Diseases and Disorders
Cholecystitis and Cholelithiasis
General
DRG Category: 412
Mean LOS: 6.4 days
Description SURGICAL Cholecystectomy With Common Duct Exploration With Complication or Comorbidity
DRG Category: 418
Mean LOS: 4.3 days
Description SURGICAL Laparoscopic Cholecystectomy Without Common Duct Exploration With Complication or Comorbidity
Introduction
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 most commonly lodge in the cystic duct and cause obstruction. Biliary sludge is a reversible suspension of particles such as crystals and salts that form a thick liquid derived from bile and can lead to cholelithiasis. Silent gallstones may also occur and are so common that most people 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. Cholecystectomy is the most common major surgical procedure performed by general surgeons in the United States.
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 size, thus decreasing tissue perfusion. If the gallbladder becomes ischemic as well as infected, necrosis, perforation, pancreatitis, and sepsis can follow.
Causes
Cholesterol is the major component of most gallstones in the United States, leading to speculation that a high-fat diet 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. Risk factors include older age, female sex, obesity, weight loss, and pregnancy. Cholecystitis is associated with debilitation, major traumatic stress (injury, sepsis, major surgery), diabetes, sickle cell disease, and HIV infection.
Genetic Considerations
Cholecystitis and cholelithiasis appear to be caused by the actions of several genes and the environment working together. It is estimated that 50% to 70% of patients with cholecystitis have a positive family history of the disease. 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.
Sex Life Span Considerations
The incidence of gallbladder disease increases with age in women and men. Most patients are adult women, often women who have borne several children and gained weight as they grow older. During pregnancy, increased levels of progesterone may lead to biliary stasis and increased rates of gallbladder disease. Because 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. Children with sickle cell disease, serious illness, and hemolytic conditions as well as those on total parenteral nutrition are at higher risk for gallbladder disease than other children.
Health Disparities Sexual/Gender Minority Health
Northern Europeans (Scandinavian) and Hispanic persons have increased prevalence as compared to other groups. Prevalence of gallstones is high in White persons and low in people of Asian and African descent; however, Black individuals with sickle cell disease may have gallstones at a younger age than other groups. Health disparities may exist with respect to the implementation of guidelines for diagnostic testing and standards of care. Female gender, Black race, increased number of morbidities, Medicare payer status, urban-teaching hospital location, and low household income may lead to reduced implementation of standards of care (Chouairi et al., 2021 [see Evidence-Based Practice and Health Policy]). Those factors limit evidence-based care and lead to poorer surgical outcomes. Sexual and gender minority status has no known effect on the risk for cholecystitis and cholelithiasis.
Global Health Considerations
Several European studies indicate a greater incidence in females and in those older than age 60 years. Cholelithiasis has an increased prevalence among people of Scandinavian, Western European, and Hispanic ancestry and decreased prevalence in people living in Sub-Saharan Africa and Southeast Asia.
Assessment
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 Examination
The most common symptom is upper abdominal pain. The pain may radiate to the right shoulder or scapula and may be accompanied by nausea and vomiting. 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 sign, which is positive palpation of a distended gallbladder during inhalation, may confirm a diagnosis. Older adults may present with vague symptoms such as localized tenderness and without pain and fever. Children may also present without classic findings.
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 4,500-11,100/mcL | Infection and inflammation elevate the WBC count | Leukocytosis; WBCs range from 12,000 to 15,000/mcL; 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; preferred initial imaging test |
Other Tests: Biliary scintigraphy such as hepatobiliary 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, with or without contrast. Liver function tests such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST) may be used to assess if hepatitis or common bile duct obstruction are involved. An IV cholangiogram may be used to differentiate cholelithiasis from other causes of extrahepatic obstruction. Additional tests include pregnancy testing and urinalysis.
Primary Nursing Diagnosis
Diagnosis: Acute pain related to obstruction and inflammation as evidenced by self-reports of pain, grimacing, protective behavior, and/or diaphoresis
Outcomes: Comfort status; Knowledge: Acute illness management; Pain control; Pain level; Symptom severity; Medication response
Interventions: Analgesic administration; Anxiety reduction; Environmental management: Comfort; Pain management: Acute; Medication management; Patient-controlled analgesia assistance
Planning and Implementation
Collaborative
MEDICAL Antibiotics may be given to manage infection along with bowel rest, IV hydration, correction of electrolyte imbalances, and pain management with follow-up care. Criteria for outpatient treatment include that the patient is afebrile, with no evidence of obstruction on laboratory assessment and sonogram, no underlying medical problems, adequate pain control, and proximity to an acute care facility, if needed, from home. 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 hours of acute onset of symptoms) in the course of the disease when there is minimum inflammation at the base of the gallbladder. It is considered the standard of care for the surgical management of cholecystectomy. 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.
Pharmacologic Highlights:
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Antibiotics; ciprofloxacin, meropenem, imipenem/cilastatin, ampicillin/sulbactam, piperacillin/tazobactam | 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 (drug of choice for pain control) | 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 |
Other Drugs: Antiemetics may be administered, particularly promethazine or procholperazine. 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.
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 incision from a laparoscopic cholecystectomy is small and usually heals without complications. The high incision resulting from an open cholecystectomy may make deep breathing painful, leading to shallow respirations and impaired gas exchange. Splinting the incision while encouraging the patient to cough and breathe deeply helps 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 clear explanations. 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.
Evidence Based Practice Health Policy
Chouairi, F., McCarty, T., Hathorn, K., Sharma, P., Aslanian, H., Jamidar, P., Thompson, C., & Muniraj, T. (2022). Evaluation of socioeconomic and healthcare disparities on same admission cholecystectomy after endoscopic retrograde cholangiopancreatography among patients with acute gallstone pancreatitis. Surgical Endoscopy, 36, 274-281. https://doi.org/10.1007/s00464-020-08272-2 [PMID:33481109]
- Guidelines recommend that patients with acute gallstone pancreatitis receive a cholecystectomy during their initial hospital admission The aim of this study was to investigate the role of clinical and sociodemographic factors in the management of acute gallstone pancreatitis who have same admission cholecystectomy (SAC). Cases from a national database with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) during hospitalization between 2008 and 2014 were reviewed and classified by treatment strategy.
- A total of 205,012 cases were analyzed. A majority (53.4%) of cases that did not receive SAC were at urban teaching hospitals. Although length of stay was longer with higher associated costs for patients with SAC, mortality was decreased. Multivariable regression demonstrated female gender, Black race, increased number of morbidities, Medicare payer status, urban teaching hospital location, and household income decreased the odds of undergoing same admission cholecystectomy.
Documentation Guidelines
- Pain: Location, duration, quality, response to pain medications
- Type and amount of drainage if Penrose drain or T tube is present; vital signs
- Condition of surgical incision and surrounding skin
Discharge and Home Healthcare Guidelines
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 aids 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.
