Cholelithiasis and Cholecystitis NCLEX Review

Gallbladder disease can fall into a few different categories. Gallstones, inflammation, gangrene, abscesses, cancer, and something called sclerosing cholangitis. The most common disorders are obstructions and inflammation, so we’ll be focusing on those in today’s lesson.

Gallbladder Obstruction
Obstructions of the gallbladder are a result of gallstones, which you will hear referred to as cholelithiasis. They are made up of bile substances and can stay inside the gallbladder itself, or pass into the cystic duct. When they lodge in the cystic duct, the stones block the inward and outward flow of bile which leads to inflammation of the organ and a significant amount of pain.

Gallbladder Anatomy and Physiology Review
The gallbladder is a small pear-shaped organ in the right upper quadrant. Its job is to store and concentrate bile and deliver bile into the duodenum when fats need to be digested. The duct leading in/out from the gallbladder is the cystic duct. It joins with the hepatic duct to form the common bile duct. At the entrance to the duodenum is a sphincter called the sphincter of Oddi. When fats are present in the duodenum, the gallbladder contracts and the sphincter of Oddi relaxes. Bile then enters the duodenum to aid in the digestion of fats.

What is a Gallstone?
Gallstones are formed due to the impaired metabolism of bile acids, bilirubin and cholesterol. There are three subtypes:

• The most common type of gallstones are cholesterol stones, which are mostly cholesterol. They form in bile that is overly saturated with cholesterol which forms crystals that aggregate and become stones inside the gallbladder, but can then become lodged in the cystic or common duct.
• Pigmented gallstones contain less than 30% cholesterol and can be brown or black. The brown type are soft and the black type are hard.
  • Pigmented brown stones are more common in East Asia and are associated with bacterial infection, biliary parasites, and biliary stasis. They tend to form in the common bile duct.
  • Pigmented black stones are the rarest type and typically form inside the gallbladder in patients with chronic liver disease.
• Mixed gallstones are a combination of the different types.

What About Inflammation?
Inflammation of the gallbladder is called cholecystitis. It can be acute or chronic, and the acute inflammation is the result of cholelithiasis. Gallstones lodge in the cystic duct causing obstructions to bile flow. Over time the gallbladder becomes inflamed and distended. As the organ swells, pressure is placed on the blood vessels and can lead to ischemia and even necrosis and gallbladder perforation.

Chronic cholecystitis is due to inadequate bile emptying and dysfunction of the gallbladder muscle wall that eventually cause the organ to contract and become fibrotic.

Since cholecystitis is usually a result of cholelithiasis, we’ll look at these together using the Straight A Nursing LATTE method.

How Does the Patient LOOK?

• Possibly no symptoms if the stones are inside the gallbladder (and not the ducts) and not so large in number they disrupt normal gallbladder function or cause inflammation.
• Tachycardia, fever
• Epigastric pain that may radiate to the right scapula area or shoulder.
• Pain in RUQ after eating fatty foods or large meals.
• Abdominal guarding, rebound tenderness, possibly rigidity
• Positive Murphy’s Sign: The examiner presses on the patient’s right subcostal area and asks them to take in a deep breath. If the patient experiences enough pain that it causes them to halt their inspiration, this is a positive Murphy’s sign.
• The patient may complain of N/V, flatulence, indigestion or heartburn, belching and pruritus.
• If the stone has blocked the common bile duct, jaundice and pruritus may be present. The patient may also have foamy orange urine and clay-colored stool.
• If the pancreatic duct is blocked, symptoms will be associated with pancreatitis.

How do you ASSESS the patient?

• Full pain assessment
• Vital signs
  • The patient will likely have fever and tachycardia
  • Necrotic gallbladder can cause sepsis, so monitor for hypotension as well
• Assess for Murphy’s sign (if in your scope of practice)
• Assess for the presence of jaundice
• Assess dietary habits and inquire foods that trigger attacks
• Monitor for signs of dehydration
• Monitor I/O

What TESTS are conducted?

• Initial imaging studies include ultrasound of the abdomen (which can be done endoscopically or transabdominally) and/or CT scan.
• HIDA scan involves the injection of a radioactive substance that attaches to bile-producing cells. It enables the examiner to see the flow of bile through the ducts.
• ERCP (endoscopic retrograde cholangiopancreatography) enables the examiner to visualize the location of the stones and significance of the obstruction. An ERCP can also be therapeutic (see treatments below)
• Labs include WBC (likely to have leukocytosis), bilirubin (elevated) and alkaline phosphatase (elevated)

What TREATMENTS are provided?

• Address pain
  • Analgesics as needed (typically opioid)
  • Antispasmodics to relax smooth muscle (anticholinergics)
• Address dehydration with fluid and electrolyte replacement
• Address infection if present with antibiotics
• Address nausea/vomiting
  • Keep patient NPO
  • Administer antiemetics
  • Consider NGT for decompression if severe
• Surgical interventions
  • Gallbladder removal (cholecystectomy); can be open or done laparoscopically
  • Surgical removal of the gallstone (choledocholithotomy)
  • A cholecystostomy tube may be needed to decompress the gallbladder; this procedure is done percutaneously and is often performed in Interventional Radiology.
  • A T-tube may be placed in the common bile duct after cholecystectomy to allow ror drainage of bile.
• Non-surgical interventions
  • Gallstone removal through endoscopic retrograde cholangiopancreatography and sphincterotomy with stone retrieval (ERCP with sphincterotomy)
  • Lithotripsy to break up larger stones
  • Medications that dissolve cholesterol stones (chenodeoxycholic acid and/or ursodeoxycholic acid). Adverse effects include diarrhea, elevated cholesterol and abnormal LFTs

How will you EDUCATE the patient?

• Teach the patient to consumer smaller meals with less fats
• Teach the patient how to care for any drains or tubes
• Ensure patient understands when to call the MD

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References:

Johns Hopkins Medicine. (n.d.). Primary sclerosing cholangitis. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/primary-sclerosing-cholangitis

Mayo Clinic. (n.d.). Cholecystitis—Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/cholecystitis/symptoms-causes/syc-20364867

McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (Eighth). Elsevier.

Mohamed, A. W. (2018, September 16). Gallbladder disease: Overview, types, and diagnosis. Healthline. https://www.healthline.com/health/gallbladder-disease

Nettina, Sandra M., editor. Lippincott Manual of Nursing Practice. Eleventh edition, Wolters Kluwer, 2019.

SAGES. (2020, April 1). ERCP (Endoscopic retrograde cholangio-pancreatography) patient information from sages. SAGES. https://www.sages.org/publications/patient-information/patient-information-for-ercp-endoscopic-retrograde-cholangio-pancreatography-from-sages/