Cholecystitis

definition, etiology, pathophysiology, clinical manifeatations, diagnosis and management of cholecystitis

1. GALLBLADDER DISORDERS B y Y.V.Vanaja Lecturer Vijay Marie College of Nursing

2. Biliary tract disorders includes Cholelithiasis Acute cholecystitis Chronic cholecystitis

3. CHOLELITHIASIS / GALLSTONES

4. DEFINITION Gallstones are collections of cholesterol, bile pigment or a combination of the two, which can form in the gallbladder or within the bile ducts of the liver . calculi or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape and composition. “ Brunner’’

5. INCIDENCE The incidence increases with age The incidence of cholelithiasis is higher in women, multiparous women Post menopausal women on estrogen therapy Oral contraceptive pills Familial tendency Obesity

6. TYPES OF GALLSTONES

7. Pigment stones: pigment stones probably form when when unconjugated pigments in the bile precipitate to form stones May be black colour Cholesterol stones: In gall stone prone patients there is decreased bile acid synthesis and increased cholesterol synthesis in the liver resulting in bile supersaturated with cholesterol , which precipitate out of the bile to form bile stones. Smooth & whitish yellow to tan colour Mixed stones  Combination of cholesterol and pigment stones or other substance Calcium carbonate, phosphate , bile salts, and palmitate

8. ETIOLOGY Change in bile composition- Gallbladder stasis supersaturation of bile with cholesterol Infection and tissue injury Genetics Cirrhosis Hemolysis and infections of the biliary tract

9. Pathophysiology In gallstone prone patients there is decreased bile acid synthesis and increased cholesterol synthesis in the liver Super saturation of the bile with cholesterol or calcium Precipitation of solute from solvent to form solid crystal Crystals come together and fuse to form stones Venous and lymphatic drainage impaired Proliferation of bacteria occur

10. Localized cellular irritation & infiltration Ischemia and necrosis

11. Complaints of indigestion after eating high fat foods.  Localized pain in the right-upper quadrant epigastric region.  Anorexia, nausea , vomiting and flatulence

12. Increased heart and respiratory rate – causing patient to become diaphoretic which in turn makes them think they are having a heart attack.

13. Abdominal distention Changes in the urine and stool color Vitamin deficiency Low grade fever. Elevated leukocyte count. Mild jaundice. Stools that contain fat – steatorrhea . Clay colored stools caused by a lack of bile in the intestinal tract . Urine may be dark amber- to tea- colored .

14. DIAGNOSTICS TEST History of patient Physical examination Laboratory test for- Elevated conjugated bilirubin. Elevated alkaline phosphate Serum amylase and lipase Elevated WBC count Fecal studies .

15. Ultrasound of the gallbladder CT Scan MRI HIDA ( hepato - iminodiacetic acid) Cholangiography ERCP (endoscopic retrograde cholangiopancreatography )

16. MEDICAL MANAGEMENT MEDICAL MANAGEMENT GOALS- To resolve symptoms To remove stones To prevent complications PAIN MANAGEMENT Give analgesics Antacids , H2 blockers or proton pump inhibitors- to neutralize gastric acid For nausea and vomiting, Antiemetics given antibiotics

17. Gall stone dissolution Oral administration of agents- chenodeoxycholic acid (CDCA) or chenodal ursodeoxycholic acid (UDCA) or ursodiol Action- reduces the amount of cholesterol in bile

18. Lithotripsy Extracorporeal shock wave lithotripsy (ESWL ) 1500 shock waves directed at stones Used for fewer than 4 stones, each smaller than 3cm.

19. If stones are present in the common bile duct, an endoscopic sphincterotomy must be performed to remove them BEFORE a cholecystectomy is done. A number of various instruments are inserted through the endoscope in order to "cut" or stretch the sphincter. Once this is done, additional instruments are passed that enable the removal of stones and the stretching of narrowed regions of the ducts. Drains (stents) can also be used to prevent a narrowed area from rapidly returning to its previously narrowed state.

20. Surgical Management . Cholecystectomy or Laparoscopic Cholecystectomy – removal of the gallbladder . This is the treatment of choice. The gallbladder along with the cystic duct, vein and artery are ligated

21. Laproscopic cholecystectomy

22. CHOLECYSTITIS

23. TYPES OF CHOLECYTITIS Acute cholecystitis Chronic cholecystitis

24. ACUTE CHOLECYSTITIS DEFINITION; Acute cholecystitis refers to acute inflammation of the gallbladder wall.

25. TYPES OF ACUTE CHOLECYSTITIS Two types of acute cholecystitis can occur Calculous cholecystitis Acalculous cholecystitis 1) Calculous : -It is the obstructive cholecystitis due to gall stones having the most common variety in which around 90% of people having gall stones suffers. 2 ) Acalculous : -It is the non-obstructive type which is common in person suffering from major illness like sever sepsis, burns, DM, dehydration, multiple injury etc .

26. ETIOLOGY  Gall stone in cystic duct Obstruction in cystic duct  Bacterial infection (gram positive and gram negative aerobes and anaerobes:- E. Coli, klebsiella , Clostredium and streptococcus)

27. Pathophysiology Gall stones irritation and inflammmartion Obstruct the cystic duct , gallbladder neck, or a common bile duct When the gallbladder is inflamed trapped bile is reabsorbed and acts as a chemical irritant to the gallbladder wall reabsorbed bile, in combination with impaired circulation, edema, and distention of gallbladder, causes ischemia and infection The result is tissue sloughing with necrosis and gangrene the gallbladder wall may eventually perforate peritonitis

28. PROGRESSION OF ACUTE CHOLECYSTITIS. - Gallbladder has a grayish appearance & is edematous . - There is an obstruction of the cystic duct and the gallbladder begins to swell . - It no longer has the "robin egg blue" appearance of a normal gallbladder.

29. - As acute cholecystitis progresses, the gallbladder begins to become necrotic and gets a speckled appearance as the wall begins to die.

30. - Gallbladder undergoes gangrenous change and the wall becomes very dark green or black. - This is the stage when perforation occurs.

31. SIGNS AND SYMPTOMS Complain of pain In right upper quadrant In epigastric region In right subscapular Onset sudden Peak in 30min Nausea and vomiting Low grade fever Mild jaundice

32. CHRONIC CHOLECYSTITIS DEFINITION- Repeated inflammation and infection of gallbladder

33. SIGNS AND SYMPTOMS  Epigastric pain Indigestion Fat intolerance Heart burn Fibrosis of gall tissues Inability to concentrate bile

34. MEDICAL MANAGEMENT GOAL-  to treat symptomatic causes  to prevent complication

35. Antibiotic therapy- Ampicillin  Ureidopenicillins – piperacillin or mezlocillin Third generation cephalosporins - Ceftriaxone, cefixime , Cefotaxime Aminoglycosides – Gentamicin, Amikacin , Neomycin

36. SURGICAL MANAGEMENT cholecystectomy

37. Nursing Interventions Post Op - Cholesystectomy 1. Administer oral analgesics to facilitate movement and deep breathing – and to stay ahead of pts pain. 2. Observe dressings frequently for exudate and hemorrhage . 3. Vitals are routinely checked. 4. Patient teaching: -Must understand how to splint the abd . before coughing. -Report any abnormalities such as, severe pain, tenderness in RUQ, increase in pulse, etc . . -Instructed that they usually can return to work in 3 days & can resume full activity in 1 week. 5. Fluid balance is maintained IV – potassium added to compensate for loss from surgery.

38. Nursing Interventions 1. Urine and stool should be observed for alterations in the presence of bilirubin. 2. NG tube must be monitored for amount, color & consistency of output. Also, tube must be on LOW suction and nasal area should be monitored for irritation and necrosis. 3. Anti-emetics may be administered if nausea persists. 4. I & O are measured and described carefully. 5. Pt. must understand how to splint the abdomen for post op coughing, turning and deep breathing. Interventions center on keeping patient comfortable by carefully administering meds and watching for reactions.