute complication of cholelithiasis, is an acute infection of the gallbladder. Most patients with cholecystitis have gallstones (calculous cholecystitis). A gallstone obstructs bile outflow  and bile in the gallbladder initiates a chemical reaction, resulting in edema, compromise of the vascular supply, and gangrene. In tge absence of gallstones, cholecystitis (acalculous) may occur after surgery, sever trauma, or burns, or with torsion, cystic duct obstruction, multiple blood transfusions, and primary bacterial infections of the gallbladder, infection causes pain, tenderness, and rigidity of the upper right abdomen and is associated with nausea and vomiting and the usual signs of inflammation. Purulent fluid inside the gallbladder indicates an empyema of the gallbladder. 

Clinical manifestation 

• May be silent, producing no pain and only mild GI symptoms. 
• May be acute or chronic with epigastric distress  ( fullness, abdominal distention, and vague upper right quadrant pain); may follow a meal rich in fried or fatty foods. 
• If the cystic duct is obstructed, the gallbladder becomes distended, inflamed, and eventually infected; fever and palpable abdominal mass; biliary colic with excruciating upper right abdominal pain, radiating to back or right shoulder with, nausea and vomiting several hours after a heavy meal; restlessness and constant or colicky pain. 
• Jaundice, accompanied by marked itching, with obstruction of the common bile duct, in a small percentage of patients. 
• Very dark urine; grayish or clay-colored stool. 
• Deficiencies of vitamins A, D, E, and K (fat soluble vitamins ) 

Assessment and Diagnostic methods 

• Cholecystogram, cholangiogram, celiac axis arteriography
• Laparoscopy.
• Ultrasonography. EUS
• Helical CT scans and MRI; ERCP.
• Serum alkaline phosphatase; gamma-glutamyl (GGT), gamma-glutamyl transpeptidase (GGTPP), LDH.
• Cholesterol levels. 

Medical management 

Major objectives of medical therapy are to reduce the incidence of acute episodes of gallbladder pain and cholecystitis by supportive and dietary management and, if possible, to remove the cause by pharmacotherapy, endoscopic procedures, or surgical intervention. 

Nutritional and supportive therapy

• Achieve remission with rest, IV fluids, nasogastric suction, analgesia, and antibiotics. 
• Diet immediately after an episode is usually low-fat liquids with high protein and carbohydrates followed by solid soft foods, as tolerated, avoiding eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. 

Pharmacologic Therapy

• Ursodeoxycholic acid (UDCA [Urso, Actigall]) and chenodeocycholic ( chenodiol or CDCA [Chenix}) are effective in dissolving primary cholesterol stone.
• Patients with significant , frequent symptoms; cystic duct occlusion; or pigment stones are not candidates for therapy with UDCA.

Non surgical removal of gallstones

 In addition to dissolving gallstones, they can be removed by other instrumentation (e.g. catheter and instrument with a basket attached are threaded through the T tube tract or fistula formed at the time of T tube insertion, ERCP endoscope),intracorporeal lithotripsy (laser pulse), or extracorporeal shock wave therapy ( lithotripsy or extracorporeal shock wave lithotripsy [ESWL]

Surgical Management

Goal of surgery is to relieve persistent symptoms, to remove the cause of biliary colic, and to treat acute cholecystitis.

• Laparoscopic cholecystectomy: performed through a small incision or puncture made through the abdominal wall in the umbilicus.
• Cholecystectomy: Gallbladder is removed through an abdominal incision (usually right subcostal) after ligation of the cystic duct and artery.
• Minicholecystectomy: Gallbladder is removed through a small incision.
• Choledochostomy: incision into the common duct for stone removal.
• Cholecystostomy ( surgical or percutaneous): Gallbladder is opened, and the stone, bile, or purulent drainage is removed.

Nursing Process:The patient undergoing cholecystectomy

Assessment

• Assess the health history: Note history of smoking or prior respiratory problems.
• Assess the respiratory status: Note shallow respirations, persistent cough, or ineffective or adventitious breath sounds.
• Evaluate nutritional status ( dietary history, general examination, and laboratory study results).

Diagnosis

Nursing diagnoses

• Acute pain and discomfort related to surgical incision.
• Impaired gas exchange relate to high abdominal surgical incision.
• Impaired skin integrity related to altered biliary drainage after surgical incision.
• Imbalanced nutrition, less than body requirements, related to inadequate bile secretion
• Deficient knowledge about self care activities related to incisional care, dietary modifications (if needed), medications,

Collaborative Problems/Potential Complications

• Bleeding
• Gastrointestinal symptoms

Planing and Goals

Goals include relief of pain, adequate ventilation, intact skin and improved biliary drainage, optimal nutritional intake, absence of complications, and understanding of self care routines.

Nursing interventions: Postoperative

• Place patient in low Fowler's position.
• Provide IV fluids and nasogastric suction.
• Provide water and other fluids soft diet, after bowel sounds return.

Relieving Pain

• Administer analgesic agents as ordered.
• Help patient turn, cough, breathe deeply, and ambulate as indicated.
• Instruct patient to use a pillow or binder to splint incision.

Improving respiratory status.

• Remind patient to take deep breaths and cough every hour, to expand the the lungs fully and prevent atelectasis; promote early ambulation.
• Monitor elderly and obese patients and those with preexisting pulmonary disease most closely for respiratory problems.

Maintaining skin integrity and promoting biliary drainage

• Connect tubes to drainage receptacle and secure tubing to avoid kinking ( elevate above abdomen).
• Place drainage bag in patient's pocket when ambulating , 
• Observe for indications of infection, leakage of bile, and obstruction of bile drainage.
• Observe for jaundice 
• Note and report right upper quadrant abdominal pain, nausea and vomiting, bile drainage around any  drainage tube, clay-colored stools, and a change in vital signs.
• Change dressing frequently, using ointment to protect skin from irritation.
• Measure bile collected every 24 hours; document amount, color, and character drainage.
• Keep careful record of intake and output.

Improving nutritional status

Encourages the patient to eat a diet that is low fats and high in carbohydrates and proteins immediately after surgery. At the time of discharge, advise patient to maintain a nutritious diet and avoid excessive fats; fat restriction is usually lifted in 4 to 6 weeks.

Monitoring and managing complications

• Bleeding: Assess periodically for increased tenderness and rigidity of abdomen and report; instruct patient and family to report change in color of stools. Monitor vital signs closely.
• Gastrointestinal symptoms; Assess for loss of appetite, vomiting, pain, distention of abdomen, and temperature to report symptoms promptly; provide written reinforcement of verbal instructions.

Promoting home and community based care

Teaching patients self-care

• Teach about medications and their actions.
• Instruct patient to report to physician symptoms of jaundice, dark urine, pale stools, pruritus, or signs of inflammation and infection ( e.g pain and fever)
• Instruct patient, verbally and in writing, about care of drainage tubes and to report to physician promptly changes in amount or characteristics of drainage.
• Refer for home care if necessary.
• Emphasize importance of keeping follow-up appointments.