Cholecystitis

Department of Surgery
 Prepared By:
Team Leader : Mostafa Mahmoud Lotfy
Team Members
 Abdullah Hussein Kamel  Mostafa Khairy Hussein

 Mohamed Saber Mohamed  Omar Beshir Eissa

 Mohamed Abdelghani  Mostafa Yousry

 Noureldin Moahmed  Mostafa Hany Abdullah

 Mahmoud Atef Mahmoud  Mohamed Algamal

 Outlines
Introduction
Basics of Disease
Definition ,Pathophysiology
Types ,Causes ,Signs and symptoms
Risk factors , Complications

Pain Assessment
Diagnostic Test
Medical Treatment
Nursing Care Plan
Acute Pain ,Impaired body temperature
Risk for Impaired skin integrity ,Anxiety
Risk for Deficient Fluid Volume , Risk for Imbalanced Nutrition
Knowledge Deficit
Diet ,Life style ,Exercise ,Post operative care
Introduction
 Introduction
Gallbladder Cholecystitis inflammation

Gallbladder
is a small, pear-shaped organ in your upper right abdomen
Your gallbladder stores and releases bile to help your digestive system break down fats.
 Introduction
Anatomy of Gallbladder
Gallbladder lies with the fossa formed between inferior
aspect of right Lobes of liver.

Gallbladder composed of three anatomic portions:

1.fundus
2.Body(corpus)
3.Neck
Basics of Disease
 Basics of Disease
Definition
A Redness and swelling (inflammation) of Gallbladder

Pathophysiology
Cholelithiasis : stone in the gallbladder is most
composed primarily of cholesterol

Choledocholithiasis: gallstone in the

common bile duct

Pigment stone : appear to be composed of

calcium bilirubinate which occurs when free
bilirubin combines with calcium
 Basics of Disease
Pathophysiology
Calcular Cholecystitis
Calcular cholecystitis is the more common form and is
associated with the presence of gallstones (cholelithiasis).
Gallstones These gallstones are solid particles that can form in the
gallbladder due to imbalances in bile composition, such as
high cholesterol or bilirubin levels.
In calcular cholecystitis, the inflammation and associated
symptoms are primarily caused by gallstones blocking the
cystic duct or the neck of the gallbladder. This obstruction
Patho prevents the gallbladder from emptying properly, leading
physiology to bile stasis and increased pressure inside the gallbladder.
The trapped bile can irritate the gallbladder lining and
cause inflammation, which can progress to infection in
severe cases.
Patients with calcular cholecystitis typically experience
severe abdominal pain, especially in the right upper
Symptoms quadrant, often following the consumption of fatty foods.
Other symptoms may include nausea, vomiting, fever, and
jaundice.
Acalculous Cholecystitis
Acalculous cholecystitis is characterized by the absence of
gallstones in the gallbladder. The term "acalculous" means
"without calculi" or stones.
Acalculous cholecystitis can be caused by various factors
other than gallstones, such as severe illness or trauma. It is
often associated with underlying medical conditions like
critical illness, burns, major surgery, or systemic infections. In
these cases, the inflammation of the gallbladder is not
directly related to gallstones but may be due to issues such as
impaired blood flow, bile stasis, or ischemia.
The symptoms of acalculous cholecystitis are similar to
calcular cholecystitis and may include severe abdominal pain,
nausea, vomiting, and fever. Patients with acalculous
cholecystitis often have a history of recent critical illness or
surgery.
 Basics of Disease
Pathophysiology
The right and left hepatic ducts originate from the liver and carry bile, a digestive fluid, produced by
the liver cells (hepatocytes). These ducts merge to form the common hepatic duct.

The common hepatic duct joins with the cystic duct (coming from the gallbladder) to form the
common bile duct. The common bile duct carries bile from the liver and gallbladder to the
duodenum, where it aids in digestion

Bile is produced continuously by the liver and is stored in the gallbladder between
meals. The gallbladder releases bile into the duodenum in response to a meal to
aid in the digestion and absorption of fats.

Gallstones can form in the gallbladder due to imbalances in the composition of

bile, such as high cholesterol or bilirubin levels. Gallstones can range in size and
can either remain in the gallbladder (asymptomatic) or move into the ducts.
 Basics of Disease
Pathophysiology
In cases of acute cholecystitis, a gallstone often becomes lodged in the cystic duct, blocking the flow
of bile from the gallbladder. This obstruction prevents the gallbladder from emptying and leads to
the accumulation of bile.
The trapped bile becomes concentrated and can irritate the gallbladder's inner lining. Over time, this
concentration of bile and the inability to empty it properly can lead to inflammation and swelling of
the gallbladder wall.

The inflammation and swelling can compress blood vessels supplying the
gallbladder, leading to ischemia (lack of blood flow). Ischemia can result in tissue
damage and, if severe, tissue death (necrosis).

In some cases, the inflamed and damaged gallbladder can become infected,
leading to purulent (pus-filled) cholecystitis. This is a more severe form of the
condition and often necessitates surgical intervention.
 Basics of Disease
Types
Acute cholecystitis
is the sudden inflammation of the gallbladder that causes marked abdominal
pain, often with nausea, vomiting and fever.

Chronic cholecystitis
is a lower intensity inflammation of the gallbladder that lasts a long time. It may
be caused by repeat attacks of acute cholecystitis. Chronic cholecystitis may
cause intermittent mild abdominal pain, or no symptoms at all. Damage to the
walls of the gallbladder leads to a thickened, scarred gallbladder. Ultimately, the
gallbladder can shrink and lose its ability to store and release bile
 Basics of Disease
Causes
1. Bile duct blockage. Stones or thickened bile and tiny particles (sludge) can
block the bile duct and lead to cholecystitis. Kinking or scarring of the bile ducts
can also cause blockage
 Basics of Disease
Causes
2. Gallstones. Most often, cholecystitis is the result of hard
particles that develop in your gallbladder (gallstones).
Gallstones can block the tube (cystic duct) through which bile
flows when it leaves the gallbladder. Bile builds up in the
gallbladder, causing
 Basics of Disease
Causes
3. Tumor. A tumor may prevent bile from draining out of your
gallbladder properly

4. Infection. AIDS and certain viral infections can trigger gallbladder

inflammation.

5. Severe illness. Very severe illness can damage blood vessels and decrease
blood flow to the gallbladder, leading to cholecystitis.
 Basics of Disease
Signs and Symptoms
1. Severe pain in your upper right or center abdomen
2. Pain that spreads to your right shoulde or back
3. Tenderness over your abdomen when it's touched
4. Nausea
5. Vomiting
6. Fever
 Basics of Disease
Risk Factors
• Nearly 25million people have Gallstones, and about 1million
newcases are diagnosed each year.
• Gallstonesand inflammation of the gallbladder and common bile
duct are the most common disorders of the biliary system.
• Gender and age. Gallstones are more common among women and
older people.
• Genetics. Family history of gallstones.
• Obesity(fatty).
• Estrogen(fertile)
The five Fs
• Pregnancy fair, female, fat, fertile and Forty
• Diabetes.
• Rapid weight loss.
 Basics of Disease
Complication
• Infection and pus buildup within the gallbladder. If bile builds up
within your gallbladder, causing cholecystitis, the bile may become
infected.

• Death of gallbladder tissue. Untreated cholecystitis can cause tissue

in the gallbladder to die (gangrene). It's the most common
complication, especially among older people, those who wait to get
treatment and those with diabetes. This can lead to a tear in the
gallbladder, or it may cause your gallbladder to burst

• Torn gallbladder. A tear (perforation) in your gallbladder may result

from gallbladder swelling, infection or death of tissue.
 Basics of Disease
Complication
• Bile duct injury that can affect your liver

• Infection and inflammation of your pancreas (pancreatitis)

• Infection and inflammation of the lining of your belly (peritonitis)

• If your gallbladder has not been removed and you have more attacks
of cholecystitis, you may develop long-term (chronic) cholecystitis.
Chronic cholecystitis may not cause any symptoms. But it can damage
the walls of your gallbladder. The walls can become scarred and get
thicker. Your gallbladder will start to get smaller. Over time, it will be
less able to store and release bile. You will need surgery to remove your
gallbladder
 Pain
Assessment
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Pain Assessment
Characteristics of pain:

1-Acute. ( chronic )
2-Severity ( sever )
3-Site ( Right hypochondriac region.)
4-Honest ( sudden. Or gradually )
5-Duration ( may be From 2 to 6 hours)
6-Radiation (right shoulder _Scapula)
7-Aggrevating factors (walking _ Breathe _
Eat heavy meal _ Cough )
8-Reliving factors (rest )
 Pain Assessment
Physical Examination:

☆Clinical manifestation
☆Abdominal Guarding: guarding is when the
abdominal
muscles tense up when palpating
☆The Murphy sign: is discribe as tenderness
and an inspiratory pause elicited during
palpitation of (RUQ)
1- Ask patient to exhale
2- Examiner places hand below costal margin
on the right side at the mid-clavicular line .
3- The patient is instructed to inspire
Diagnostic
Test
 Diagnostic Test
1- patient history 2- physical examination

3- Diagnostic test
(Lab investigation _diagnostic procedures)

• _liver function test

• _blood test(WBC)
• _ bilirubin test
• _stool analysis
• _ERCP
• _Oral cholecystography
• _Abdominal Altra sound
• _Computerized tomography (CT)
 Medical
Treatment
 Medical Treatment
Treatment for cholecystitis usually involves a hospital stay to control the inflammation
in your gallbladder. Sometimes, surgery is need
Supportive treatment
1-Fasting. You may not be allowed to eat or drink at first in order to
take stress off your inflamed gallbladder.

2-Fluids through a vein in your arm. This treatment helps prevent

dehydration.

3-Analgesics .help control pain until the inflammation in your

gallbladder is relieved.

4-Anti-emetics
Medical Treatment
Supportive treatment
5-Antibiotics to fight infection, If your gallbladder is
infected, your provider likely will recommend
antibiotics.

6-Gallbladder drainage. In some cases, such as when

surgery to remove the gallbladder is not an option,
gallbladder drainage (cholecystostomy) may be
done to remove infection.
Drainage is done through the skin on the abdomen
(percutaneous) or by passing a scope through the
mouth (endoscopic)
Medical Treatment
Supportive treatment

7- Extracorporeal shoch-wave
lithotripsy (ESWL)
 Medical Treatment
Gallbladder removal surgery
1- The procedure to remove the gallbladder is called a cholecystectomy
Usually, this is a minimally invasive procedure, involving a few tiny cuts
(incisions) in your abdomen (laparoscopic cholecystectomy).

2- open procedure, in which a long incision is made in your abdomen, is

rarely required.
Incision Laparoscope
Nursing
Care Plan

Nursing Diagnosis
Acute pain
Site :
Epigastric Region ,Chest
Right Shoulder ,Right
Scapula
related to :
The obstruction of
gallstones
as Evidenced by :
- Pt report pain
- Facial expression
- pain score increased
- hyperthermia and
tachycardia
- elevated Bilirubin and liver
Enzymes
Nursing Care Plan
Goal
Pt will to relief from pain with
absence of symptoms and
decrease in pain score
as Evidenced by :
- pain score decrease
- normal temperature
(36.6/37.2)
- normal heart rate (60/100)
Nursing Intervention
1- Assess severity of Pain (0-10 scale).Location of Pain,
Vital Signs
2- Provide Comfortable Position by lying The Left
Lateral Position and Pillows supported To The sides
3- Provide relaxation Like hearing music , reading books
and Watching TV (etc.)
4- Advice The client To Take Low Fat diet Like bland
diet and to drink more Liquids and eat light diet
5- Advice The client To avoid like milk, cream, Chasse,
Fried foods, pastries spicy gravies and Nuts.
6- Provide Psychological and Emotional
 Nursing Care Plan
Nursing Diagnosis Goal Nursing Intervention
7- Control environmental Temperature

8- Administer drugs Like ursodiol, Chenadiol

9-Administer Analgesics Like Meperidine

10-sedatives Phenobarbital (promotes rest and relaxes

Smooth muscle, receiving pain)

11- Prepare The client For Surgical Procedure and

manage Post-operative Pain with Analgesics and
sedatives Like morphine or Codeine

12- Reassess of Vital Signs, The degree of Pain and is

Location, Liver enzymes and Bilirubin
 Nursing Care Plan
Nursing Diagnosis Goal
Impaired body temperature. -the Patient will re stablish
normal body temperature
related to:- between (36,6-37,2)
Inflammation of the
gollbladder -the pt will maintain
adequate hydration.
evidenced by:-
as evidenced by:-
-sweating
- normal urine output.
-Shivering
-stable vital signs.
-anorexia
Nursing Intervention
1-administer Prescribed antipyretic medication
(Paracetamol) to reduce fever.
2- encourage Pt to remove excessess Clothing and
covering without Causing Shivering.
3-Keep Clothing and bed dry and clean.
4-apply cool compressess to the to the Pt's forehead
and neck to promote heat loss.
5- increase Intake fluids at least (2,5 - 3 L/d) to replace
fluid lost

-dehydration
 Nursing Care Plan
Nursing Diagnosis Goal Nursing Intervention
6- control environment temperature to 21c to 27c to
promote heat loss.

7- Limit physical activity and allow rest periods to

decrease heat production.

8- monitor the patient's temperature every 1 hour.

9-reassess:-
-The patient vital signs every hour.
-the patient's nutrition and weight.
 Nursing Care Plan
Nursing Diagnosis Goal Nursing Intervention
Impaired skin integrity. Patient will maintain the skin 1- Advice the patient to take more of oral fluid.
integrity with relief from 2- Encourage the patient to eat small and frequent
Related to itching and break down foods.
increased bilirubin 3- Administer multi vitamin B1 supplement.
concentration of blood 4- Advice the patient to avoid drinking alcohol.
causing excretion of bile 5-Assess the areas of skin for itching and skin break
through skin leading to down.
scratching and skin break 6- Encourage the patient to keep the nails short.
down. 7- Advice the patient to avoid alkaline based soap on
skin.
Evidenced by 8- Encourage patient to dry with soft towel.
Redness or Erythema 9- provide skin hygiene ,nails care and back care.
Swelling or Edema 10- In case of skin break down provide dressing with
Pain or Discomfort aseptic precautions.
Open Wounds or Ulcers

Nursing Diagnosis
risk for deficient fluid
volume
related to
diarrhea, nausea , anorexia ,
clotting , dehydration and
impaired perfusion.
Nursing Care Plan
Goal
Patient will demonstrate
adequate fluid balance
evidenced by
stable vital signs, moist
mucous membranes, good
skin turgor, capillary refill,
individually appropriate
urinary output, and absence
of vomiting.
Nursing Intervention
1- Maintain accurate record of I&O, noting output less
than intake, and increased urine specific gravity.
2- Assess skin and mucous membranes, peripheral
pulses, and capillary refill.
3- Monitor for signs and symptoms of increased or
continued nausea or vomiting, abdominal cramps,
weakness, twitching, seizures, irregular heart rate,
paresthesia, hypoactive or absent bowel sounds, and
depressed respirations.
4- Assess for unusual bleeding: oozing from injection
sites, epistaxis, bleeding gums, ecchymosis, petechiae,
hematemesis, or melena.
 Nursing Care Plan
Nursing Diagnosis Goal Nursing Intervention
Risk for imbalanced patient will maintain 1- Collaborate with a registered dietitian to develop a
nutrition: an ideal body weight meal plan that meets the patient's individual needs and
Less than body with an intake of dietary restrictions.
requirements adequate nutrition 2- Encourage the patient to eat small, frequent meals
throughout the day.
May be related to 3- Choose foods that are low in fat and easy to digest.
Self-imposed or prescribed 4- Provide the patient with a variety of foods to choose
dietary restrictions from.
5- Create a comfortable and relaxed environment for
_nausea/vomiting eating.
_dyspepsia 6- Offer the patient assistance with eating if needed.
_pain 7- Monitor the patient's food intake and weight.
_Loss of nutrients Educate the patient about the importance of nutrition
_impaired fat digestion and how to make healthy food choices.
due to obstruction of bile
Flow
 Nursing Care Plan
Nursing Diagnosis Goal Nursing Intervention
Anxiety The patient will report a 1- Observe non-verbal cues, such as restlessness,
Related to reduction in anxiety fidgeting, and facial expressions, which may
associated pain and discomfort. indicate anxiety.
2- Discuss possible outcomes and expected
recovery.
3- Encourage the patient to express their fears and
concerns. Listen actively and empathetically.
4- Offer reassurance and answer questions
truthfully.
5- Provide guidance on relaxation techniques such
as deep breathing exercises, progressive muscle
relaxation, and guided imagery.
6- Involve the patient's family or support system in
their care to provide emotional support.
7- Ensure a comfortable and quiet environment to
promote rest and sleep, which can help reduce
anxiety.
 Nursing Care Plan
Nursing Diagnosis Goal Nursing Intervention
8- Administer prescribed anxiolytic medications as
ordered by the healthcare provider and Monitor the
patient for any side effects or adverse reactions to
these medications.

9- If the patient's anxiety is severe and significantly

impairs their ability to cope, consult with a mental
health professional or counselor for additional
support

10- Regularly assess the patient's anxiety levels to

determine if they have decreased.

Nursing Diagnosis
Knowledge Deficit
related to Post operative care
Nursing Care Plan
Goal Nursing Intervention
The patient will actively 1- Educate the patient about the reasons for the
participate in self-care surgery, surgical procedure (laparoscopic or open),
and adhere to the post- and potential risks and benefits.
operative care plan. 2- Emphasize the importance of hand hygiene.
3- Explain how to care for the incision site, keep it
clean, and watch for signs of infection.
4- Encourage gentle ambulation and provide
guidelines for gradually increasing physical activity.
5- Stress the importance of seeking immediate
medical attention if they experience severe
abdominal pain, high fever, jaundice, or other
concerning symptoms.
6- Monitor the surgical incision site for signs of
infection or other issues.

Nursing Diagnosis
Knowledge Deficit related to Diet
Nursing Care Plan
Goal Nursing Intervention
The patient will identify 1- Ask about their dietary habits, preferences, and
and choose foods that any misconceptions they may have.
are appropriate for their 2- Explain that a low-fat diet is often recommended
condition. to reduce gallbladder stimulation and the risk of
triggering painful symptoms.
3- Explain that fried foods, fatty cuts of meat, and
heavily processed foods should be limited or
avoided.
4- Discuss strategies for meal preparation and
cooking methods that reduce fat content, such as
baking, broiling, or steaming.
5- Teach the patient how to recognize and respond
to symptoms of cholecystitis, such as abdominal
pain or nausea, and how diet can influence these
symptoms.
6- Evaluate the patient's ability to create a balanced
and low-fat meal plan.
 Nursing Care Plan
Nursing Diagnosis Goal Nursing Intervention
Knowledge Deficit The patient will 1- Assess the patient's current lifestyle habits and
related to Lifestyle comprehend the lifestyle knowledge regarding the relationship between
modifications necessary lifestyle and cholecystitis
for managing
cholecystitis. 2- Explain how lifestyle factors, including diet,
exercise, and stress, can impact cholecystitis.

3- Offer resources or referrals for smoking cessation

or substance abuse support.

4- Discuss the recommended daily water intake

5- Monitor the patient's progress in managing their

cholecystitis and overall well-being.
 Nursing Care Plan
Nursing Diagnosis
Knowledge Deficit related to Exercise
Goal Nursing Intervention
The patient will 1- Assess the patient's current knowledge and
understand the beliefs about exercise
importance of exercise in 2- Discuss the importance of warming up and
managing cholecystitis. cooling down to prevent strain or injury.
3- Explain that starting slowly and gradually
increasing the intensity and duration of exercise is
important.
4- Offer encouragement and positive reinforcement
5- Discuss signs to watch for during exercise, such
as severe pain, shortness of breath, dizziness, or
nausea, and the importance of stopping if these
symptoms occur.
6- Determine if the patient can correctly identify
safe and suitable exercises.