Acute Cholecystitis

1. Dave Jay S. Manriquez RN.
Acute Cholecystitis
I. Introduction
Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis
is usually caused by a gallstone in the cystic duct, the duct that connects the gallbladder to the
hepatic duct. The presence of gallstones in the gallbladder is called cholelithiasis. Cholelithiasis is
the pathologic state of stones or calculi within the gallbladder lumen. A common digestive
disorder worldwide, the annual overall cost of cholelithiasis is approximately $5 billion in the
United States, where 75­80% of gallstones are of the cholesterol type, and approximately 10­25%
of gallstones are bilirubinate of either black or brown pigment. In Asia, pigmented stones
predominate, although recent studies have shown an increase in cholesterol stones in the Far
East.
Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of
particles, accumulation) of normal or abnormal bile constituents. According to various theories,
there are four possible explanations for stone formation. First, bile may undergo a change in
composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose
a person to stone formation. Fourth, genetics and demography can affect stone formation.
Risk factors associated with development of gallstones include heredity, obesity, rapid weight
loss, through diet or surgery, age over 60, Native American or Mexican American racial makeup,
female gender where gallbladder disease is more common in women than in men. Women with
high estrogen levels, as a result of pregnancy, hormone replacement therapy, or the use of birth
control pills, are at particularly high risk for gallstone formation. Diet with very low calorie diets,
prolonged fasting, and low­fiber/high­cholesterol/high­starch diets all may contribute to gallstone
formation.
Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will
eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion,
especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or
pickles, (2) Nausea and bloating (3) Attacks of sharp pains in the upper right part of the abdomen.
This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying
(usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a
gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow
of bile from both the gallbladder and the liver. This is a serious complication and usually requires
immediate treatment.
The only treatment that cures gallbladder disease is surgical removal of the gallbladder, called
cholecystectomy. Generally, when stones are present and causing symptoms, or when the
gallbladder is infected and inflamed, removal of the organ is usually necessary. When the

2. gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X­rays, and
remove any stones that may be lodged there. The ducts are not removed so that the liver can
continue to secrete bile into the intestine. Most patients experience no further symptoms after
cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled
with a special diet and medication.
II. Epidemiology
 Frequency
An estimated 10­20% of Americans have gallstones, and as many as one third of these people
develop acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute
cholecystitis is the most common major surgical procedure performed by general surgeons,
resulting in approximately 500,000 operations annually.
Cholelithiasis, the major risk factor for cholecystitis, has an increased prevalence among people
of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less
common among individuals from sub­Saharan Africa and Asia.
 Mortality/Morbidity
Most patients with acute cholecystitis have a complete remission within 1­4 days. However, 25­
30% of patients either require surgery or develop some complication. Patients with acalculous
cholecystitis have a mortality rate ranging from 10­50%, which far exceeds the expected 4%
mortality rate observed in patients with calculous cholecystitis. Emphysematous cholecystitis has
a mortality rate approaching 15%. Perforation occurs in 10­15% of cases.
 Race
Pima Indian and Scandinavian people have the highest prevalence of cholelithiasis and,
consequently, cholecystitis. Populations at the lowest risk reside in sub­Saharan Africa and Asia.
In the United States, white people have a higher prevalence than black people.
 Sex
Gallstones are 2­3 times more frequent in females than in males, resulting in a higher incidence
of calculous cholecystitis in females. Elevated progesterone levels during pregnancy may cause
biliary stasis, resulting in higher rates of gallbladder disease in pregnant females. Acalculous
cholecystitis is observed more often in elderly men.
 Age
The incidence of cholecystitis increases with age. The physiologic explanation for the increasing
incidence of gallstone disease in the elderly population is unclear. The increased incidence in
elderly men has been linked to changing androgen­to­estrogen ratios.

3. III. Anatomy and Physiology
Gallbladder, a muscular organ that serves as a reservoir for bile, is usually present in most
vertebrates. In humans, it is a pear­shaped membranous sac on the undersurface of the right
lobe of the liver just below the lower ribs. It is generally about 7.5 cm (about 3 in) long and 2.5 cm
(1 in) in diameter at its thickest part; it has a capacity varying from 1 to 1.5 fluid ounces. The body
(corpus) and neck (collum) of the gallbladder extend backward, upward, and to the left. The wide
end (fundus) points downward and forward, sometimes extending slightly beyond the edge of the
liver. Structurally, the gallbladder consists of an outer peritoneal coat (tunica serosa); a middle
coat of fibrous tissue and unstriped muscle (tunica muscularis); and an inner mucous membrane
coat (tunica mucosa)
The function of the gallbladder is to store bile, secreted by the liver and transmitted from that
organ via the cystic and hepatic ducts, until it is needed in the digestive process. The gallbladder,
when functioning normally, empties through the biliary ducts into the duodenum to aid digestion
by promoting peristalsis and absorption, preventing putrefaction, and emulsifying fat. Digestion of
fat occurs mainly in the small intestine, by pancreatic enzymes called lipases. The purpose of
bile is to; help the lipases to work, by emulsifying fat into smaller droplets to increase access for
the enzymes, Enable intake of fat, including fat­soluble vitamins: Vitamin A, D, E, and K, rid the
body of surpluses and metabolic wastes cholesterol and bilirubin.

4. IV. Pathophysiology
RISK FACTORS
Heredity
Obesity
Rapid Weight Loss, through diet or surgery
Age over 60
Bile must become The solute precipitate Crystals must come
supersaturated with from solution as solid together and fuse to
cholesterol and calcium crystals form stones
Gallstones
Obstruction of the cystic duct and common bile duct
Sharp pain in the right part Jaundice
of the abdomen
Distention of the gall bladder
Localized cellular
Venous and lymphatic Areas of ischemia may
Proliferation of bacteria irritation or infiltration or
drainage is impaired occur
both take place
Inflammation of the gall bladder
CHOLECYSTITIS

5. V. Signs and Symptoms
• intense and sudden pain in the upper right part of the abdomen
• recurrent painful attacks for several hours after meals
• pain (often worse with deep breaths, and extending to the lower part of the right shoulder
blade)
• nausea
• vomiting
• rigid abdominal muscles on right side
• slight fever
• chills
• jaundice ­ yellowing of the skin and eyes
• loose, light­colored bowel movements
• abdominal bloating
VI. Diagnostic and Laboratory Procedures
a. Complete Blood Count
 This is to determine blood components and the response to inflammatory process
and streptococcal infection
b. Fasting Blood Sugar
 This is to measure the blood glucose levels
c. Creatinine
 This is the indicator of the renal function
d. Blood Urea Nitrogen (BUN)
 This is an indicator of renal function and perfusion, dietary intake of protein and the
level of protein metabolism
e. Urinalysis
 Urinalysis yields a large amount of information about possible disorders of the kidney
and lower urinary tract, and systematic disorders that alter urine composition.
Urinalysis data include color, specific gravity, pH, and the presence of protein, RBC’s,
WBC’s, bacteria, leukocyte, esterase, bilirubin, glucose, ketones, casts and crystals
f. Chest X­ray
 This is used to rule out respiratory causes of referred pain.
g. Ultrasound/Sonography

6.  A diagnostic imaging technique which uses high­frequency sound waves to create an
image of the internal organs. Ultrasounds are used to view internal organs of the
abdomen such as the liver spleen, and kidneys and to assess blood flow through
various vessels.
h. Hepatobiliary Scintigraphy
 An imaging technique of the liver, bile ducts, gallbladder, and upper part of the small
intestine.
i. Cholangiography
 X­ray examination of the bile ducts using an intravenous (IV) dye (contrast).
j. Percutaneous Transhepatic Cholangiography (PTC)
 A needle is introduced through the skin and into the liver where the dye (contrast) is
deposited and the bile duct structures can be viewed by x­ray.
k. Endoscopic Retrograde Cholangiopancreatography (ERCP)
 A procedure that allows the physician to diagnose and treat problems in the liver,
gallbladder, bile ducts, and pancreas. The procedure combines x­ray and the use of
an endoscope. A long, flexible, lighted tube is used. The scope is guided through the
patient's mouth and throat, then through the esophagus, stomach, and duodenum.
The physician can examine the inside of these organs and detect any abnormalities.
A tube is then passed through the scope, and a dye is injected which will allow the
internal organs to appear on an x­ray.
l. Computed Tomography Scan (CT Scan)
 A diagnostic imaging procedure using a combination of x­rays and computer
technology to produce cross­sectional images (often called slices), both horizontally
and vertically, of the body. A CT scan shows detailed images of any part of the body,
including the bones, muscles, fat, and organs. CT scans are more detailed than
general x­rays.
VII. Medical / Surgical Interventions
1. Intake and Output – I&O measurement provide another means of assessing fluid
balance. This data provide insight into the cause of imbalance such as decrease fluid
intake or increase fluid loss. This measurement is not that accurate as body weight,
however, because of relative risk of errors in recording.
2. Electrocardiogram – The ECG is an essential tool in evaluating cardiac rhythm.
Electrocardiography detects and amplifies the very small electrical potential changes

7. between different points on the surface of the body as a myocardial cell depolarize and
repolarize, causing the heart to contract.
3. O2 Inhalation – Oxygen therapies are used to provide more oxygen to the body into
order to promote healing and health.
4. Intravenous Rehydration – when the fluid loss is severe or life threatening, intravenous
(IV) fluids are used for replacement.
5. Cholecystectomy – removal of the gallbladder. This procedure may be performed to
treat chronic or acute cholecystitis, with or without cholelithiasis, to remove a malignancy
or to remove polyps.
6. Cholecystotomy – the establishment of an opening into the gallbladder to allow
drainage of the organ and removal of stones. A tube is then placed in the gallbladder to
established external drainage. This is performed when the patient cannot tolerate
cholecystectomy.
7. Choledochoscopy – the insertion of a choledochoscope into the common bile duct in
order to directly visualize stones and facilitate their extraction.
VIII. Nursing Management
A. Pain Management
ACTIONS / INTERVENTIONS RATIONALE
­>assists in differentiating cause of pain and
1. Observe and document location, severity (0–10
provides information about disease
scale), and character of pain (e.g., steady,
progression/resolution, development of
intermittent, colicky).
complications, and effectiveness of interventions
­>severe pain not relieved by routine measures
2. Note response to medication, and report to
may indicate developing complications/need for
physician if pain is not being relieved.
further intervention
­>bed rest in low­Fowler’s position reduces intra­
3. Promote bed rest, allowing patient to assume
abdominal pressure; however, patient will
position of comfort.
naturally assume least painful position
4. Use soft/cotton linens; calamine lotion, oil (Alpha­ ­>reduces irritation/dryness of the skin and itching
Keri) bath; cool/moist compresses as indicated. sensation
­>cool surroundings aid in minimizing dermal
5. Control environmental temperature.
discomfort

8. 6. Encourage use of relaxation techniques, e.g.,
­>promotes rest, redirects attention, may enhance
guided imagery, visualization, deep­breathing
coping
exercises. Provide diversional activities.
7. Make time to listen to and maintain frequent ­>helpful in alleviating anxiety and refocusing
contact with patient. attention, which can relieve pain
B. Maintain Adequate Fluid Balance
ACTIONS / INTERVENTIONS RATIONALE
1. Maintain accurate I&O, noting output less than
intake, increased urine specific gravity. Assess ­>provides information about fluid
skin/mucous membranes, peripheral pulses, and status/circulating volume and replacement needs
capillary refill.
2. Monitor for signs/symptoms of increased/continued
nausea or vomiting, abdominal cramps, weakness, ­>prolonged vomiting, gastric aspiration, and
twitching, seizures, irregular heart rate, restricted oral intake can lead to deficits in
paresthesia, hypoactive or absent bowel sounds, sodium, potassium, and chloride
depressed respirations.
3. Eliminate noxious sights/smells from environment. ­>reduces stimulation of vomiting center
4. Perform frequent oral hygiene with alcohol­free ­>decreases dryness of oral mucous membranes;
mouthwash; apply lubricants. reduces risk of oral bleeding
5. Use small­gauge needles for injections and apply
­>reduces trauma, risk of bleeding/hematoma
firm pressure for longer than usual after
formation
venipuncture.
6. Assess for unusual bleeding, e.g., oozing from ­>prothrombin is reduced and coagulation time
injection sites, epistaxis, bleeding gums, prolonged when bile flow is obstructed, increasing
ecchymosis, petechiae, and hematemesis/melena. risk of bleeding/hemorrhage
C. Nutrition Management
ACTIONS / INTERVENTIONS RATIONALE
­>identifies nutritional deficiencies/needs.
1. Estimate/calculate caloric intake. Keep comments
Focusing on problem creates a negative
about appetite to a minimum.
atmosphere and may interfere with intake
2. Weigh as indicated. ­>monitors effectiveness of dietary plan
3. Consult with patient about likes/dislikes, foods that ­>involving patient in planning enables patient to
cause distress, and preferred meal schedule. have a sense of control and encourages eating
4. Provide a pleasant atmosphere at mealtime;
­>useful in promoting appetite/reducing nausea
remove noxious stimuli.

9. 5. Provide oral hygiene before meals. ­>a clean mouth enhances appetite
­>may lessen nausea and relieve gas.
6. Offer effervescent drinks with meals, if tolerated. Note: may be contraindicated if beverage causes
gas formation/gastric discomfort
7. Assess for abdominal distension, frequent belching, ­>nonverbal signs of discomfort associated with
guarding, and reluctance to move. impaired digestion, gas pain
­>helpful in expulsion of flatus, reduction of
abdominal distension. Contributes to overall
8. Ambulate and increase activity as tolerated. recovery and sense of well­being and decreases
possibility of secondary problems related to
immobility (e.g., pneumonia, thrombophlebitis)
D. Teaching the Disease Process
ACTIONS / INTERVENTIONS RATIONALE
1. Provide explanations of/reasons for test procedures ­>information can decrease anxiety, thereby
and preparation needed. reducing sympathetic stimulation
2. Review disease process/prognosis. Discuss ­>provides knowledge base from which patient
hospitalization and prospective treatment as can make informed choices. Effective
indicated. Encourage questions, expression of communication and support at this time can
concern. diminish anxiety and promote healing
­>Gallstones often recur, necessitating long­term
therapy. Development of diarrhea/cramps during
chenodiol therapy may be dose related or
3. Review drug regimen, possible side effects. correctable.
Note: Women of childbearing age should be
counseled regarding birth control to prevent
pregnancy and risk of fetal hepatic damage
­>obesity is a risk factor associated with
4. Discuss weight reduction programs if indicated. cholecystitis, and weight loss is beneficial in
medical management of chronic condition
5. Instruct patient to avoid food/fluids high in fats (e.g.,
whole milk, ice cream, butter, fried foods, nuts,
gravies, pork), gas producers (e.g., cabbage, ­>prevents/limits recurrence of gallbladder attacks
beans, onions, carbonated beverages), or gastric
irritants (e.g., spicy foods, caffeine, citrus).
6. Review signs/symptoms requiring medical ­>indicative of progression of disease
intervention, e.g., recurrent fever; persistent process/development of complications requiring
nausea/vomiting, or pain; jaundice of skin or eyes, further intervention
itching; dark urine; clay­colored stools; blood in
urine, stools; vomitus; or bleeding from mucous

10. membranes.
7. Recommend resting in semi­Fowler’s position after ­>promotes flow of bile and general relaxation
meals. during initial digestive process.
8. Suggest patient limit gum chewing, sucking on ­>promotes gas formation, which can increase
straw/hard candy, or smoking. gastric distension/discomfort
9. Discuss avoidance of aspirin­containing products,
forceful blowing of nose, straining for bowel ­>reduces risk of bleeding related to changes in
movement, contact sports. Recommend use of soft coagulation time, mucosal irritation, and trauma
toothbrush, electric razor.

11. References
Books
 Black, J.M. & Hawks, H.H. (2004). Medical­surgical nursing: clinical management for positive
outcomes (7th ed.). Singapore: Elsevier Saunders., Vol. 1, pp.1311­1313.
 Doenges, M.E., et. al. (2002). Nursing care plans: guidelines for individualizing patient care
(6th ed.). Philadelphia: F.A. Davis Co. pp.351­361.
Online Resources
 Brunetti, J.C. (2005). eMedicine specialties: cholelithiasis. Retrieved December 17, 2008 at
http://emedicine.medscape.com/article/366246­overview
 Lee, F.M., et. al. (2006). eMedicine specialties: cholelithiasis. Retrieved December 17, 2008
at http://emedicine.medscape.com/article/774352­overview
 Medical Encyclopedia (2008). Gall bladder. Retrieved December 17, 2008
at http://www.nlm.nih.gov/medlineplus/ency/imagepages/8732.htm
 Sharma, R., et. al. (2007). eMedicine specialties: cholecystitis and biliary colic. Retrieved
December 17, 2008 at http://emedicine.medscape.com/article/774352­overview
 University of Virginia Health System (2004). Liver, biliary, & pancreatic disorders:
cholecystitis. Retrieved December 17, 2008 at
http://www.healthsystem.virginia.edu/uvahealth/adult_liver/chole.cfm