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

 Most Common Gastrointestinal Emergencies

What are common gastrointestinal problems?

GI problems are frequently encountered in emergency care areas, and patients can present with wide-ranging Symptoms. Symptoms that suggest an underlying GI problem can include: abdominal pain, nausea, vomiting, diarrhoea, melaena, haematemesis, Constipation, jaundice, and abdominal distension. Abdominal pain is a common ED presentation and can be the cause of a wide variety of GI problems. Pain is usually present where there is a disorder within the GI tract, but its severity is not a reliable indicator of the seriousness of the condition. However, the site and characteristics of the pain can often indicate the cause. The pain usually arises from an organ within the abdominal cavity that is either inflamed, distended, perforated or ischaemic. Abdominal wall pain arises from irritation of the peritoneum and abdominal musculature from inflamed organs, free blood, or leaked gastric contents. Pain can also be referred from an organ outside the abdominal cavity, e.g. an inferior MI can present as epigastric pain.

1. Epigastric Pain

Epigastric pain is a very common presentation, both in 1° care and the ED. A wide variety of problems can present with epigastric pain, some relatively benign, e. g. Indigestion, others much more serious, e.g. pancreatitis, inferior MI, PUD.

Nursing Assessment

Nursing Evaluation should take into account the need to assess for a range of problems and may need to include some, or all, of the following:

1. Vital Signs
2. ECG
3. Pain Assessment and score
4. CXR
5. CBG
6. CBC, U&E, amylase and lipase, LFT

Nursing Interventions

1. Analgesia
2. Antacid
3. Anti-emetic
4. IV fluids

2. Gastrointestinal Bleeding

Bleeding can occur from any part of the GI system. Acute upper GI bleeding can present as haematemesis ± melaena. It is commonly caused by PUD (50%), oesophagal varices (10-20%), gastric erosions (15-20%) and Mallory-Weiss syndrome (5-10%). Chronic GI bleeding usually presents as anaemia. Iron deficiency anaemia in men and post-menopausal women is usually of GI origin, and investigations of the upper and lower GI tract may be necessary to identify the cause if it is not apparent from history and examination.

  Massive acute lower GI bleeding is rare and most commonly seen in the elderly. A small amount of bleeding from haemorrhoids is much commoner and a frequent cause of anxiety that prompts an ED attendance. Massive lower GI bleeding is usually due to diverticular disease, inflammatory bowel disease(IBD), tumour, or ischaemic colitis. Patients require the same rapid assessment and resuscitation as those with upper GI bleeding.

Haematemesis

Vomiting fresh blood or darker blood  (sometimes called 'coffee grounds') occurs after bleeding in the oesophagus, stomach, or duodenum. Darker/coffee-ground vomit occurs, as blood is altered in the stomach over time by gastric acid.

Melaena

Melaena is abnormally black tarry stools with a distinctive offensive odour. The stool contain digested blood that has usually originated from an upper GI bleed that may be acute or chronic.

Mallory-Weiss syndrome

Mallory-Weiss syndrome is bleeding from a tear in the mucosa at the gastro-oesophagal junction. It is usually caused by protected vomiting /retching and is often associated with the prolonged vomiting that results from excessive alcohol intake! Blood loss may be large, but, in most patients, it stops spontaneously. Diagnosis by endoscopy, which then allows early discharge from the hospital.

Massive Gastrointestinal bleeding

Bleeding from PUD or oesophageal varices accounts for up to 70% of upper GI haemorrhages, Urgent resuscitation is required prior to any in-depth assessment as to the cause.

Bleeding from ruptured varices can be phenomenal like a hosepipe! Loss of >40% of blood volume is immediately life-threatening, and blood loss is often underestimated. Initiation of the massive haemorrhage protocol may be required.  Early involvement and advice from a haematologist will guide blood replacement and help manage derangements in clotting that are often a consequence of massive transfusion.

• Airway protection. In patients with massive haemorrhage and a reduced level of consciousness, urgent Intubation may be required to protect the airway.
• O2 administration may be difficult if there is continued vomiting. Nasal prongs may be useful way of administering low-flow O2.
• IV access. ×2 large-bore cannulae into large veins will allow rapid infusion of warmed fluids, blood, platelets and FFP. Immediate central access may be indicated if the bleeding is significant.
• Blood sent for CBC, U&E, LFT, cross match, clotting.
• ABG.
• IV fluids. Give warmed crystalloid or colloid, followed by blood. Blood transfusion is indicated when 30% of circulating volume is lost.
• Replacement platelets /clotting factors. FFP, Platelets and cryoprecipitate may need to be given in massive blood loss
• Tranexamic acid may be indicated.
• CVP monitoring.
• Arterial line to enable continuous invasive monitoring.
• Urinary catheter. Aim for a urine output >30mL/h.
• NG tube.
• Keep the patient warm. Hypothermia increases the risk of serious complications. e.g. DIC.
• Further cardiovascular support may be needed with inotropes and vasopressors.

Monitoring of patient's with massive blood loss

• Pulse
• RR
• SpO2
• BP
• CVP
• Urinary output
• GCS
• Continuous cardiac monitoring
• 12lead Ecg
• CXR
• Repeated blood
• Repeated ABG.

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

3. Peptic Ulcer Disease

PUD is a collective term given to ulcers in the stomach (gastric ulcer) or the duodenum (duodenal ulcers). The commonest cause of upper GI bleeding is peptic ulcer, according to for about 50% of cases.

  In health, a balance exists between peptic acid secretion and gastroduodenal mucosal defence. Inflammation and ulceration occur when the balance is disrupted. Factors, such as NSAIDs, Helicobacter pylori infection, and alcohol, can alter the mucosal defence by allowing acid to diffuse back and cause epithelial cell injury.

• Gastritis is a superficial inflammation of the mucosa.
• In ulceration, there is a complete break in the mucosa down to the muscular layer.

Signs and Symptoms

• Epigastric pain: the patient may point directly to the epigastrium. Pain can be relieved by eating. Severe sudden pain may indicate a perforation.
• Nocturnal pain
• Nausea
• Heartburn
• Anorexia and weight loss
• Melaena
• Haematemesis
• Shock in perforation
• Fever in peritonitis

4. Peritonitis

Peritonitis is a common consequence of perforation of the GI tract and can be caused for example, by a perforated ulcer, appendix, or diverticulum. Patients with peritonitis are often critically ill with septic shock.

Signs and Symptoms of Peritonitis

• Severe abdominal pain.
• Rigid 'board-like abdomen
• Absent bowel sounds
• Hypovolemic shock
• Septic shock as time progresses.
• Fever
• Vomiting
• Tachycardia
• Tachypnoea

Nursing Management

Patients with simple gastritis may require little more than antacids and GP follow-up. However, nursing assessment should be aimed at ensuring that all serious underlying problems are ruled out prior to discharge.

• Vital signs
• Evaluate for signs of hypovolemic or septic shock.
• Pain assessment and score
• Blood: CBC U&E, amylase lipase.
• ABG
• Erect Xray. In 75% of patient's with an acute perforation, free gas can be seen under the diaphragm.

Nursing Intervention for Patients with Perforation

Patients with acute perforation exhibit signs of Peritonitis due to the leakage of gastric contents that irritate/infect and inflame the peritoneum.

• IV analgesia
• Anti-emetic
• IV access
• O2 therapy
• IV antibiotics
• Fluid resuscitation
• NG tube
• Urinary Catheter
• Prepare for theatre.

5.Oesophageal Varices

Acute bleeding from oesophageal varices is a fairly common ED presentation that accounts for 10-20% of acute upper GI bleeding. There is usually a history of alcohol abuse and cirrhosis. Patients with severe cirrhosis and large varices are most likely to bleed. Interestingly, the majority of patient's with alcoholic cirrhosis who stop drinking have a reduction in the size of liver varices- sometimes they disappear completely.

Varices develop, as necrosis of liver cells damage the structure and function of the liver. In patient with cirrhosis, all functions of the liver is disrupted, e.g. clotting is deranged as protein synthesis is affected. Because the structure of the liver is grossly abnormal, blood flow is affected. Portal hypertension develops, as blood can no longer drain freely from the GI tract via the portal vein into the liver. As the blood 'backflows' and portal pressure increase, the venous system dilates, and a collateral circulation develops. The commonest site of the collateral circulation is at the gastro-oesophagal junction. Because these gastro-oesophagal veins are superficial, they tend to rupture. Fifty per cent of patients with portal hypertension will bleed from their varices.

1. Mortality is extremely high- 50% of patients die, following the first episode of bleeding.
2. Patients may also have decompensated liver disease with encephalopathy.

Nursing Interventions

Urgent endoscopy available: If endoscopy is available, then the varices will be either ligated or subject to sclerotherapy (chemical injected into the vein to cause into narrow/clot.).

Urgent endoscopy not available: Several pharmacological interventions are available to control acute bleeding.

1. Vasopressin ± GTN infusion.
2. Somatostatin, octreotide.
3. Insertion of Sengstaken tube

Appendicitis: Nursing interventions

6. Appendicitis 

Appendicitis is a commonest surgical emergency and should be considered as a cause of an acute abdomen in all patients if it has not been removed.

The presentation can range from mild/moderate right iliac fossa pain to generalized peritonitis with associated shock.

The diagnosis of appendicitis is a clinical one unless a CT scan has been performed and excludes it. 

Signs and Symptoms

1. Nausea.
2. Vomiting.
3. Abdominal pain. Classically, pain begins vaguely centrally/periumbilical and then localizes to the right iliac fossa.
4. Fever.

Nursing Assessment

Accurate nursing assessment should enable differentiation between patients with localised pain in the right iliac fossa and those with more serious pathology, e.g. generalized peritonitis shock. Assessment should also include investigations that may point to another cause.

1. Vital signs
2. Pain assessment and score
3. Urinalysis
4. LMP; risk of pregnancy
5. FBC. The WCC may be raised, but not always.
6. U&E.

Nursing Interventions

1. IV access
2. Analgesia
3. IV fluid if NPM or dehydrated
4. IV antibiotics reduce the risk of post-operative complications associated with infection.
5. Prepare for admission
6. Preoperative preparations.

7. Biliary Colic and acute Cholecystitis

Gallstones are very common and are present in many people, often remaining asymptomatic throughout life.

1. However, in some people, they move out of the gall bladder and cause severe pain when they become lodged in the gall bladder neck, common bile duct, or cyst duct. This is often termed biliary Colic and is usually a temporary obstruction. The term 'colic' can be confusing when used in this context, as it usually does not 'come and go' but is constant and severe and increase in severity.
2. Acute Cholecystitis is the term given in to inflammation of the gall bladder that results from a stone preventing the gall bladder from emptying. When the cyst duct is blocked, the gall bladder distends, becomes inflamed, and them may become infected and even distended by pus.

Signs and Symptoms of Biliary Colic 

Patients tend to be systemically well and can even be discharged home for GP follow-up and further investigation if their pain subsides, examination is normal, and blood results are not significantly abnormal.

1. Pain is usually epigastric but can be localised to the RUQ. Pain may radiate to the right shoulder through to the back.
2. Pain may be related to eating food with a high-fat content.
3. Nausea and vomiting in more severe cases.

Signs and Symptoms of Cholecystitis.

Initially, the signs and symptoms are similar to those of biliary Colic. However, as time passes, severe pain localised to the RUQ. There is overlying peritonitis due to inflammatory changes in the gall bladder. Patients tend to be systemically unwell and require admission. Occasionally, there can be a shock, which requires resuscitation.

1. Severe RUQ pain.
2. RUQ guarding and rigidity
3. Fever
4. Mass in the RUQ. Occasionally, there is a palpable mass.

Nursing Assessment

1. Vital signs
2. Pain assessment and score
3. LMP. Ruptured ectopic can present with shoulder tip pain.
4. ECG to rule out MI.
5. CBC, U&E, LFTs, amylase/lipase.
6. Ultrasound is the most useful investigation, as it can confirm Cholecystitis.

Nursing Interventions

1. IV access
2. Analgesia, usually opiate
3. IV fluid if NPM, dehydrated.
4. Fluid resuscitation if shocked.
5. IV antibiotics.

8. Pancreatitis

Pancreatitis can be acute or chronic, and episodes can be recurrent. In the ED, the differentiation between an acute episode or one that develops on a background of chronic disease is difficult and probably unnecessary. Patients who have had previous episodes of pancreatitis are quick to recognize their symptoms and may present regularly to the ED, particularly those with chronic alcohol problems.

1. The commonest causes of acute pancreatitis are alcohol, gallstones, and trauma.
2. Gallstones that obstruct the pancreatic duct can cause pancreatitis.
3. Increased alcohol intake is frequently associated with chronic pancreatitis
4. The severity of pancreatitis is wide-ranging; inflammation may be mild and self-limiting, but, in its severest form, it has a mortality of 40-50% 
5. Consider a diagnosis of pancreatitis in all patients with epigastric pain.

Signs and Symptoms

Mild disease may present with minimal signs and symptoms. 25% of all patients with pancreatitis will have severe disease; they will be critically ill, requiring resuscitation and intensive care. The earlier severe disease is identified, the sooner aggressive treatment can begin. However, in those with only mild symptoms, it is difficult to predict who will develop severe complications. The ED nurse needs to be vigilant in the ongoing assessment of the patient's physiological status. Predictive tools can be used to assess the severity of pancreatitis, but most are of limited value on presentation.

1. Pain. Classically, it is epigastric and radiates through on the back.
2. Nausea and vomiting
3. Tachycardia
4. Hypotensive
5. Septic
6. Oliguric
7. Absent bowel sounds
8. Jaundice if there is obstruction within the biliary tract or associated cirrhosis.

Nursing Assessment

1. Vital signs
2. Pain assessment and score
3. Urine output
4. CBC, U&E, LFTs, Clotting, Lactic acid Ca+
5. ABG
6. Erect Xray 
7. ECG

Nursing Interventions

• O2
• IV access
• IV fluids
• IV antibiotics
• Fluid resuscitation if shocked
• Analgesia
• Anti-emetic
• NPM
• NG tube
• CVP monitoring in the critically ill.

Listening for bowel sounds: Nursing guidelines

9. Intestinal Obstruction

Intestinal obstruction is a common cause of acute abdomen and has different causes in the small and large bowel.

1. Small bowel obstruction is very commonly caused by adhesions. Less common causes are strangulated hernias and intussusception.
2. Obstruction of the colon is commonly caused by tumour, sigmoid volvulus, or diverticular disease.

The bowel becomes distended above the obstruction, inflamed, infiltrated by bacteria and in strangulation, ischaemic and gangrenous.

Signs and Symptoms

• Abdominal pain, Severe pain suggests strangulation
• Abdominal distension
• Vomiting, especially in small bowel obstruction
• Constipation
• Signs of shock
• Signs of peritonitis
• Fever
• Bowel sounds may be 'tinkling' or absent.

Nursing Assessment

1. Vital signs
2. Pain assessment and score
3. LMP
4. CBC,U&E, LFT, amylase/lipase, group
5. ECG
6. CXray
7. Abdominal Xray 
8. ABG

Nursing Interventions

1. IV access
2. O2
3. Analgesia
4. Anti-emetic
5. IV fluids
6. Fluid resuscitation if shock
7. IV antibiotics
8. NG tube

10. Diverticulitis

Diverticulitis is a common GI disease, thought to be a result of increased pressure in the lumen of the colon associated with a lack of dietary fibre. Increased luminal pressure contributes to the development of 'pouches' or diverticula on the outside of the colon. When these diverticula get blocked with food particles or faeces, they become infected. The severity of the symptoms depends on the extent of the infection and development of any complications e.g peritonitis from perforation. Diverticulitis is commoner in the middle-aged and elderly. Older patients and the immunosuppressed may not mount pyrexia or have obvious signs of peritonitis.

Signs and Symptoms

1. LLQ pain 
2. Fever 
3. Nausea
4. Constipation or diarrhoea
5. Peritonitis if the diverticula perforate.
6. A tender palpable mass in the LLQ may indicate abscess formation

Nursing Assessment

1. Vital signs
2. Pain assessment and score
3. LMP
4. CBC U&E , Grouping, blood cultures
5. Erect Xray
6. ABG

Nursing Interventions

1. IV access
2. NPM
3. Analgesia
4. Anti-emetic
5. IV fluids
6. Fluid resuscitation if shock
7. IV antibiotics
8. NG tube

Complications

1. Perforation
2. Intestinal obstruction
3. Massive PR bleeding
4. Fistula (small bowel, vaginal, bladder).