Health alterations class 22: Cholecystitis

Cholelithiasis

Stones in gall bladder

Made of pigment (bile) or fat (cholesterol, most common)

Cholecystitis

Inflammation of gallbladder

Usually associated with cholelithiasis

Acute or chronic

Cholelithiasis signs and symptoms

May be silent (may never cause an obstruction)

Mild to severe pain 3-6 hours a high fat meal:

Abdominal distension

RUQ pain radiating to shoulder (so rule out cardiac issues)

Severe pain up to an hour, them residual RUQ tenderness (guarding on palpation)

Tachycardia, Diaphoresis, weakness

Spasms “biliary colic’

Signs and symptoms of acute Cholecystitis

RUQ pain and tenderness

Indigestion

N/V

Restlessness

Diaphoresis and fever

Positive Murphy’s sign

Positive murphys sign

Place hand on RUQ and gel, patient to take a deep breath

Patient has extreme pain or guarding upon palpation or from deep breath

Signs and symptoms of chronic Cholecystitis

Recurrent attacks

Fat intolerance

Dyspepsia

Heartburn

Flatulence

Complications of Cholelithiasis and Cholecystitis

Gangrenous (necrotic) Cholecystitis, could rupture

Subphrenic abscess (infected fluid)

Acute pancreatitis

Cholangitis (inflammation of bile ducts)

Biliary cirrhosis (scarring of biliary duct)

Fistulas

Rupture of gallbladder-peritonitis

Choledocholithiasis-stone in common bile ducts (gallbladder and liver affected)

Clinical manifestations caused by obstructed by bile flow

Risk of bleeding-prothrombin

Clay coloured stools-blockage of flow of bile salts

Dark amber urine-bilirubin in urine

Intolerance of fatty foods (N/V, fullness, anorexia)-no bile in small intestine for fat digestion

Obstructive jaundice-no bile flow in duodenum

Pruritus- bile salts in skin

Steatorrhea (fatty stools)-no bile salts, preventing fat emulsion and digestion

Diagnosis of Cholecystitis

History and physical (High fat diet, smoking, alcohol, lifestyle, obesity, increased risk in women over 40, abdominal assessment)

Ultrasound

ERCP-Endoscope inserted to look at gallbladder, cystic duct, common hepatic duct and common bile ducts) post op gag reflex- NPO until returns

Labs (increased liver enzymes, increased WBCs, Increased bilirubin, increased amylase and lipase)

When to use conservative therapy vs surgery

Conservative therapy: uncomplicated, no major issues, may pass on own

Surgery:Symptomatic

Conservative therapy for Cholelithiasis

Bile acids-administered to dissolve stones (UDCA) takes 6-12 months to

ERCP-widened to allow stones to pass or be retrieved

Extra corneal shock wave lithotripsy (ESWL): stones fragmented by laser pulse

Cholecystitis conservative therapy

Pain management-analgesics and anticholinergic

Control of possible infection-antibiotics

Fluid and electrolyte balance-IV fluids

NPO (to rest gallbladder)

NG tube-severe N/V and gastric decompression (low continuous suction)

Surgical therapy of Cholecystitis

Laparoscopic cholecystectomy (small incisions under X-ray, ideal surgical treatment)

Open cholecystectomy (T tube in common bile duct-ensures patency of the duct until edema from trauma of exploring duct subsides)

Transhepatic biliary catheter (preop in biliary obstruction and hepatic dysfunction, secondary to obstructive jaundice). Palliative, catheter inserted in common bile duct and duodenum and connected to drainage bag (bile can flow freely)

Nursing Care post op

V/S, IV fluids NPO

Sips, clear fluid, full fluids

Soft diet when bowel sounds return

Splint incision (when deep breaths and cough)

Pain management

Deep breath and cough/incentive spirometer (splint)

Turn and reposition and ambulate asap, walking to help move air

Dressing and drain care

N/V, anorexia

Complications:

Bleeding, peritonitis, pneumonia, jaundice

Medication therapy of Cholecystitis

Analgesics (morphine)

Anticholinergic

Fat soluble vitamins (A,D,E,K)-chronic gallbladder disease or biliary tract obstruction

Bile salts-facilitate digestion and vitamin absorption

Cholestyramine-for pruritus

Nutritional therapy of Cholecystitis

Small, frequent meals

Low saturated fats

High fever and calcium

Avoid rapid weight loss, promotes gallstone formation

What to report for Cholecystitis

Jaundice

Pruritus

Dark urine

Clay coloured stool

Pain

N/V

Abdominal distension/rigidity (could be peritonitis or bleeding)

Post op Cholecystitis/lithiasis surgery

Ambulate gradually

Avoid gas forming foods or high fat foods

No heavy lifting for 4-6 weeks

Watch infection at site

Follow up with family HCP

Loose stools initially due to lack of duct, gradually returns to normal as body adjusts

Common causes of pancreatitis

Gallbladder disease

Alcohol

Trauma

Infections

Meds

Post op complication

Post ERCP pancreatitis

Clinical manifestations of pancreatitis

Severe LUQ pain, radiating to back, worse when lying down (may be leaning forward), aggravated when eating and not relived by vomiting

Decreased or absent bowel sounds

Abdominal distension

Patient may flex spine to relive pain

Lung crackers, hypotension, tachycardia

N/V, low grade fever

Eccymosis around flank or umbilicus (severe sign)

Shock

Complications of pancreatitis: pseudocyst

accumulation of fluid, enzymes, tissue debris and exudate.

Get abdominal pain, palpable mass.

Can resolve or perforate (peritonitis)

Treat by internal drainage with an anatomosis between pancreatic duct and jejunum

Complications of pancreatitis: Abscess

Results from infected pseudocyst

Can rupture or perforate adjacent organs

Upper abdominal pain, abdominal mass, high fever, leukocystitis

Treat by surgical drainage to prevent sepsis

Complications of pancreatitis: systemic complications

Hypotension, tachycardia, pleural effusion, atelectasis, pneumonia, acute respiratory distress syndrome, coagulation disorders (increased clot risk)

Diagnosis of pancreatitis

History and physical (alcohol, gallstones)

Increased amylase (elevates early and stays elevated for 24-72 hours)

Increased lipase

Increased liver enzymes, triglycerides and glucose

Abdominal ultrasound, x ray or ct scan

CT with contrast dye and MRCP, for detecting complications

Conservative therapy of pancreatitis

Pain management (opioids, antispasmodic, nitroglycerin)

Fluid and lytes (ringers lactate)

Treat shock (plasma or plasma volume expanders, albumin)

Reduce pancreatic enzyme secretion (decrease stimulation of pancreas, NPO, NG to LCS, parenteral nutrition if needed)

Prevent infection (inflamed and necrotic pancreatic tissue promotes bacterial overgrowth, prophylactic antibiotics if needed)

Interventional therapy of pancreatitis

ERCP and endoscopic sphinecterotomy and lap cholecystectomy (when pancreatitis is related to gallstones)

Drainage of necrotic fluid (surgically with CT guidance or endoscopically)

Pseudocyst (Percutaneous and tube is left in place and hooked up to drainage bag)

Medication therapy for acute pancreatitis

Antacids

Antispasmotics

Carbonic anydrase inhibitor (decreased secretions)

Morphine

Nitroglycerin or papaverine

PPIs (inhibit secretions)

Medication therapy for chronic pancreatitis

Insulin

Pancreatin

Pancrelipase

Nutritional therapy for pancreatitis

NPO initially

Enteral or parenteral nutrition may be required

Nutritional BW

Care of NG and oral care

Then, small frequent meals, high carbs, no alcohol, fat soluble vitamins

Nursing assessment of pancreatitis

Vitals

Pain

Electrolyte imbalances

Signs of shock

Respiratory

Abdominal

Signs of hypocalemia (signs of tetany)

Blood glucose levels

Oral care for NG

Wound care

Common causes of chronic pancreatitis

Most associated with alcohol abuse

Can be idiopathic or follow acute pancreatitis

Obstructive: associated with biliary disease or cancer

Non obstructive: associated with inflammation and sclerosis (alcohol)

Clinical manifestation of chronic pancreatitis

Heavy, gnawing abdominal pain

Not relived with food

Malabsorption and weight loss

Constipation

Mild jaundice and dark urine

Steatorrhea

Diabetes

Diagnosis of chronic pancreatitis

Signs and symptoms

Labs (increased amylase and lipase, bilirubin and alkaline phosphate)

Mild leukocytosis

Stool samples for fecal fat content

Deficiencies in fat soluble vitamins

Diabetes

ECRP, CT, MRI, MRCP, trans abdominal ultrasound, endoscopic ultrasound