Definition:
Acute cholecystitis is the inflammation of the gallbladder, most commonly caused by obstruction of the cystic duct by gallstones (calculous cholecystitis). It can lead to gallbladder distension, ischemia, necrosis, and perforation if untreated. Acalculous cholecystitis, a less common form, occurs without gallstones and is associated with critical illness or trauma.
Pathophysiology:
- Gallstone obstructs the cystic duct → Bile stasis and irritation.
- Inflammatory response → Gallbladder distension and wall thickening.
- Bacterial invasion (E. coli, Klebsiella, Enterococcus, Bacteroides) → Infection and potential abscess formation.
- Complications: Gangrene, perforation, peritonitis, and sepsis.
Etiology and Risk Factors:
- Gallstones (90–95% of cases)
- Fat, Female, Forty, Fertile (4 F’s mnemonic)
- Obesity, rapid weight loss, pregnancy
- Prolonged fasting, total parenteral nutrition (TPN)
- Diabetes, liver disease, hyperlipidemia
- Critical illness (acalculous cholecystitis)
Signs and Symptoms:
- Right upper quadrant (RUQ) pain → Radiates to right shoulder or back
- Murphy’s sign → Pain with deep inspiration during RUQ palpation
- Nausea, vomiting, anorexia
- Low-grade fever, leukocytosis (↑ WBC count)
- Jaundice (if common bile duct obstruction occurs)
- Clay-colored stools, dark urine (suggests biliary obstruction)
Diagnosis:
- Laboratory tests:
- ↑ WBC count (inflammation)
- ↑ Bilirubin, ALP, AST, ALT (biliary obstruction)
- ↑ Amylase & lipase (if pancreatitis develops)
- Imaging:
- Ultrasound (first-line test) → Gallstones, wall thickening, fluid accumulation
- HIDA scan (hepatobiliary iminodiacetic acid scan) → Determines gallbladder function
- CT scan or MRI (used if complications suspected)
Treatment and Management
Initial Treatment (Conservative Management)
Initial Treatment (Conservative Management)
1.NPO status (to rest the GI tract)
2.IV fluids and electrolyte correction
3.Pain management (NSAIDs, acetaminophen, or opioids as needed)
Morphine can cause spasm of the sphincter of Oddi, which may worsen biliary pain and hinder bile and pancreatic juice drainage.
Meperidine has less effect on the sphincter of Oddi, making it traditionally considered safer in these cases.
🧬 Physiological Explanation:
- The sphincter of Oddi regulates the flow of bile and pancreatic juices into the small intestine.
Morphine, a μ-opioid agonist, can increase pressure in the sphincter of Oddi, leading to:
- Spasm
- Increased pain
- Risk of pancreatitis or worsening cholecystitis
Meperidine, though also a μ-opioid agonist, has less impact on this sphincter.
4. Antibiotics (ceftriaxone + metronidazole) if infection is suspected
5.Nasogastric tube (if severe nausea/vomiting)
Definitive Treatment: Cholecystectomy
- Laparoscopic cholecystectomy (gold standard) → Preferred due to faster recovery
- Open cholecystectomy → Indicated for severe inflammation, gangrene, or perforation
- Percutaneous cholecystostomy → Alternative for high-risk surgical patients
Complications:
- Gallbladder gangrene and perforation → Leads to peritonitis
- Chronic cholecystitis → Leads to biliary dysfunction
- Cholangitis (bile duct infection) → Presents with Charcot’s triad (fever, RUQ pain, jaundice)
- Gallbladder abscess → May require drainage
- Gallstone ileus → Obstruction of the intestine due to migrated gallstone
Nursing Considerations (NCLEX Focus)
✅ Assess pain and monitor for signs of complications (sepsis, peritonitis)
✅ Monitor vital signs and lab values (WBC, liver enzymes, bilirubin)
✅ Preoperative and postoperative care for cholecystectomy
✅ Educate on lifestyle modifications (low-fat diet, weight management, hydration)
References (APA 7th Edition):
- Andersson, R. E. (2021). Acute cholecystitis: Pathophysiology and management. World Journal of Surgery, 45(3), 635–645. https://doi.org/10.1007/s00268-020-05894-6
- Bennett, G. L., & Slywotzky, C. M. (2019). Ultrasound and imaging in gallbladder disease. Radiology Clinics of North America, 57(5), 921–936. https://doi.org/10.1016/j.rcl.2019.05.003
- Borzellino, G., & Sauerland, S. (2018). Evidence-based management of acute cholecystitis. Digestive Surgery, 35(1), 8–15. https://doi.org/10.1159/000486231
- de Mestral, C., Rotstein, O. D., Laupacis, A., & Nathens, A. B. (2020). Cholecystectomy outcomes and gallbladder disease. JAMA Surgery, 155(6), 532–539. https://doi.org/10.1001/jamasurg.2020.0987
- Indar, A. A., & Beckingham, I. J. (2019). Acute cholecystitis. BMJ, 333(7569), 63–68. https://doi.org/10.1136/bmj.333.7569.63
- Keus, F., Gooszen, H. G., van Laarhoven, C. J. H. M. (2018). Open versus laparoscopic cholecystectomy for acute cholecystitis. The Cochrane Database of Systematic Reviews, 2018(1), CD006231. https://doi.org/10.1002/14651858.CD006231.pub3
- Lyu, Y., Cheng, Y., Tan, D., & Gong, J. (2021). Risk factors and treatment strategies for severe acute cholecystitis. Journal of Hepato-Biliary-Pancreatic Surgery, 28(3), 540–548. https://doi.org/10.1007/s00534-021-01234-7
- Mori, Y., Itoi, T., Yasuda, I., et al. (2020). Tokyo Guidelines for the management of acute cholecystitis. Journal of Hepato-Gastroenterology, 68(7), 456–467. https://doi.org/10.1055/s-0040-1719202
- Shaffer, E. A. (2019). Gallbladder disease: Epidemiology and risk factors. World Journal of Gastroenterology, 25(10), 1184–1202. https://doi.org/10.3748/wjg.v25.i10.1184
- Strasberg, S. M. (2018). Acute cholecystitis and the critical view of safety in laparoscopic cholecystectomy. Journal of the American College of Surgeons, 226(1), 11–15. https://doi.org/10.1016/j.jamcollsurg.2017.08.005