Cholecystitis Treatment and Management †Free Samples to Students

Question: Discuss about the Cholecystitis Treatment and Management. Answer: Introduction Gallstonesareminimally sized stones which are made from cholesterol and are subsequently deposited in the gall bladder. Although gallstones do not often have any symptoms that present physically, they can however, cause periodic pain (referred to as biliary colic) or can develop into a more advanced form referred to as acute cholecystitis (NHS, 2015). The latter form of infection is potentially serious and requires for a person to visit a hospital immediately they experience painful discomfort. Acute cholecystitis is normally treated with antibiotics and intravenous fluids. The main symptoms include sudden pain that is experienced in the right hand side of the abdomen and which spreads slowly to the right shoulder. The sharp pain is more centralized in the affected tender part of the abdomen and taking deep breathes only worsens the pain (NHS, 2015). Unlike other abdominal pain types, acute cholecystitis pain continues persistently for several hours before residing. Some people experience the pain with other symptoms including: high fever; vomiting and nausea; sweating; appetite loss; jaundice; and an abdominal bulge. The causes can be categorized into two: calculous and acalculuous. Calculous is the most common yet less serious of the two types and accounts for approximately 95% of all incidences of cholecystitis. It occurs when the gallbladder's main opening known as the cystic duct, is blocked by biliary sludge or gallstones. Biliary sludge comprises of a mix of bile, salt crystals, and cholesterol pellets. This blockage results in build up of bile in the gall bladder which in turn results in pressure build up causing the gall bladder to become inflammed. 1 in every 5 inflammed bladders often ends up with a bacterial infection (NHS, 2015). Acalculous cholecystitis is more serious but not as prevalent as the calculuous type. It often develops as a serious illness complication, injury, or infection to the gallbladder that causes it to be damaged. It may result from an accidental damage to the gallbladder during a surgical procedure, blood poisoning, burns, AIDS, or severe malnutrition (NHS, 2015) The patient presented at the healthcare center was a 49 year old male accompanied by his 12 year old daughter. The patient had cholecystitis and complained of having an acute abdominal pain in his RUQ and which had gone on for two days. He also had a high body fever, was nauseated as well as vomiting. The handover notes indicated that his HR was 126, temperature was peaked at 38.8 and his BP was at a low of 100/45; his RUQ experienced severe pain and vomiting hade continued for two hours. The notes also indicated that the patient had a dry mucous membrane, pale skin, and that he was thirsty. The shoulder tip pain was recorded at a score of 7/10. The patient had a pale mucous membrane which is a sign of severe dehydration. He also requested for water (Modic, 2013). Extrinsic shoulder pain could be as a result of diaphragmatic pain which is a direct consequence of a subphrenic abscess or gallbladder disease (Patient, 2016). Kasim came with his 12 year old daughter which probably infers that she is the one who takes care of him during times of sickness and when he reports for hospital checkups. In the event that the patient needs to be admitted, this will pose a problem as the daughter cannot sign patient consent forms and neither will she be in position to go back home by herself when her father gets admitted. Plans will need to be made to accommodate the situation Pain in the Right Upper Quadrant Right upper quadrant (RUQ) pain is one that manifests locally on the abdomen's right hand side subcostal region. The pain often radiates superiorly and spreads over to the anterior hemithorax on the right side, followed by medial spread to the epigastrium, inferolaterallly toward the lower quadrant or flank on the right side, and then postterolaterally toward the hemithorax posterior right side (Chandra, 2016). The acute pain can develop over a number of days or hours or can be subacute to chronic, which develops over a period of a few months or weeks. The pain quality varies from a dull ache to a sharp pain which is colic or continuous as well as being intermittent. At times the pain may commence as colic and advance to a persistent and continuous pain. The visceral area lies over the hepato-biliary system and any infection of these causes pain in the RUQ. Other organs in the visceral area include the pancreas head, the duodenum, the colon hepatic flexure, and the right kidney upper pole,. A differential diagnosis should be done to rule out any other infection when treating for RUQ. The most common etiologies for RUQ include biliary tree (this is acute bacterial infection cholangitis, or choledocholithiasis); gall bladder (acute cholecystitis or cholelithiasis); or liver (acute hepatitis caused by alcohol or viral infection) The patient's heart rate was 126 and the BP was 100/45. When a person's body is dehydrated, the blood circulation is restricted within the vessels. This causes buildup within the blood stream which causes the heart to pump blood faster in an attempt to flush out the accumulated wastes. This forced pumping of blood is manifested in symptoms which include: low blood pressure and high heart rates as was observed in the patient. In addition, the patient has dry mucous membrane and was thirsty. Gallstones develop when crystal like particles form in the bile and can range in size from minute to golf ball size. Gallstones cause irritation, pressure, and infection of the gall bladder. The gall bladder walls become thick making it harder to function efficiently. Additionally, cholecystitis can result from CBD drainage system infection; blockage of the CBD; excess deposits of cholesterol in the gallbladder due to rapid weight loss or pregnancy; pancreatic or liver tumours; gallbladder tumours; and diabetes that causes decreased blood flow to the gallbladder (Healthline, 2015) Chronic cholecystitis occurs after frequent and prolonged attack episodes. According to the Cleveland Clinic(2014) the risk of developing cholecystitis increases when a person reaches the age of 40 years. In addition, people who are obese are also prone to becoming infected. Rapid weight gain or loss is also linked to the disease formation. In the case scenario, the patient presented with symptoms of cholecystitis which included cholangitis as symptomized by a high fever and vomiting, hypotension, and in some cases confusion (Medicinenet, 2016) Patient assessment and intervention The patient's history as well as a physical exam forms the basis of diagnosis. Murphy's sign has been found to give a 95% accuracy report for persons presenting with temporary respiratory arrest or pain on the right subcostal deep palpitations, a pointer for acute cholecystitis. The patient will go through a few lab tests including complete CBC, liver function tests, amylase, and lipase. An x-ray f the abdomen will also be necessary for determining the exact cause of the RUQ. An ultrasound will detect presence of gallstones while a CT scan will show any delineation of organ structures. The results from these tests will be sufficient to diagnose presence of gallstones as well as show and other infections in the visceral organs (Mayo, 2015). Besides the high heart beat rate, the high temperature/fever, and low blood pressure, that the patient is recorded to have, the tests for dehydration will also include checking for presence of sweat. The skin will also be assessed for elasticity. As dehydration intensifies in the body, the skin turgor decreases even as the water content in the body is lost through the skin. The amount of sweat will be checked in the armpit as it is one of the two areas that tend to normally have moisture. The nurse will not check for sweat in the patient's groin (the other area for sweat testing) simply because the patient, based on the nurse's perception, will perceive the process to be culturally inappropriate. The mouth and nasal cavity will also be examined and so too will the tongue, to determine their level of moisture (Wedro, 2015) Normal bodily functions for a healthy adult include: a heart rate of between 60-100bpm (Pulse Vital, 2017); blood pressure levels at 120/80mmHg (Mayo, 2017); body temperature of 36.5 to 37.2 degrees Celsius (WebMD, 2016) Conclusion Treatment interventions for cholecystitis depend on the condition's severity as well as the absence or presence of complications. For cases where there are no complications, the patient can be treated at the ER and discharged on the same day while in complicated cases; the patient may require undergoing surgical procedure to correct the anomaly. For unstable patients, it may be appropriate to use percutaneous drainage transhepatic cholecystostomy. Infection is managed by administering antibiotics. A definitive therapy will include drainage device placement or cholecystectomy, hence, it will be necessary to consult a surgeon. In addition, a gastroenterologist will need to be consulted in the need arises for an endoscopic retrograde cholangiopancreatography (ERCP) in the case of choledocholithiasis (Bloom, 2016). Severe dehydration requires for the patient to be admitted in the hospital where isotonic saline will be administered as well as monitor for hyponametric and hypernametric states. The patient was vomiting and hence he will not b able to tolerate oral rehydration therapy which means that admission to the hospital will be necessary for intravenous fluid or nasogastric therapy (Schols, De Groot, Van Der Cammen,2009). The 12 year old daughter will need to be assisted to get back home by either calling for any one of her relatives to come and pick her up. In case there is no close relative, the social service department at the hospital will be tasked with her placement until such time when her father will be discharged from the hospital. References Bloom, A(2016). CholecystitisTreatment Management. (Retrieved on 1st May, 2017). https://emedicine.medscape.com/article/171886-treatment Chandra, R (2016). Right-upper quadrant abdominal pain. (Retrieved on 1st May, 2017). from Clinical Advisor. https://www.clinicaladvisor.com/hospital-medicine/right-upper-quadrant-abdominal-pain/article/601167/ Cleveland Clinic (2014). Gallstones. (Retrieved on 1st May, 2017). https://my.clevelandclinic.org/health/articles/gallstones Healthline, (2015). What is chronic cholecystitis? (Retrieved on 1st May, 2017). https://www.healthline.com/health/chronic-cholecystitis#overview1 Mayo Clinic (2017). High Blood Pressure (hypertension). (Retrieved on 1st May, 2017). https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/blood-pressure/art-20050982 MedicineNet (2016). Gall Bladder Pain. (Retrieved on 1st May, 2017). https://www.medicinenet.com/gallbladder_pain_gall_bladder_pain/page4.htm Modric, J. (2013). Dehydration Symptoms and Signs. (Retrieved on 1st May, 2017). https://www.ehealthstar.com/dehydration/symptoms-and-signs NHS (2015) Acute cholecystitis. (Retrieved on 1st May 2017). https://www.nhs.uk/conditions/Cholecystitis-acute/Pages/Introduction.aspx#Symptoms Patient (2016). Shoulder Pain. (Retrieved on 1st May, 2017). https://patient.info/doctor/shoulder-pain-pro Pulse Vital (2017). Adult: Heart rate 126 or resting heart rate 126 - good or bad? Adult: Heart rate 126 or resting heart rate 126 - good or bad? (Retrieved on 1st May, 2017). https://pulsevital.com/heartrate/126/adult/ Schols, J. M., De Groot, C. P., Van Der Cammen, T. J., Olde Rikkert, M. G. (2009). Preventing and treating dehydration in the elderly during periods of illness and warm weather.The journal of nutrition, health aging,13(2), 150-157. WebMd (2016). Body Temperature. (Retrieved on 1st May, 2017). https://www.webmd.com/first-aid/body-temperature#1 Wedro, B (2016). Dehydration. (Retrieved on 1st May, 2017). https://www.medicinenet.com/dehydration/page5.htm