Cholelithiasis, cholecystitis, and cholangitis

53 Cholelithiasis, cholecystitis, and cholangitis

Overview/pathophysiology

Gallstones may be found anywhere in the biliary system. They may cause pain and other symptoms or remain asymptomatic for years. Cholelithiasis is characterized by the presence of stones in the gallbladder. Choledocholithiasis is the term used to describe gallstones that have migrated to the common bile duct. Gallstones are classified as cholesterol or pigment stones. Cholesterol stones are more common in the United States and represent approximately 80% of cases. Black-pigment stones result from an increase of calcium and unconjugated bilirubin and are associated with cirrhosis and chronic hemolysis. Brown-pigment stones are the predominant type found in native Asians and may be associated with bacterial infection of the bile. Precipitating factors for stone formation include disturbances in metabolism, biliary stasis, obstruction, hypertriglyceridemia, and infection. Gallstones are especially prevalent in women who are multiparous, are taking estrogen therapy, or use oral contraceptives. Other risk factors include obesity, dietary intake of fats, sedentary lifestyle, and familial tendencies. The incidence increases with age, and it is estimated that one of every three persons who reach 75 yr of age has gallstones. Cholelithiasis is commonly seen in disease states such as diabetes mellitus, regional enteritis, and certain blood dyscrasias. Usually cholelithiasis is asymptomatic until a stone becomes lodged in the cystic tract. If the obstruction is unrelieved, biliary colic (intermittent painful episodes) and cholecystitis can ensue.

Acute cholecystitis is most commonly associated with cystic duct obstructions caused by impacted gallstones; however, it may also result from stasis, bacterial infection, or ischemia of the gallbladder. Cholecystitis involves acute inflammation of the gallbladder and is associated with pain, tenderness, and fever. With obstruction, structural changes such as swelling and thickening of the gallbladder walls can occur. If the edema is prolonged, the walls become scarred and fibrosed and the constant pressure of bile can lead to mucosal irritation. As a complication of the impaired circulation and edema, pressure ischemia and necrosis can develop, resulting in gangrene or perforation. With chronic cholecystitis, stones almost always are present and the gallbladder walls are thickened and fibrosed.

Cholangitis is the most serious complication of gallstones and is more difficult to diagnose than either cholelithiasis or cholecystitis. It is caused by an impacted stone in the common bile duct, resulting in bile stasis, bacteremia, and septicemia if left untreated. Cholangitis is most likely to occur when an already infected bile duct becomes obstructed. Mortality rate is high if not recognized and treated early.

Health care setting

Primary care; acute care

Assessment

Cholelithiasis:

History of occasional discomfort after eating. As the stone moves through the duct or becomes lodged, a sudden onset of mild, aching pain occurs in the mid-epigastrium after eating (especially after a high-fat meal) and increases in intensity during a colic attack, potentially radiating to the right upper quadrant (RUQ), right subscapular region, or right shoulder. Nausea, vomiting, tachycardia, mild fever, and diaphoresis also can occur. Many individuals with gallstones are entirely asymptomatic.

Acute cholecystitis:

Marked by right upper quadrant pain, fever, and leukocytosis. There may be a history of discomfort after eating, including regurgitation, flatulence, belching, epigastric heaviness, indigestion, heartburn, chronic upper abdominal pain, and nausea. Amber-colored urine, clay-colored stools, pruritus, jaundice, steatorrhea, fever, and bleeding tendencies can be present if there is biliary obstruction. Symptoms may be vague. An acute attack may last 7-10 days, but it usually resolves in several hours.

Cholangitis:

Fever is present in nearly all patients with bacterial cholangitis. Jaundice, chills, mild and transient pain, mental confusion, and lethargy are part of the presenting symptoms. Leukocytosis and elevated bilirubin are present in 80% of cases.

Physical assessment

Cholelithiasis:

Palpation of the RUQ reveals a tender abdomen during episode of biliary colic. Otherwise, between episodes of pain, the examination is usually normal.

Acute cholecystitis:

Palpation elicits tenderness localized behind the inferior margin of the liver. With progressive symptoms, a tender, globular mass may be palpated behind the lower border of the liver. Rebound tenderness and guarding also may be present. With the patient taking a deep breath, palpation over the RUQ elicits Murphy’s sign (pain and inability to inspire when the examiner’s hand comes in contact with the gallbladder).

Cholangitis:

RUQ tenderness is present in 90% of cases. Peritoneal signs (abdominal pain, tenderness, guarding, decreased or absent bowel sounds, nausea) are not common and only occur in 15% of patients. Hypotension and mental confusion are present in severe cases.

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Jul 18, 2016 | Posted by admin in NURSING | Comments Off

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