Cholecystitis

Chole: bile Cyst: membranous sac

When you put all of this together you get: A membranous sac that contains bile is
inflamed. Therefore, cholecystitis is the inflammation of the gallbladder.

What’s the gallbladder?

It’s a dark green organ that is round in shape. Some may say that it sort of looks like a
little green pear.

The gallbladder is found under the liver on the right side of the body, which is very
convenient since the liver and gallbladder are connected to each other and work
together. They share their love for BILE!

Bile is a greenish brownish substance and is created by the liver and travels to the
gallbladder to be stored and concentrated via the hepatic ducts, which is why the organ
is greenish in color.

Bile helps us digest and absorb fats that we consume like fat soluble vitamins such as
A, D, E, and K. So, if our gallbladder isn’t working (like from a blockage or inflammation)
our body can’t have access to these fats and they will exit the body as greasy/fatty
stools called “steatorrhea”.

In addition, bile is also a vehicle for helping the body rid itself of bilirubin, which is
created from the breakdown of old/worn out red blood cells. Bilirubin is a
brownish/orange/yellowish substance and helps give our stool its brown color.

So, if the gallbladder isn’t releasing bile properly (which contains bilirubin) the stool will
become a light color (like clay), the sclera of the eyes could turn orange/yellow
along with the skin (jaundice), and the urine will turn dark in color. This is because
the bilirubin has leaked into the skin and urine rather than exiting the body in the stool.

How does the gallbladder deal with bile?

The gallbladder squirts bile into the duodenum (a part of the small intestines). This
happens when chyme (a thick semi-pulpy liquid that contains gastric juices and half-
way digested food created by the stomach) enters into the duodenum which stimulates
the gallbladder to contract.

When this occurs, bile travels down the cystic duct and into the common bile duct
and then into the duodenum. Bile will then fulfill its role with helping digest fats and help
the bilirubin leave the body via stool. BUT IF GALLBLADDER IS INFLAMED, THINGS
WOULD CHANGE!
The inflammation can become so severe it can cause = inflammation of the liver
(hepatitis), pancreas (pancreatitis), sepsis, or perforate.

Causes of Cholecystitis : Obstruction of some type:

Cholelithiasis “gallstones”: main “Cause”

● Risk factors: woman, obese, older, family history, pregnant, Native American or
Mexican American
Or any other type of obstruction in the gallbladder where bile can’t flow out via the cystic
duct

What happens? Bile stays in the gallbladder and becomes thick. This increases
pressure in the gallbladder and damages the wall of the gallbladder, which causes
inflammation and swelling of the gallbladder. Furthermore, due to the swelling and
inflammation, blood flow to the gallbladder can be compromised and lead to death of
the organ.

Acalculous “without a gallstone issue”: “Absence” This is where the gallbladder is

NOT working properly and it doesn’t contract
● This tends to occur to high acuity patient (very sick patients who are
hospitalized), after surgery or during a severe illness like sepsis, burns, or
major trauma, and even when a patient has been on TPN for a long period
of time (the gallbladder isn’t being stimulated).

What happens? Bile becomes thick and the gallbladder is not contracting like it should
(not being stimulated) and this leads to inflammation.

Signs and Symptoms of Cholecystitis

● Nausea/Vomiting
● Pain in abdomen (epigastric) that tends to radiate to the right shoulder pain,
especially after consuming a greasy meal
● Positive Murphy’s Sign: lay patient in supine position and palpate under
the ribs on the right side at the midclavicular line. Then have the patient
breathe out and then take a deep breath in. While the patient is breathing
in, palpate on this area under the ribs…if the patient stops breathing in
during palpation it is considered a positive Murphy’s Sign.
● Fever
● Bloating
● Steatorrhea, jaundice, dark brown urine, light colored stools (chronic
cholecystitis)

Diagnosed? abdominal ultrasound, HIDA scan, or CT scan

Nursing Interventions for Cholecystitis
“Gallbladder”

GI rest

● NPO until recovered then clear liquids and advanced as tolerated per MD
order
● When diet is ordered to be advanced, assess how the patient is tolerating
the advancement…are they having nausea/vomiting, pain?
● Nausea/vomiting may be very severe and a nasogastric tube with GI
decompression may be inserted. The NG tube, per MD order, may be set
to low intermittent suction to help remove stomach contents so the
gallbladder isn’t stimulated.
● Provide mouth care

Analgesics for pain, Antiemetics for nausea

Low-fat, gas-free foods diet when recovered

Large bore IV for fluids to hydrate and maintain electrolytes (bcs nausea and vomiting)

Breathing in stopped by patient during palpation of gallbladder because it hurts

“Murphy’s Sign”

Labs: electrolytes, bilirubin (jaundice?), WBC, liver enzymes, pancreatic enzymes, renal
function

Antibiotics for infection (IV)

Drain care

● Cholecystostomy tube “C-tube”: this is different from a t-tube which is

placed after the removal of the gallbladder and is placed in the bile duct.
● C-tubes are placed through the abdominal wall and into the gallbladder.
They are for patients who can’t have surgery immediately to remove the
gallbladder but the infected bile needs to be removed.
● It will drain infected fluid from the gallbladder.

Things to remember:

● keep the collection bag at waist level to drain

● empty and record drainage
● Note color
● Monitor insertion site for infection
 ● Flush per MD order so it won’t get blocked and
teach patients how to care for the drain.

Deterioration signs and symptoms? How to tell if treatment is not helping and the patient
is getting worse?

● Mental status changes, increased heart rate, decreased blood pressure,

high temperature, high WBC, change in stool consistency and color
(steatorrhea, light colored, jaundice, dark urine…no bilirubin), increasing or
worsening abdominal pain (RUQ)

ERCP to remove the gallstones from the bile duct and assess areas of the
gallbladder…an endoscope is inserted through the mouth and into the stomach to the
small intestine and to the bile duct.

Removal of gallbladder “cholecystectomy”

● Since the gallbladder is removed bile will now drain from the liver via the
bile duct into the duodenum.
● This procedure can be performed laparoscopically (most common) or
open.
● Monitor for infection.
● Be aware that many patients who have the gallbladder removed
laparoscopically will have shoulder pain from carbon dioxide (that was used
during the procedure) not being reabsorbed by the body.
● Side lying with knees bent can help the pain along with heat
application to the shoulders, or analgesics.
● Make sure the patient is ambulating soon after the procedure to prevent
post-op complications and coughing and deep breathing (splinting incision)
…remind the patient how to use the incentive spirometer.
● T-Tube care:
● A t-tube works as a drain and it can be used for testing where
dye is injected into the tube and an x-ray is taken to see if
there are any more stones. It will light up the biliary tree.
● The T part of the t-tube is placed in the bile duct to drain bile
while the duct is healing after surgery because there will be
swelling in the duct. It helps drain the excessive bile so it
doesn’t all go into the small intestine because it will have to get
used to having this amount of bile draining down (remember
normally the gallbladder contracted and delivered it at
intervals).

Things to Remember:
Patient will have a drainage bag that will need to be kept at the abdomen so it can drain
properly and the patient should be upright in the Semi-Fowlers position to help with
draining.

Monitor drainage and that is it actually draining because it can become blocked.

Drainage should NOT be more than 500 mL/day ... .first day post-op the drainage may
be bloody and then will turn greenish/brown.

Maintain skin care because bile is harsh on the skin.

You must have a physician’s order to flush the t-tube.

You may be ordered to clamp the tube 1 hour before and 1 hour after meals (MUST
HAVE MD ORDER FOR THIS) so bile can enter the small intestine to help digest fats.

When the tube is clamped monitor how the patient tolerates it ... .notify MD if the patient
has nausea/vomiting, pain etc.