Medical Surginal Nursing: CHOLECYCTITIS

CHOLECYCTITIS

Background: Cholecystitis is defined as inflammation of the gallbladder that

occurs most commonly because of an obstruction of the cystic duct from
cholelithiasis. Ninety percent of cases involve stones in the cystic duct (ie,
calculous cholecystitis), with the other 10% representing acalculous cholecystitis.
Although bile cultures are positive for bacteria in 50-75% of cases, bacterial
proliferation may be a result of cholecystitis and not the precipitating factor. Risk
factors for cholecystitis mirror those for cholelithiasis and include increasing age,
female sex, certain ethnic groups, obesity or rapid weight loss, drugs, and
pregnancy.

Acalculous cholecystitis is related to conditions associated with biliary stasis,

including debilitation, major surgery, severe trauma, sepsis, long-term total
parenteral nutrition (TPN), and prolonged fasting. Other causes of acalculous
cholecystitis include cardiac events; sickle cell disease; Salmonella infections;
diabetes mellitus; and cytomegalovirus, cryptosporidiosis, or microsporidiosis
infections in patients with AIDS.

Pathophysiology: Acute calculous cholecystitis is caused by obstruction of the

cystic duct, leading to distention of the gallbladder. As the gallbladder becomes
distended, blood flow and lymphatic drainage are compromised, leading to
mucosal ischemia and necrosis. A study by Cullen et al (2000) demonstrated the
ability of endotoxin to cause necrosis, hemorrhage, areas of fibrin deposition, and
extensive mucosal loss, consistent with an acute ischemic insult. Endotoxin also
abolished the contractile response to cholecystokinin (CCK), leading to gallbladder
stasis.

Although the exact mechanism of acalculous cholecystitis is unclear, a couple of

theories exist. Injury may be the result of retained concentrated bile, an
extremely noxious substance. In the presence of prolonged fasting, the
gallbladder never receives a CCK stimulus to empty; thus, the concentrated bile
remains stagnant in the lumen.

Frequency:

In the US: An estimated 10-20% of Americans have gallstones, and as many as

one third of these people develop acute cholecystitis. Cholecystectomy for either
recurrent biliary colic or acute cholecystitis is the most common major surgical
procedure performed by general surgeons, resulting in approximately 500,000
operations annually.

Mortality/Morbidity:

Most patients with acute cholecystitis have a complete remission within 1-4 days.
However, 25-30% of patients either require surgery or develop some
complication.
Patients with acalculous cholecystitis have a mortality rate ranging from 10-50%,
which far exceeds the expected 4% mortality rate observed in patients with
calculous cholecystitis. Emphysematous cholecystitis has a mortality rate
approaching 15%.
Perforation occurs in 10-15% of cases.
Race: