Cholecystitis is more than just a gall bladder attack, this is when the gall bladder becomes inflamed and irritated, and at risk for infection. Nurses come across this often in urgent care and Er settings when patients have gall bladder attacks. Sometimes these gall bladder attacks can become severe and cause bad infection, and emergency surgery is needed! Want to know more? Keep reading! 👇🏻
Important Concepts Behind Gall Bladder Attacks
The gallbladder is a small balloon-like organ located near the liver that holds bile. Bile is a thick fluid that breaks down fat – also called emulsification. This helps your body break down fats for digestion.
The gallbladder is connected to the stomach by tubes or ducts. The common bile duct connects the gall bladder to the stomach. If this duct becomes obstructed (such as will a gallstone), then this can lead to a gall bladder attack or worse!
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A gallstone is a hardened deposit that forms within the gallbladder, primarily consisting of cholesterol, bilirubin, and calcium. Studies show that approximately 6% of men and 9% of women develop gallstones in their lifetime. However, most remain asymptomatic!
Biliary colic describes intermittent pain from the gall bladder that occurs when a stone temporarily blocks the common bile duct. This is a classic gall bladder attack! This pain usually occurs shortly after eating a high-fatty meal. This usually is severe pain for 30 minutes, then starts to improve within an hour. This never typically lasts longer than 6 hours. This can be associated with nausea and vomiting, but typically doesn’t cause lab abnormalities or fevers.
Acute Cholecystitis is the most common complication of gallstones. As the suffix -itis suggests, this is when there is acute inflammation of the gallbladder – often from a blocked stone or duct. This can lead to pain, infection, abnormal labs, and a need of surgical removal. We will focus on this gallstone complication in this article as this is the most common complication of gallstones.
Choledocolithiasis stands for when there is a stone actively stuck within the common bile duct.
Acute cholangitis (sometimes referred to as ascending cholangitis) refers to infection in the setting of biliary obstruction. This is more severe than cholecystitis and can happen at the same time, and these patients are typically sent to the ICU!
Causes of Acute Cholecystitis
The main cause of gall bladder disease and cholecystitis is gallstones blocking up the gallbladder.
The most common cause of gall bladder attacks and cholecystitis is gallstones. These hard particles can become lodged in the neck of the gallbladder, or in the cystic duct, leading to inflammation as the bile builds up in the gall bladder.
Causes of gallstones include:
- Excess cholesterol
- Excess bilirubin
- Rapid weight loss
- High fat / low fiber diet
- Certain medications such as estrogen, ceftriaxone, thiazide diuretics, and orlistat
The 5 F’s
There is a mnemonic that can help identify risk factors for gallstones. This is known as the “5Fs”:
However, it may be more beneficial to substitute “Familial” for “Forty”, as a family history seems to be more predictive than the patient’s age.
Biliary sludge is kind of like chunky fluid – there’s not full stones formed, but it can still clog up the ducts and lead to symptoms. This is usually associated with biliary colic, and less commonly with cholecystitis.
Tumors or other masses can block the ducts and lead to inflammation and/ or infection as well. This may be from gallbladder cancer or nearby malignant or benign tumor that compresses the ducts.
Acalculous cholecystitis means there is inflammation of the gallbladder without a stone as a cause. This often happens in ICU patients or after major surgery.
The causes can include reduced blood flow to the gallbladder, infections, or trauma. Other factors can also influence it including prolonged fasting or rapid weight loss. can lead to severe complications.
Nursing Assessment of Cholecystitis
The nursing assessment should pay close attention to GI symptoms, and really focus on the abdominal assessment.
Symptoms of acute cholecystitis include:
RUQ Abdominal Pain
The gallbladder Is located in the right upper quadrant – and this is the area that typically hurts when there is a gall bladder attack and especially during acute cholecystitis. The pain is said to be intense but dull. This can also be located in the epigastric region as well, and often radiates to the right shoulder blade or back.
In cholecystitis, pain often lasts > 5-6 hours (which is abnormal with just biliary colic).
Nausea & Vomiting
Nausea and vomiting are common with all gallbladder disease.
Diaphoresis, or excessive sweating, is a part of the body’s response to pain and inflammation. The inflammation of the gallbladder can lead to visceral pain, which activates the sympathetic nervous system, which can cause sweating.
Fevers & Chills
The patient may report fevers and chills. Fevers are present in 35% of cases, and chills present in 13% of cases.
What About Jaundice?
Jaundice really should not be occurring with cholecystitis – if it does, this increases the likelihood of cholangitis.
The physical exam should focus on the abdominal assessment:
Vital signs may show fever, especially if there is active infection like cholangitis, gangrene, or sepsis. Tachycardia is common with acute cholecystitis, especially due to the patient’s pain and other symptoms such as vomiting. Blood pressure may be low (hypotension) in these severe infection cases as well.
The abdominal assessment is key with cholecystitis. The patient will often have RUQ tenderness with possible guarding. They may also have hypoactive bowel sounds – this is because the inflammation and irritation in the gallbladder can affect nearby digestive organs, leading to a decreased motility and function of the intestines.
A positive Murphy’s sign is when you hook your fingers underneath the patient’s right ribs, have them inspire deeply, and if they stop breathing or wince from pain – this is a positive Murphy’s sign.
A positive Murphy’s sign is highly sensitive for acute cholecystitis, often cited as being around 65-97% sensitive, but is less specific, with specificity values often ranging from 48% to 87%.
Patients with acute cholecystitis generally appear ill and in pain. They are often sitting still since movement exacerbates their pain due to local peritoneal irritation. This is not as obvious in the case of a simple gall bladder attack.
Signs of Jaundice
If jaundice is present, this usually means something more serious than just acute cholecystitis is going on, such as ascending cholangitis. Jaundice can be seen by yellowing of the eyes (known as scleral icterus), or in severe cases yellowing of the skin itself.
Workup for Gall Bladder Attacks
A workup for gall bladder disease includes checking labs, as well as imaging.
Labs play a critical role in supporting the diagnosis and ruling out alternative diagnoses. The idea is to narrow down the list of potential culprits causing a patient’s symptoms.
Labs that are often checked during a gall bladder attack include:
- CBC: Often elevated WBC in acute cholecystitis
- CMP: In patients with cholecystitis, liver enzymes, total bilirubin, and alkaline phosphatase are typically within the normal range. However, abnormal results in these labs should heighten suspicion for more severe complications. For instance, abnormalities can suggest conditions like cholangitis or choledocolithiasis, which involve inflammation or stone presence in the bile duct, respectively.
- Lipase: If elevated, this indicates pancreatitis.
Depending on the patients history and symptoms, other diseases may need to be ruled out with additional labs, including:
- Troponin: to rule out cardiac ischemia
- D-dimer: To help rule out Pulmonary embolism
- Urinalysis: to rule out UTI
Imaging during a gall bladder attack usually starts with an ultrasound, since this is very sensitive for gallstones, and does not predispose the patient to harmful radiation.
However, there are alternative imaging studies that may be ordered or required, including:
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RUQ US is performed transabdominally - or on top of the stomach (instead of inside anywhere). This is the first preferred imaging method, and can detect gall stones as well as gallbladder wall thickening, pericholecystic fluid, or edema, which all support cholecystitis.
CT Abdomen/Pelvis WITHOUT contrast
A CT is usually checked in the ER to rule out alternative diagnoses or complications such as gangrene, perforation, emphysematous cholecystitis, or bowel obstruction.
EUS stands for endoscopic ultrasound, which is done by the gastroenterologist during an endoscope. This can view the gallbladder without bowel interference - so this is more sensitive than a regular RUQ US.
ERCP stands for Endoscopic Retrograde Cholangiopancreatography. It's a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. If needed, they can remove a gallstone or place a stent.
MRCP stands for Magnetic Resonance Cholangiopancreatography. It's a type of MRI that produces detailed images of the hepatobiliary and pancreatic systems, including the liver, gallbladder, bile ducts, pancreas, and pancreatic duct.
HIDA scan, also known as Hepatobiliary Iminodiacetic Acid scan, is a type of nuclear imaging study that evaluates the function and anatomy of the gallbladder and bile ducts.
Treatment of Acute Cholecystitis
Treatment of acute cholecystitis includes supportive care, antibiotics, and surgical removal of the gall bladder. Patients with acute cholecystitis are more likely to have recurrent attacks or more severe complications, so its best to just remove it when this occurs.
The patient is typically made NPO (nothing by mouth), and IV fluids are given to maintain hydration.
Common fluids: NS @ 75-150ml/hr. The more the patient weighs, the more they’ll need to maintain hydration.
Calculating Maintenance Fluids
To calculate a patient’s maintenance fluids, you take the patient’s weight in Kgs. The first 20kg will be 60ml/hr. Then the remaining Kgs are 1ml/hr.
For example: An 80kg patient should be ordered 120ml/hr (First 20 Kg = 60ml, then 60Kg left at 1ml/kg = 60ml. Add them together and they equal 120ml/hr. Read more about this in my IV FLUIDS article!
Keep in mind this will be up to the ordering Provider to order the fluids and the rate.
Acute cholecystitis is very painful, so patients often need IV pain medications.
- Toradol 10-30mg IV every 6 hours PRN
- Morphine 2-4mg IV every 2-4 hours PRN
- Dilaudid 0.5-1mg every 2-4 hours PRN
Antibiotics are typically started in patients with acute cholecystitis, even though not every case of acute cholecystitis has active infection.
This is because bacteria can possibly still be present, it helps prevent further infectious complications, and many patients with acute cholecystitis will be going to surgery anyway, and antibiotics will reduce the risk of postoperative infections.
Common antibiotic regimens for acute cholecystitis include:
- Zosyn 4.5g IV q8h OR
- Ertapenem 1g IV q24h OR
- Flagyl 1g loading, then 500mg IV q6h AND ceftriaxone 2g IV or cipro
Laparoscopic cholecystectomy is standard treatment for acute cholecystitis to prevent further gall bladder attacks. This means that the gallbladder is removed with the assistance of a robot (guided by the surgeon). Instead of opening up the abdomen completely, 4 small incisions are used. This leads to less complications and a much quicker recovery period.
It is recommended that the surgery be performed within the first 48 hours of presentation with acute cholecystitis. Another option for patients who are poor surgical candidates include percutaneous decompression. Other options include extracorporeal shock wave lithotripsy or oral dissolution therapy.
Monitoring of Cholecystitis
Monitoring of the patient includes managing their pain, as well as assessment for gallbladder complications and post-surgical complications.
Pain should be assessed frequently as above.
After a laparoscopic cholecystectomy, patients often experience less pain in comparison to their previous gallbladder pain before the surgery. However, some typical post-operative sensations include:
- Shoulder pain caused by residual carbon dioxide used during the procedure that is irritating the diaphragm
- Mild to moderate incisional pain around the surgical incisions, which usually resolves in a few days
- Abdominal discomfort, due ot the manipulation during the procedure
At home management will consistent of Tylenol, NSAIDs, and in sometimes short courses of PO opioid analgesics.
Be sure to monitor the abdomen for worsening pain or signs of generalized peritonitis which can indicate perforation, which includes:
- Rigid abdomen: When the abdominal wall becomes hard and inflexible.
- Involuntary Guarding: A reflex contraciton of the abdominal muscles.
- Rebound tenderness: Pain that increases when pressure from palpation is released suddenly.
- Hypoactive or absent bowel sounds can suggest paralytic ileus or peritonitis
Other signs to watch out for include:
- Distension: Abdominal swelling mean bloating and gas, but can also mean ascites or internal bleeding.
- Discoloration: Particularly around the belly button (Cullen’s sign) or on the flanks (Grey Turner’s sign), which can indicate internal bleeding.
- Visible Veins: These might be a sign of portal hypertension or inferior vena cava obstruction.
Typically labs won’t need to be rechecked more than daily, but you should see slowly improving leukocytosis and liver enzymes (if they were abnormal to begin with).
Laparoscopic cholecystectomy is minimally invasive and generally has a quicker recovery time than open surgery. However, proper care of the surgical wounds is crucial to prevent complications.
- Keep the wound clean. Wash daily with mild soap and water. Pat dry – don’t rub.
- Keep the wound open to air (unless ordered otherwise by the surgeon)
- Regularly inspect the surgical sites for redness, swelling, pus, or increasing pain at the wound site, as these can all indicate infection. Mild redness can be normal.
- Limit activities like lifting heavy objects or vigorous physical activity in the post-operative period.
- Avoid submerging in water (like bathtubs or swimming pools) until fully healed.
- If Steri-strips were applied, they typically fall off within 1 week. If they’re still there 10 days later – they can be pulled off.
Possible Complications of Acute Cholecystitis
While many people might only have typical course of illness, some patients with acute cholecystitis can face serious complications. These can come from the inflammation itself, the spread of any infection, or changes in the gallbladder’s structure. It’s important to know and spot these complications early. Let’s dive into a detailed list of these potential issues.
This is a severe form of acute cholecystitis where the gallbladder becomes gangrenous. It occurs due to prolonged inflammation and can lead to perforation if not treated promptly.
Prolonged inflammation can cause the gallbladder wall to break down, leading to a hole or perforation. This can result in bile leaking into the abdominal cavity, leading to peritonitis.
In some cases, the gallbladder fills with pus due to an infection, a condition called empyema. This can cause fever and increased pain, requiring urgent drainage or surgery.
Stones from the gallbladder can block the common bile duct, leading to cholangitis, which is an infection of the bile duct. This condition can be life-threatening and requires immediate intervention.
Patients should be educated on dietary modifications to prevent recurrent attacks (if gallbladder not removed), or changes that will need to be made to accommodate for the removed gallbladder.
Patient Education (For Gall bladder attacks)
Patients who still have their gallbladder but want to prevent further gall bladder attacks should be educated to:
- Decrease dietary fat and cholesterol intake
- Limit rapid weight loss
- Increase fiber intake
- Limit refined sugars and carbs
- Stay hydrated
- Limit caffeine and alcohol
- Avoid trigger foods. This can sometimes be spicy food, dairy products, or even certain vegetables. Keeping a food diary can help!
- Weight loss (if applicable), but not too quickly
Post-Operative Patient Education
Proper dietary habits can help in avoiding undue stress on the healing gallbladder and in preventing potential complications. Some education includes:
- Gradually progress to a regular diet (Clear liquid diet usually ordered by surgeon to start)
- Maintain a low-fat diet, especially within the first few weeks after surgery
- Increase fiber-rich foods to prevent constipation
- Stay hydrated
- Limit caffeine and spicy foods
- Eat small frequent meals
- Avoid gas-producing foods (beans, cabbage, carbonated drinks, etc)
- Keep a food diary to avoid foods that upset your stomach
Summary of Acute Cholecystitis
Acute Cholecystitis is usually caused by gallstones which are stuck in the gall bladder neck, cystic duct, or common bile duct. More rarely it could be caused by another obstruction or partial obstruction like biliary sludge or nearby tumors.
Symptoms of acute cholecystitis including RUQ abdominal pain, nausea/vomiting, and sometimes fevers and chills.
Vital signs may show fever, tachycardia, and hypotension if the patient is septic. Abdominal assessment may show RUQ tenderness with guarding. Murphy’s sign is often positive. There may be hypoactive bowel sounds. Jaundice is abnormal with acute cholecystitis but can happen in severe cases.
Treatment of acute cholecystitis includes IV hydration, pain management, IV antibiotics, and usually surgical removal of the gallbladder.
Patient monitoring includes pain assessments and management, abdominal assessments, wound assessments, and ensuring labs return to normal if they were abnormal to begin with.
As you can see, acute cholecystitis is NOT something you want to experience, but it is pretty common and you will see this in the ER and inpatient settings. You will also definitely see a gall bladder attack (simple biliary colic). As with many medical conditions, patient education plays a crucial role in ensuring optimal recovery and preventing recurrence.
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