Treatment of Cholecystitis in Older People

Introduction:

The gallbladder is a four-inch, pear-shaped organ on the right side of the abdomen, beneath the liver. The gall bladder is the storage area of the bile made by the liver. Bile is a combination of fluids, fat, and cholesterol. The gallbladder travels through the cystic duct and delivers the bile into the small intestine through the common bile duct. The bile helps to break down food in the intestines allowing for easy absorption of fat-soluble vitamins and nutrients into the bloodstream. The common bile duct connects the liver, gallbladder, and pancreas to the small intestine. Cholecystitis can be acute or chronic. It can become chronic if it persists for a longer period of time or if there are recurring symptoms from the inflammation present. If left untreated, cholecystitis can lead to serious, life-threatening conditions such as gall bladder rupture, tissue death, or infection within the gall bladder. Gallstones are involved in 95 % of cholecystitis. About 10 to 15 % of adults in the developed world have gallstones. Women get gallstones more often than men and more commonly after the age of 40 years.

What Are the Types of Cholecystitis?

There are two classifications of cholecystitis:

• Calculus Cholecystitis- In calculus cholecystitis, a gall bladder stone obstructs bile flow.

• Acalculous Cholecystitis- Acalculous cholecystitis is acute inflammation without obstruction by gallstones.

What Causes Cholecystitis?

There are numerous reasons that can lead to cholecystitis which include:

• The most common cause of the condition is gallstone obstructing the bile ducts. This blockage leads to a buildup of bile in the gallbladder, causing the gallbladder to be inflamed. The risk factors for gallstones are more in females, obesity, increasing age, diabetes, oral contraceptives, and rapid weight loss.

• A tumor can prevent bile from draining out of the gallbladder, causing bile buildup that can lead to cholecystitis.

• Scarring of the bile ducts can cause bile ducts blockage that can lead to cholecystitis.

• Decreased blood supply to the gallbladder, especially from diabetes, can cause cholecystitis.

• Immunodeficiency such as AIDS (acquired immunodeficiency syndrome) can trigger gallbladder inflammation.

What Are the Signs and Symptoms of Cholecystitis?

The symptoms mentioned below usually worsen after a meal that is high in fat.

• Nausea.

• Vomiting.

• Fever.

• Severe pain in the upper right or center quadrant of the abdomen.

• Little or no appetite.

• Tenderness over the abdomen while touching.

• Chills.

• Pain that spreads to the back or below the right shoulder.

• Jaundice may occur, but it is often mild.

• Loose, light-colored stool.

What Are the Complications Related to Cholecystitis?

If cholecystitis is left untreated, it could lead to certain serious complications, such as:

• Emphysema- An emphysema of the bladder develops if the gallbladder becomes filled with purulent fluid.

• Gangrene- Gangrene develops because tissue does not receive enough oxygen and nourishment.

• Cholangitis- The infection can progress if it reaches the bile duct.

How Cholecystitis Is Diagnosed?

A physician will take a medical history and carry out a physical examination to rule out symptoms of other conditions that are similar to cholecystitis. The following tests can be ordered by the doctor to help confirm the diagnosis:

• Blood Tests- These may be ordered to look for signs of infection in the bloodstream.

• Ultrasound- To show any gallstones and the condition of the bladder.

• CT (Computed Tomography) Scan- It can be used to create an image of the gallbladder that may reveal the signs of cholecystitis or stone in the bile ducts and gallbladder.

• Hepatobiliary Iminodiacetic Acid Scan (HIDA)- It creates pictures of the liver, gall bladder, biliary tract, and small intestine. It tracks the production and flow of the bile from the liver to the small intestines showing blockage.

What Are the Treatment Options for Cholecystitis?

Treatment options may include hospitalization to control the inflammation in the gall bladder; sometimes, surgery is needed. Fasting may be advised to take the stress off the inflamed gall bladder. The patient is given fluids intravenously to help prevent dehydration while fasting. Antibiotics to fight off infections and pain medications can also be given. The doctor may remove any stones blocking the bile ducts or cystic ducts using a procedure called endoscopic retrograde cholangiopancreatography (ERCP). The surgical removal involves the removal of the gallbladder, termed cholecystectomy. This is done either by open abdominal excision or laparoscopically.

How to Manage Cholecystitis in Older People?

In elderly patients with cholecystitis, the choice of treatment is not limited by age but rather by the severity of the disease. In patients with grade 1 to 2 cholecystitis, cholecystectomy can be done, and in patients with grade 3 to 4 cholecystitis, proper management with medication and surgical treatment should be considered. The major goal of the treatment of the elderly patients should include the following:

• Relieve pain and promote rest.

• Maintain fluid and electrolyte balance.

• Prevent complications.

• Provide information about the disease process, prognosis, and treatment needs.

• Promote adequate rest.

• Administer intravenous fluids, and monitor intake and output.

• Monitor nasogastric tube and suctioning.

• Pharmacological management with analgesics like Morphine and antibiotics such as Metronidazole can be administered.

• After the patient is discharged, home care guidelines should be given.

• Patients with cholecystitis must be educated about the cause of the disease, complications if the disease is left untreated, and medical and surgical options.

• Ambulate and increase physical activity as tolerated.

• Consult with a dietician or nutritional support to establish nutritional needs.

• Postoperative, the patient’s respiration should be paid attention to, and asked to perform deep breathing exercises.

• After discharge, low-fat meals are recommended in the diet.

• Patients can expect diarrhea and acidity after surgery for a few days.

Conclusion:

Although cholecystectomy is the standard choice of treatment for cholecystitis, it should be properly managed in the case of elderly patients as they are associated with comorbidities and decreased physiological reserve. A long-term management plan should be established, and surgery options should be considered as it will free the patient from pain and resume and maintain optimal diet and nutrition. Cholecystitis is the most common case in the emergency room among the older population, and it should be treated after a diagnosis to avoid further serious complications.