CHOLECYSTITIS with

CHOLECYSTOLITHIASIS
 Overview

The normal anatomy and physiology of the GB

 
GALLBLADDER

The GB which is a small pear - shaped organ that stores and concentrates the
bile . The gallbladder is connected to the liver by the hepatic duct . It is
approximately 3 to 4 inches ( 7 . 6 to 10 . 2 cm ) long and about 1 inch ( 2 . 5 cm )
wide .

What is its Function?

The function of the gallbladder is to store bile and concentrate . Bile is a

digestive liquid continually secreted by the liver . The bile emulsifies
fats and neutralizes acids in partly digested food . A muscular valve in the
common bile duct opens , and the bile flows from the gallbladder into the
cystic duct , along the common bile duct , and into the duodenum ( part of the
small intestine ).

Cholecystitis

Cholecystitis is painful inflammation of the gallbladder , a small organ

near the liver that plays a part in digesting food . Normally , fluid called
bile passes out of the gallbladder on its way to the small intestine . If
the flow of bile is blocked , it builds up inside the gallbladder , causing
swelling , pain , and possible infection .

Cholecystolithiasis

The presence of one or more gallstones in the gallbladder.

 Overview

What are the symptoms?

The most common symptom of cholecystitis is pain in your upper right

abdomen that can sometimes move around to your back or right shoulder
blade . Other symptoms include :

Nausea or vomiting .
Tenderness in the right abdomen .
Fever .
Pain that gets worse during a deep breath .
Pain for more than 6 hours , particularly after meals .
Constant pain in the right upper abdomen . It is usually made worse
by moving .
Jaundiced skin

Older people may not have fever or pain . Their only symptom may be a tender
area in the abdomen .

Eating fatty foods will often make the symptoms worse . When the bacterial
infection sets in , many patients experience a higher fever and shaking
chills .
 
 Overview
What causes it?

A gallstone stuck in the cystic duct , a tube that carries bile from the
gallbladder , is most often the cause of sudden ( acute ) cholecystitis .
The gallstone blocks fluid from passing out of the gallbladder . This
results in an irritated and swollen gallbladder . Infection or trauma ,
such as an injury from a car accident , can also cause cholecystitis .

Who gets it?

Cholecystitis strikes :

Twice as many women than men , particularly those between the

ages of twenty and sixty .

Pregnant women , or those on birth control pills or estrogen

replacement therapy have a greater risk of developing cholecystitis .

People who are overweight , or who lose a large amount of weight

quickly are also at greater risk for developing the condition .
 PATIENT ’ S PROFILE
Name : Patient “X”
Birth date : 11-14-35
Nationality : Filipino
Religion : Roman Catholic
Occupation : Palay Buying Station (Self-proprietor)
Admission : 8-13-09
Admission time : 9:15 am
Physician : Dr. Lagunilla
Chief Complaint : Right Lower Quadrant pain
 
History of Present illness

One year prior to admission the patient experiences Right Lower

Quadrant pain but did not consult a doctor and chose to self medicate with
pain relievers.

Few hours PTA as RLQ pain with vomiting, weakness.

Genetics
Has family history of “gallstones” (-) Hypertension
First hospital confinement (-) diabetes
Non-smoker
 CHOLECYSTITIS
Is inflammation of the gallbladder, usually resulting from
a gallstone blocking the cystic duct.

Gallbladder inflammation usually results from a gallstone

blocking the flow of bile.

Typically, people have abdominal pain that lasts more than 6

hours, fever, and nausea.

Ultrasonography can usually detect signs of gallbladder

inflammation.

The gallbladder is removed, often using a laparoscope.

Is the most common problem resulting from gallbladder stones. It

occurs when a stone blocks the cystic duct, which carries bile from
the gallbladder.

Cholecystitis is classified as acute or chronic.

 CHOLECYSTITIS
Acute Cholecystitis:

Acute cholecystitis begins suddenly, resulting in

severe, steady pain in the upper abdomen.

At least 95% of people with acute cholecystitis have

gallstones.

The inflammation almost always begins without infection,

although infection may follow later.

Inflammation may cause the gallbladder to fill with fluid and

its walls to thicken.

Rarely, a form of acute cholecystitis without gallstones

(acalculous cholecystitis) occurs.
 
 CHOLECYSTITIS
Acalculous cholecystitis is more serious than other
types of cholecystitis. It tends to occur after the following:

Major surgery

Critical illnesses such as serious injuries, major burns,

and bodywide infections (sepsis)

Intravenous feedings for a long time

Fasting for a prolonged time

A deficiency in the immune system

It can occur in young children, perhaps developing from a viral

or another infection.
 
 CHOLECYSTITIS
Chronic Cholecystitis:

Chronic cholecystitis is gallbladder inflammation that has

lasted a long time. It almost always results from gallstones.

It is characterized by repeated attacks of pain (biliary colic).

In chronic cholecystitis, the gallbladder is damaged by repeated
attacks of acute inflammation, usually due to gallstones, and
may become thick-walled, scarred, and small.

The gallbladder usually contains sludge (microscopic particles of

materials similar to those in gallstones), or gallstones that either block its
opening into the cystic duct or reside in the cystic duct itself.

Gallstones (choleliths) are crystalline bodies formed within the body

by accretion or concretion of normal or abnormal bile components.
CHOLECYSTOLITHIASIS
 
 CHOLECYSTOLITHIASIS
CHOLECYSTOLITHIASIS

The presence of one or more gallstones in the

gallbladder.

 
 DIAGNOSTIC PROCEDURE
DIAGNOSTIC PROCEDURES

ASSESSMENT and DIAGNOSTIC METHODS

Abdominal radiograph ultrasonography or

cholecytography radionuclide imaging or
cholescintigraphy. (ERCP) Percutaneous transhepatic
cholangiography (PTC)
 
ULTRA- SOUND RESULTS
 
The gallbladder is normal in size. The wall is thick,
thickness measures 8mm. There is a large highly
 DIAGNOSTIC PROCEDURE
CD and CND are normal in caliber. No billiary
obstruction.

The liver is not enlarged. The echo texture is

uniform. No focal lesion.

The pancreas, spleen and both kidneys are

unremarkable.

The urinary bladder shows smooth wall no

intraluminal echo.

The uterus is atropic.

 DIAGNOSTIC PROCEDURE
BLOOD TEST
HEMATOCRIT .32 Normal Value
( female = . 37 -. 42 )
( Male =. 42 -. 48 )

WBC Count 10 . 0 (N) ( female = 5 . 0 - 10 . 0x

109 L )
( Male = 5 . 0 - 10 . 0x109L )

Neutrophil .83 . 55 -. 65

Lymphocyte .17 . 25 -. 35
 DIAGNOSTIC PROCEDURE
IV FLUIDS TAKEN
Date of Bottle No . Volume in cc IV - Fluid Regulation
Infusion

8 - 12 - 09 0 1000cc D5LRS 41 - 42gttts / min

8 - 13 - 09 1 1000cc D5LRS 41 - 42gtts / min

8 - 13 - 09 2 1000cc D5 LRS SR

8 - 14 - 09 3 1000cc D5 LRS SR

8 - 15 - 09 4 1000cc D5 NSS 41 - 42gtts / min

8 - 16 - 09 5 1000cc D5 NSS 41 - 42gtts / min

8 - 17 - 09 6 1000CC D5 NSS 41 - 42gtts / min

 DIAGNOSTIC PROCEDURE
URINALYSIS
Date ordered : 08 – 18 – Microscopic
09

Color : yellow puscell : 3 – 6

Character : slightly R.B.C: 8 – 15
turbid
Epith . Cells : moderate
Date ordered : 08 – 18 – microscopic
09
Color : yellow puscell : 3 – 6
Character : slightly R.B.C: 8 – 15
turbid
Epith . Cells : moderate
 DIAGNOSTIC PROCEDURE
DIAGNOSTIC SONOGRAPHY (ULTRASONOGRAPHY)
Is an ultrasound-based diagnostic imaging technique
used to visualize subcutaneous body structures including
tendons, muscles, joints, vessels and internal organs foe
possible pathology or lesions.

CHOLESCINTIGRAPHY
Is a test done by nuclear medicine physicians to
diagnose obstruction of the bile ducts (foe example, by a
gallstone or a tumor), disease of the gallbladder, and bile leaks.
It sometimes is referred to as a HIDA scan or a GALLBLADDER
scan.
 
PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY (PTHC or PTC)
Is a radiologic technique used to visualize the
anatomy of the biliary tract. A contrast medium is injected into
 PATHOPHYSIOLOGY
Risk Factors
Heredity, age over
40, gender,obesity

Bile is The solute Crystals come

supersaturated with precipitate from together and
cholesterol and solution as solid fuse to form
calcium crystals stones

Gallstones

Obstruction of the cystic duct and

common bile duct

Sharp pain in
the right lower Jaundice
part of the Distention of the
abdomen gall bladder

Venous and lymphatic Proliferatio Localized

drainage is impaired n of cellular
Bacteria Irritation

The gall bladder gets

inflammed
 PATHOPHYSIOLOGY
Cholelithiasis is the presence of stones in the
gallbladder.

Cholecystitis is acute or chronic inflammation of the

gallbladder.

Most gallstones result from supersaturation of cholesterol in

the bile, which acts as an irritant, producing inflammation in
the gallbladder, and which precipitates out of bile, causing stones.

Risk factors include :

gender (women four times as like to develop cholesterol

stones as men),
age (older than age 40),
multiple parity, obesity,
use of estrogen and cholesterol-lowering drugs,
bile acid malabsorption with GI disease,
genetic predisposition, rapid weight loss.
 MEDICAL MANAGEMENT
NURSING
NAME INDICATION ACTION SIDE EFFECT MANAGEMENT

PARACETAMOL Can be taken to Used for the relief Skin rashes, blood You may need to
(ACETAMINOPHEN relieve a variety of of fever, disorders and a adjust your usual dose
of anticoagulants (eg
) common aches and headaches, and swollen pancreas warfarin) if you take
pains including other minor aches have occasionally paracetamol regularly.
headache, muscle and pains. happened in Check with your
and joint pain, Paracetamol is people taking the anticoagulation clinic.
backache and also useful in drug on a regular Otherwise there are no
period pains. managing more basis for a long serious interactions
between paracetamol
severe pain, time.
and other drugs
allowing lower
dosages of
additional non-
steroidal anti-
inflammatory
drugs (NSAIDs)
 MEDICAL MANAGEMENT
MOTILIUM Motilium is a Motilium works by Stomach cramps. Folic Acid may be
(DOMPERIDONE) medicine that blocking the action Diarrhoea. Itchy taken with or without
increases the of a chemical nettle-type rash food.
movements or messenger in the (urticaria). Swallow whole. Do
contractions of the brain which causes Abnormal or not break, crush, or
stomach and bowel. the feeling of nausea uncontrolled chew before
Motilium is also and vomiting, as movements of the swallowing.
used to treat nausea well as increasing hands, legs, face,
and vomiting caused the movement or eyes, neck or tongue,
by other drugs used contractions of the for example tremor,
to treat Parkinson's stomach and twitching or stiffness
Disease. intestines, allowing (extrapyramidal
food to move more effects). Consult a
easily through the doctor straight away
stomach. if you notice any
symptoms like this.
Allergic reaction
 MEDICAL MANAGEMENT
TORADOL Reduces the production of Ketorolac is most often Common side effects An FDA-approved
(KETOROLAC) prostaglandins, chemicals used to treat pain from ketorolac include medication guide must be
that cells of the immune following a procedure rash, distributed when
system make that cause the but may also be used ringing in the ears, dispensing an oral
redness, fever, and pain of for such things as pain headaches, dizziness, outpatient prescription
inflammation and that also caused by drowsiness, (new or refill) where this
are believed to be kidney stones, abdominal pain, nausea medication is to be used
important in the back pain, or cancer , diarrhea, constipation without direct
production of non- pain. , heartburn, and fluid supervision of a health
inflammatory pain. It does retention. NSAIDs care provider.
this by blocking the reduce the ability of
enzymes that cells use to blood to clot and Assess Pain ( Note :
make prostaglandins therefore increase Type Location
Intensity )
(cyclooxygenase 1 and 2). bleeding after an
As a result, pain as well as injury. Ketorolac may Short term
inflammation and its signs cause ulcers and management of pain
and symptoms - redness, bleeding in the stomach
swelling, fever, and pain - and intestines,
are reduced. particularly with use
for more than five
days.
 MEDICAL MANAGEMENT
METOCROPLAMIDE Is an Treat slow Get emergency You should not
( REGLAN ) antiemetic and gastric medical help take this
gastroprokinetic
emptying in if you have medication if
agent . Thus people with any of these you are
it is diabetes ( also signs of an allergic to
primarily used called allergic metoclopramide ,
to treat diabetic reaction : or if you have
nausea and gastroparesis ) hives ; bleeding or
vomiting , and , which can difficulty blockage in
to facilitate cause nausea , breathing ; your stomach
gastric vomiting , swelling of or intestines ,
emptying in heartburn , your face , epilepsy or
patients with loss of lips , tongue , other seizure
gastroparesis. appetite , and or throat . disorder , or an
a feeling of adrenal gland
fullness tumor
after meals (pheochromocyto
ma ).
 MEDICAL MANAGEMENT
CEFUROXIME As for the Cefuroxime is Nausea , CEFTIN should
( CEFTIN ) other used to treat vomiting , be used only
cephalosporins many kinds of diarrhea , to treat or
, although as bacterial stomach pain ; prevent
a second - infections , sleep infections
generation it including problems that are
is less severe or ( insomnia ); or proven or
susceptible to life - vaginal strongly
Beta - lactamase threatening itching or suspected to
and so may forms . discharge . be caused by
have greater bacteria .
activity
against
Haemophilus
influenzae,
Neisseria
gonorrhoeae
and
Lyme disease.
 SURGICAL INTERVENTIO
CHOLECYSTECTOMY

is the surgical removal of the gallbladder. The

operation is done to remove gallstones or to remove
an infected or inflamed gallbladder.

BENEFITS and RISK

Gallbladder removal will relieve pain, treat infection, and in most

cases stop gallstones from coming back. The risks of not having
surgery are the possibility of worsening symptoms, infection, or
bursting of the gallbladder.

Possible complications include bleeding, bile duct injury, fever,

liver injury, infection, numbness, raised scars, hernia at the
incision, anesthesia complications, puncture of the intestine, and
death.
 NURSING MANAGEMENT
Discharge planning:

Advise patient to continue medication as ordered by the

physician.

Instruct the patient to do exercise as tolerated such as

walking.

Encourage the patient to increase fluid intake

Encourage the patient to have enough and adequate rest

Instruct patient to attend follow up checkups to the

physician.

Advised patient to a diet as tolerated but preferably low

salt and low fat diet.
 NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation

Short term : > Obtain > To rule out > After eight
Subjective : Acute pain   client ’ s worsening of hours of nursing
related to > After eight assessment of underlying intervention the
>” Masakit ang inflammation and hours of pain to include condition / client ’ s pain and
tagiliran ko .” as distortion of nursing location , development of discomforts are
verbalized by tissues as characteristics , complications . relieved .
the patient . intervention ,
evidenced by onset / duration ,  
verbal reports , the client will frequency , > To note > The goal is
Objective : guarding and be able to quality , factors that can met .
protective / distr report that intensity and affect responses  
> Observed action behaviors . pain is precipitating / ag to analgesics > After a week
evidence of pain . relieved / gravating and / or choice of of nursing
controlled . factors . Note and interventions intervention , the
> Guarding investigate for pain patient is able
behavior ; changes from management . to verbalize &
protective Long term :
previous reports .   demonstrate use
gestures ;
positioning to > After a week   > To medicate of relaxation
of nursing > Determine prophylactically skills and
avoid pain factors in as appropriate . diversional
intervention , client ’ s activities , as
>Grimacing the patient lifestyle ( e . g . > to indicated for
will be able to alcohol / other alleviate / contro individual
>Restlessness verbalize & drug use / abuse ) l pain . situation .
demonstrate use
> Change in blood of relaxation > Note when pain > to promote non -
pressure , heart > The goal is
rate & skills and occurs ( e . g . only pharmacological met .
respiratory rate . diversion with ambulation , pain management .  
activities , as every evening ,  
indicated , for every movement .)  
individual
situation .
 NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation

> Collaborate in > To maintain

treatment of acceptable
underlying “ level of pain ”.
condition / diseas Notify physician
e processes if regimen is
causing pain & inadequate to
proactive meet pain
management of control goal .
pain .  
  > To distract
> Provide comfort attention and
measures ( e . g . reduce tension .
touch ,  
repositioning , > To reduce
nurse ’ s concern of the
presence ), quiet unknown and
environment , and associated
calm activities . muscle tension .
   
> Administer > To help reduce
analgesics , as precipitating
indicated to factors that may
maximum dosage , increase pain .
as needed .  
> To prevent
fatigue .
 NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation

> Instruct
in / encourage use
of relaxation
techniques , such
as focused
breathing ,
imaging ,
CD ’ s / tapes ( e . g .
“ white , noise ,
music ,
instructional ”)
 
> Review
procedures / expect
ations and tell
client when
treatment may
cause pain
 
> Review ways to
lessen pain ,
including
techniques such
as therapeutic
touch ( TT ),
biofeedback ,
self - hypnosis and
relaxation skills
 
> Encourage
adequate rest
periods .
 NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective : Activity Short term : > Note presence of > Fatigue affects > After eight
intolerance   factors both the client ’ s hours of nursing
>” Nanghihina secondary to the > After eight contributing to actual and intervention , the
ako ,” as underlying hours of nursing fatigue ( e . g . age , perceived ability client is able to
verbalized by the disease process intervention , thefrail , acute or to participate in achieve optimum
patient . client will be chronic illness , activities . level of
able to achieve heart failures , functioning .
Objective : optimum level of hypothyroidism , > Symptoms may be
functioning . cancer and cancer result of / or > The goal is
> weak in therapies . contribute to met .
appearance Long term : intolerance of
> abnormal heart > Note client activity . > After a week of
rate / blood > After a week of reports of nursing
pressure response nursing weakness , fatigue , > To determine intervention , the
to activity . intervention the pain , difficulty current status patient is able
>electrocardiogra patient will be accomplishing and needs to verbalize and
phic changes able to verbalize tasks , and / or associated with demonstrate
reflecting and demonstrate insomnia . participation in relaxation skills
arrhythmias / or relaxation skills needed / desired and increase in
ischemia ( pallor , and increase the > Ascertain activities . activity
cyanosis ) activity ability to tolerance .
tolerance . stand and move > To conserve
about and degree energy . > The goal is
of assistance met .
necessary / use of > To sustain
equipments . motivation .
> Increase
exercise /
activity levels
gradually .
 NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation

> Give client > Both activity

information that tolerance and
provides evidence health status may
of daily / weekly improve with
progress . progressive
training .
> Plan for
progressive
increase of
activity and
participation in
exercise
training , as
tolerated by
client .
 NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective : Alteration in Short term : > Monitor core > To rule out > After 15
>” masakit ang ulo body temperature > After 15 min of care temperature worsening of minutes of
ko at nilalamig related to the nursing preferably . underlying nursing
ako ,” as body ’ s primary intervention , the condition intervention , the
verbalized by the reaction to client will be > Administer > To reduce body client ’ s headache
patient . infection , as able to report antipyretics , temperature . and fever and
evidenced by that headache and orally / rectally > To support chills are
Objective : hyperthermia fever and chills ( e . g . aspirin , circulating relieved .
> Febrile : 38 . 9 ° C is relieved . acetaminophen ) volume and tissue > The goal is
> flushed skin ; Long term : > Administer perfusion . met .
warm to touch . > After 2 days , replacement of > To reduce > After 2 days ,
> tachypnea ; 30 the patient will fluids and metabolic the patient is
breaths / min be able to electrolytes . demands / oxygen able to verbalize
( unstable BP ) verbalize relief > Maintain bed consumption relief of
of headache and rest . > To prevent headache and
fever and chills . > Discuss dehydration fever and chills .
importance of > Indicates need > The goal is
adequate fluid for prompt met .
intake intervention .
> Review signs /
symptoms of
hyperthermia ( e . g .
flushed skin ,
increased body
temperature ,
increased
respiratory /
heart rate ,
fainting , loss of
consciousness ,
seizures .