NWT Clinical Practice Guidelines for Primary Community Care Nursing - Gastrointestinal System Gallbladder Disease: Biliary Colic And Cholecystitis Definition Rates of gallstones, cholecystitis and stones of the The spectrum of gallbladder disease ranges from common bile duct increase with age. Elderly asymptomatic gallstones to biliary colic, clients are more likely to have asymptomatic cholecystitis, choledocholithiasis and cholangitis. gallstones that result in serious complications without gallbladder colic. Cholecystitis is inflammation of the gallbladder caused by obstruction of the cystic duct, usually The causes of gallstones in teenagers are the same by a gallstone (calculous cholecystitis). The as for adults, and there is a higher prevalence inflammation may be sterile or bacterial. The among girls and during pregnancy. obstruction may be acalculous or caused by sludge. History Most gallstones (60% to 80%) are asymptomatic. Choledocholithiasis occurs when the stones Small stones are more likely to be symptomatic become lodged in the common bile duct; from than large ones. Almost all patients experience this, cholangitis and ascending infections can symptoms before complications occur. occur. Indigestion, belching, bloating and intolerance of fatty food are thought to be typical symptoms of Causes gallstones; however, these symptoms are just as Biliary Colic common in people without gallstones and Gallstones temporarily obstruct the cystic duct or frequently are not cured by cholecystectomy. pass into the common bile duct. Biliary Colic Cholecystitis • 1-5 hours of constant pain, commonly in the The cystic duct or common bile duct becomes epigastrium or right upper quadrant obstructed for hours, or gallstones irritate the • Pain may radiate to the right scapular region or gallbladder. Bacterial infection is thought to be a back consequence, not a cause, of cholecystitis. • Client tends to move around to seek relief from pain The most common organisms are E. coli, • Onset of pain occurs hours after a meal, Klebsiella spp. and enterococci. Stones of the frequently at night, waking the client from sleep common bile duct (occurring in 10% of patients • Peritoneal irritation by direct contact with the with gallbladder disease) are secondary (from the gallbladder localizes the pain to the right upper gallbladder) or primary (formed in the bile ducts). quadrant • Pain is severe, dull, or boring and constant (not Risk Factors colicky) The phrase "fair, fat and fertile female" • Associated symptoms include nausea, vomiting, summarizes the major risk factors for gallstones. pleuritic pain and fever Although gallstones and cholecystitis are more common in women, men with gallstones are more Cholecystitis likely to experience cholecystitis than women with • Persistence of the biliary obstruction leads to gallstones. It is unknown if women who are cholecystitis pregnant or have multiple pregnancies are more • Persistent right upper quadrant pain likely to have gallstones or if they simply have more symptoms of the stones. • The character of the pain is similar to the pain associated with gallbladder colic, except that it Some oral contraceptives and estrogen is prolonged and lasts for hours or days replacement therapy may increase the risk of • Nausea, vomiting and low-grade fever are more gallstones. commonly associated with cholecystitis September 2004 Gallbladder Disease: Biliary Colic And Cholecystitis - Adult 1 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Gastrointestinal System Physical Findings Acute Cholecystitis • Vitals signs parallel the degree of illness • Perforation • Clients with biliary colic have relatively normal • Gangrene vital signs • Peritonitis • Clients with cholangitis are more likely to have • Cholangitis tachycardia or hypotension (or both) and fever • Abscess • Fever may be absent, especially in elderly • Fistula clients • Pancreatitis • Jaundice (in < 20% of patients) • Ileus Abdominal Examination in Gallbladder Diagnostic Tests Colic and Cholecystitis The choice of laboratory tests will depend on • Epigastric or right upper quadrant tenderness whether the client is well enough to be treated as • Murphy's sign (an inspiratory pause on palpation an outpatient or requires admission to hospital. of the right upper quadrant; specific but not The results of lab tests should be completely sensitive for gallbladder disease) normal if the client has cholelithiasis or • Guarding on palpation gallbladder colic. • Fullness in the right upper quadrant may be • White blood cell (WBC) count and liver palpated function tests (LFTs) (AST, ALT, bilirubin and alkaline phosphate levels) may be helpful in the As in anyone with abdominal pain, a complete diagnosis of cholecystitis physical examination must be performed • An elevated WBC count is expected; however, a (including rectal and pelvic examinations in normal value does not rule out cholecystitis women). In elderly and diabetic clients, occult • Bilirubin >3.5 µmol/L may indicate stone in the cholecystitis or cholangitis may be the source of common bile duct or ascending cholangitis fever, sepsis or changes in mental status. • Mild elevation of amylase (up to 3 times normal level) may be present in cholecystitis, especially Differential Diagnosis if there is gangrene • Appendicitis • Urinalysis • Acute bowel obstruction • Pregnancy test for women of childbearing age • Ascending cholangitis • Cholelithiasis Management Of Biliary Colic • Diverticular disease Goals of Treatment • Gastroenteritis • Relieve pain, nausea and vomiting • Hepatitis • Prevent complications • Inflammatory bowel disease • Mesenteric ischemia Appropriate Consultation • Myocardial infarction Consult physician if pain does not resolve, if fever • Pancreatitis develops or if significant vomiting continues, as • Bacterial pneumonia these symptoms indicate that a complication may • Eclampsia be developing. • Hyperemesis gravidarum Nonpharmacologic Interventions • Urinary tract infection • Bed rest • Renal calculi • Clear fluids if vomiting Complications Biliary Colic • Cholecystitis September 2004 Gallbladder Disease: Biliary Colic And Cholecystitis - Adult 2 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Gastrointestinal System Client Education • Oxygen, if client is unstable on presentation • Explain disease process and prognosis • IV therapy with normal saline, rate adjusted • Counsel client about appropriate use of according to age, state of hydration and pre- medications (dose, frequency) existing medical problems • Recommend low-fat food as tolerated, once pain resolves Nonpharmacologic Interventions • Bed rest Pharmacologic Interventions • Nothing by mouth Analgesia Primary pain should be controlled with Pharmacologic Interventions anticholinergic antispasmodics: Analgesia hyoscine butylbromide (B class drug), Pain control should be given early, without 10 mg IM q6h prn (max 100mg/day) waiting for the diagnosis or surgical consult. hyoscine butylbromide (C class drug), Primary pain control should be with 10mg, 1-2 tabs, PO q6h (max 6 tabs/day) anticholinergic antispasmodics: hyoscine butylbromide (B class drug), Secondary pain should be controlled with 10 mg IM q6h prn (max 100mg/day) meperidine; do not use morphine, which may Secondary pain control should be with meperidine; increase tone in the Oddi's sphincter: do not use morphine, which may increase tone in meperidine (D class drug), 50-100 mg IM q3-4h the Oddi's sphincter: prn meperidine (D class drug), 50-100 mg IM q3-4h prn Consult physician for IV order Antiemetics Antiemetics to relieve vomiting and nausea: dimenhydrinate (A class drug), 25-50 mg IM dimenhydrinate (A class drug), 25-50 mg IM q4- q4-6h 6h prn Meperidine and dimenhydrinate can be mixed in the same syringe, but should be used immediately. Monitoring and Follow-Up Monitor for a few hours. When nausea and Antibiotics vomiting have resolved, push clear fluids. For mild cholecystitis, where inflammation is the Follow-up in 24 hours is recommended. If pain primary process, antibiotics are not usually used. increases, fever develops, or the client is unable to For acute cholecystitis (if client is febrile and tolerate intake by mouth because of vomiting, acutely ill), draw a blood sample for culture and manage as for acute cholecystitis. consult physician for IV antibiotics. For clients with allergy to penicillin use only Management Of Cholecystitis metronidazole. Goals of Treatment • Relieve pain, nausea and vomiting Monitoring and Follow-Up • Prevent complications Monitor pulse oximetry, vital signs (frequent), blood glucose, intake and output. Appropriate Consultation Severe cholecystitis can evolve into sepsis or Consult physician if pain does not resolve, if fever cholangitis, especially in diabetic or elderly clients develops or if significant vomiting continues in whom the diagnosis may be delayed. indicating that a complication may be developing. Referral Adjuvant Therapy Medevac as soon as possible; surgical consult is For clients with severe pain prehospital care required. should include the following: September 2004 Gallbladder Disease: Biliary Colic And Cholecystitis - Adult 3.