DRG Category: 412

Mean LOS: 8.4 days

Description SURGICAL: Cholecystectomy with C.D.E. with CC

DRG Category: 418

Mean LOS: 5.3 days

Description SURGICAL: Laparoscopic Cholecystectomy without C.D.E. with CC

classification section:



Cholecystitis is an inflammation of the gallbladder wall; it may be either acute or chronic. It is almost always associated with cholelithiasis, or gallstones, which lodge in the gallbladder, cystic duct, or common bile duct. Silent gallstones are so common that most of the American public may have them at some time; only stones that are symptomatic require treatment. In developed countries, the prevalence is 10% to 20%, and in the United States, approximately 20 million people have gallstones.

Gallstones are most commonly made of either cholesterol or bilirubin and calcium. If gallstones obstruct the neck of the gallbladder or the cystic duct, the gallbladder can become infected with bacteria such as Escherichia coli. The primary agents, however, are not the bacteria but mediators such as members of the prostaglandin family. The gallbladder becomes enlarged up to two to three times normal, thus decreasing tissue perfusion. If the gallbladder becomes ischemic as well as infected, necrosis, perforation, and sepsis can follow.

Cholesterol is the major component of most gallstones in North America, leading to speculation that the high-fat diet common to many North Americans is the explanation for their increased frequency. Supporting theories that point to a high-fat diet note that acute attacks of cholelithiasis may be precipitated by fasting and sudden weight loss.

Cholecystitis and cholelithiasis appear to be caused by the actions of several genes and environment working together. Studies suggest that genetic factors account for approximately 30% of susceptibility to gallstone formation. While specific genetic mechanisms have not been elucidated, many candidate genes (e.g., ABCB4 and ABCG8), including those that increase susceptibility to risk factors such as obesity, are under investigation.

The incidence of gallbladder disease increases with age. Most patients are middle-aged or older women, often women who have borne several children and gained weight during the aging process. Since there is a tendency for gallbladder disease to be familial, some young people of both sexes with a familial history as well as young women who have taken oral contraceptives can be affected. Risk factors include obesity; middle age; female gender; and Northern European, Native American, or Hispanic/Latino ancestry. Prevalence of gallstones is low in African Americans; however, African Americans with sickle cell disease may have gallstones at a younger age than other populations.

The incidence of cholecystitis appears to be greater in Hispanic and northern European countries. Several European studies indicated a greater incidence in females and in those older than 60 years. Cholelithiasis has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanics/Latinos. It is less common among individuals from sub-Saharan Africa and Asia.

HISTORY. Cholecystitis often begins as a mild intolerance to fatty food. The patient experiences discomfort after a meal, sometimes with nausea and vomiting, flatulence, and an elevated temperature. Over a period of several months or even years, symptoms progressively become more severe. Ask the patient about the pattern of attacks; some mistake severe gallbladder attacks for a heart attack until they recall similar, less severe episodes that have preceded it. An acute attack of cholecystitis is often associated with gallstones, or cholelithiasis. The classic symptom is pain in the right upper quadrant that may radiate to the right scapula, called biliary colic. Onset is usually sudden, with the duration from less than 1 to more than 6 hours. If the flow of bile has become obstructed, the patient may pass clay-colored stools and dark urine.

PHYSICAL EXAM. The patient with an acute gallbladder attack appears acutely ill, is in a great deal of discomfort, and sometimes is jaundiced. A low-grade fever is often present, especially if the disease is chronic and the walls of the gallbladder have become infected. Right upper quadrant pain is intense in acute attacks and requires no physical examination. It is often followed by residual aching or soreness for up to 24 hours. A positive Murphy's sign, which is positive palpation of a distended gallbladder during inhalation, may confirm a diagnosis.

PSYCHOSOCIAL. The patient with an acute attack of cholelithiasis may be in extreme pain and very upset. The experience may be complicated by guilt if the patient has been advised by the physician in the past to cut down on fatty foods and lose weight. The attack may also be very frightening if it is confused with a heart attack.

Diagnostic Highlights

Test	Normal Result	Abnormality with Condition	Explanation
White blood cell (WBC) count	Adult males and females 4,500–11,000/µL	Infection and inflammation elevate the WBC count	Leukocytosis; WBCs range from 12,000 to 15,000/µL; if > 20,000, the condition may be associated with gangrene or perforation
Ultrasound scan	Normal gallbladder	Gallbladder wall thickening, pericholecystic fluid collections	Sensitive/specific test for cholelithiasis; identifies presence of fluid collection

Other Tests: Biliary scintigraphy such as hydroxy iminodiacetic acid (HIDA) scan can show nonfilling of the gallbladder; biliary scintigraphy and ultrasound are the diagnostic tests most commonly used. HIDA scans have sensitivity of greater than 94% and specificity 65% to 85% for acute cholecystitis. Supporting tests include phosphatase, aspartate amino transferase, lactate dehydrogenase, alkaline phosphatase, serum amylase, and serum bilirubin levels; oral cholecystogram; and computed tomography. An intravenous cholangiogram may be used to differentiate cholelithiasis from other causes of extrahepatic obstruction.

DIAGNOSIS. Pain (acute) related to obstruction and inflammation

OUTCOMES. Comfort level; Pain control behavior; Pain level; Symptom severity

INTERVENTIONS. Analgesic administration; Anxiety reduction; Environmental management: Comfort; Pain management; Medication management; Patient-controlled analgesia assistance

COLLABORATIVE

MEDICAL. Medical management may include oral bile acid therapy. However, given the effectiveness of laparoscopic cholecystectomy, the only patients who will receive medical dissolution are generally those who are nonobese patients with very small cholesterol gallstones and a functioning gallbladder.

SURGICAL. There are several surgical or procedural treatment options. The one seen most commonly today is a laparoscopic cholecystectomy, which is performed early (within 48 hr of acute onset of symptoms) in the course of the disease when there is minimum inflammation at the base of the gallbladder. The procedure is performed with the abdomen distended by an injection of carbon dioxide, which lifts the abdominal wall away from the viscera and prevents injury to the peritoneum and other organs. A laparoscopic cholecystectomy is done either as an outpatient procedure or with less than 24 hours of hospitalization. After the surgery, the patient may complain of pain from the presence of residual carbon dioxide in the abdomen.

The traditional open cholecystectomy is performed on patients with large stones as well as with other abnormalities that need to be explored at the time of surgery. This procedure is particularly appropriate up to 72 hours after onset of acute cholecystitis. Timing of the operation is controversial. Early cholecystectomy has the advantage of resolving the acute condition early in its course. Delayed cholecystectomy can be performed after the patient recovers from initial symptoms and acute inflammation have subsided, generally 2 to 3 months after the acute event.

Extracorporeal shock wave lithotripsy similar to the type used to dissolve renal calculi is now also used for small stones. For those patients who are not good surgical candidates, both methods have the advantage of being noninvasive. However, they have the disadvantage of leaving in place a gallbladder that is diseased, with the same propensity to form stones as before treatment.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Oral bile acid therapy; ursodeoxycholic acid	10–15 mg/kg per day for 6–12 mo	Nonsurgical method to dissolve gallstones	Used for small stones (< 10 mm in diameter) in a functioning gallbladder in nonobese patients
Antibiotics	Varies with drug	Antibiotic regimen is focused on those appropriate for typical bowel flora (gram-negative rods and anaerobes): third generation cephalosporin or aminoglycoside with metronidazole	Manage bacteria that are typical bowel flora
Demerol	25–100 mg IM, IV	Opiates relieve pain and promote spasms of the biliary duct	Pain is severe; analgesia should be offered only after definitive diagnosis has occurred

Additional Pharmacologic Management: The pain is treated by both analgesics and anticholinergics such as dicyclomine (Bentyl) during acute attacks. The anticholinergics relax the smooth muscle, preventing biliary contraction and pain. If inflammation of the gallbladder has led to gallstones and obstruction of bile flow, replacement of the fat-soluble vitamins is important to supplement the diet. Bile salts may be prescribed to aid digestion and vitamin absorption as well as to increase the ratio of bile salts to cholesterol, aiding in the dissolution of some stones.

INDEPENDENT

During an acute attack, remain with the patient to provide comfort, to monitor the result of interventions, and to allay anxiety. Explain all procedures in short and simple terms. Provide explanations to the family and significant others.

If the patient requires surgery, the nurse's first priority is the maintenance of airway, breathing, and circulation. Although most patients return from surgery or a procedure breathing on their own, if stridor or airway obstruction occurs, create airway patency with an oral or nasal airway and notify the surgeon immediately. If the patient's breathing is inadequate, maintain breathing with a manual resuscitator bag until the surgeon makes a further evaluation. The high incision makes deep breathing painful, leading to shallow respirations and impaired gas exchange. Splinting the incision while encouraging the patient to cough and breathe deeply help both pain and gas exchange. Elevate the head of the bed to reduce pressure on the diaphragm and abdomen.

Patients not undergoing surgery or a procedure need a thorough education. Explain the disease process, the possible complications, and all medications. Teach the patient to avoid high-fat foods, dairy products, and, if the patient is bothered by flatulence, gas-forming foods.

• Physical response: Patency of airway; adequacy of breathing and circulation; vital signs; use of splinting or other measures to control pain while performing deep breathing

• Pain: Location, duration, quality, response to pain medications

• Type and amount of drainage from Penrose drain or T tube

• Condition of surgical incision and surrounding skin

PATIENT TEACHING. After a laparoscopic cholecystectomy, provide discharge instructions to a family member or another responsible adult as well as to the patient, because the patient goes home within 24 hours after surgery. Explain the possibility of abdominal and shoulder pain caused by the instillation of carbon dioxide so that if the pain occurs, the patient will not experience unnecessary anxiety about a heart attack. Teach the patient to avoid submerging the abdomen in the bathtub for the first 48 hours, to take the prescribed antibiotics to provide further assurance against infection, and to watch the incisions for signs of infection. Following a 3- to 5-day hospital stay for an open cholecystectomy, instruct the patient on the care of the abdomen wound, including changing the dressing and protection of any drains.

POSTOPERATIVE INSTRUCTIONS. Reinforce pain control and deep-breathing exercises until the incision is completely healed. The patient may need instruction on control of elimination after this surgery. The continued use of opiate-type analgesics for 7 to 10 days may necessitate the use of laxatives or suppositories, which are generally prescribed by the physician before discharge. Explain that gradual resumption of both a normal diet and activity aid normal elimination. Instruct the patient to report to the physician if any new symptoms occur, such as the appearance of jaundice accompanied by pain, chills and fever, dark urine, or light-colored stools. Usually, the patient has no complications and is able to resume normal activity within a few weeks. Instruct the patient who has been treated nonsurgically with bile salts or extracorporeal shock wave lithotripsy about a low-fat diet to avoid recurrence of gallstones.