Cholecystitis
Key Points
- Cholecystitis is inflammation of the gallbladder, most commonly caused by gallstones obstructing bile flow (calculous cholecystitis).
- Cholecystitis may present as an acute episode or as recurrent/chronic inflammation.
- Risk factors: Female, Forty, Fat, Fertile (the “4 Fs”) — plus rapid weight loss and family history.
- Hallmark assessment: RUQ pain after fatty meals, Murphy’s sign (pain on RUQ palpation during deep inspiration).
- Diagnosis: Ultrasound (gold standard for gallstones), CBC (leukocytosis in acute), liver enzymes, bilirubin.
- Treatment: Laparoscopic cholecystectomy; post-op right shoulder pain from CO₂ insufflation is expected and resolves in 2–3 days.
- For selected nonsurgical candidates, symptom control may include low-fat diet strategies, gallstone-dissolution therapy (for example ursodiol), or percutaneous gallbladder drainage.
Pathophysiology
The gallbladder stores and concentrates bile, releasing it via the cystic duct when fatty foods are consumed. Cholecystitis occurs when:
- Calculus cholecystitis (most common): A gallstone obstructs the cystic duct → bile backs up → gallbladder becomes inflamed and edematous. Untreated, the gallbladder can become gangrenous and rupture.
- Acalculous cholecystitis: No stone present, but impaired gallbladder contractility causes bile stasis and inflammation. Associated with critical illness, prolonged fasting, total parenteral nutrition.
Gallstones form from excess cholesterol, bilirubin, or calcium combined with biliary stasis and concentrated bile.
Nursing Assessment
NCLEX Focus
Murphy’s sign and RUQ pain after fatty meals are classic cholecystitis findings. Jaundice (yellow eyes, light-colored stools, dark urine) indicates bile duct obstruction by a stone — a complication requiring ERCP before cholecystectomy.
Risk Factors — “4 Fs + 2”
| Risk Factor | Significance |
|---|---|
| Female sex | Higher estrogen → increased cholesterol in bile |
| Forty (age 40s) | Increased prevalence with age |
| Fat (obesity) | Increased biliary cholesterol excretion |
| Fertile (pregnancy) | Estrogen + progesterone affect bile composition |
| Rapid weight loss | Mobilizes cholesterol into bile |
| Family history | Genetic predisposition |
Clinical Manifestations
- RUQ pain — primary symptom; often after fatty or spicy meals
- Murphy’s sign — RUQ pain or inspiratory pause during deep palpation of RUQ (positive sign)
- Referred pain to right shoulder or back (phrenic nerve irritation)
- Nausea, vomiting, bloating, flatulence
- Food intolerance (fatty, spicy foods)
- Jaundice (scleral icterus), light-colored stools, dark urine — indicates choledocholithiasis (bile duct stone)
Diagnostics
| Test | Finding |
|---|---|
| CT scan | Can identify gallstones and inflammatory changes consistent with cholecystitis |
| Ultrasound (gold standard) | Detects gallstones; gallbladder wall thickening |
| CBC | Normal in chronic; leukocytosis in acute cholecystitis |
| Liver enzymes/bilirubin | Elevated when bile duct obstructed |
| Lipase | Ordered to rule out pancreatitis |
| HIDA scan | Assesses bile flow; ejection fraction ≤35% = acalculous cholecystitis |
| ERCP | Required before surgery if stones are present in the bile duct |
Nursing Interventions
Acute phase:
- Administer IV fluids and analgesics as ordered
- NPO during acute inflammation to rest the gallbladder
- Monitor vital signs and abdominal assessment (changes may indicate complication)
- Monitor hydration status and nutrition tolerance while treating pain and preparing for possible surgery.
- Prepare for surgery (complete pre-op checklist)
- For clients not suitable for surgery, support provider-directed nonsurgical plans such as low-fat dietary management, ursodiol therapy, or percutaneous drainage.
Post-laparoscopic cholecystectomy:
- Right shoulder pain from CO₂ insufflation is expected and normal — reassure patient; walking helps; resolves within 2–3 days
- Monitor incision sites for infection (redness, warmth, drainage, fever)
- Advance diet slowly — low-fat diet initially (liver adapts bile production over time)
Patient Education:
- Low-fat diet in the postoperative period; fatty foods may cause GI upset until the liver compensates
- Report immediately: jaundice (yellow eyes, pale stools, dark urine), signs of infection, worsening pain
- Right shoulder pain after laparoscopic procedure is expected; walking reduces pain
- Reinforce short-term goals for pain/anxiety control and hydration, then long-term nutrition recovery as oral intake normalizes.
Complications
- Choledocholithiasis: bile duct stone → jaundice → requires ERCP before cholecystectomy
- Pancreatitis: stone lodges near pancreatic duct → elevated lipase → potential organ failure
- Gangrenous gallbladder/perforation: if untreated inflammation progresses → sepsis
Related Concepts
- digestive-system — Gallbladder anatomy, bile storage and release physiology.
- appendicitis-urgent-surgical-management — Differential diagnosis for acute abdominal pain with elevated WBC.
- perioperative-surgical-classification-anesthesia-and-innovation — Pre- and post-operative care framework.
- postoperative-pacu-priorities-and-complication-surveillance — PACU monitoring after cholecystectomy.
- abdominal-organ-enlargement-and-vascular-red-flags — Distinguishing RUQ findings on examination.
Self-Check
- A patient with suspected cholecystitis has jaundice, scleral icterus, and pale stools. What complication does this indicate, and what additional intervention is needed before surgery?
- A postoperative patient after laparoscopic cholecystectomy reports right shoulder pain. Is this expected? What should the nurse advise?
- What does a HIDA scan ejection fraction of ≤35% indicate?