8/14/2019 Approach to a Patient With Gallbladder Disease[1]

1/33

Approach to a PatientApproach to a Patientwith Gallbladderwith Gallbladder

DiseaseDisease

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

2/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

3/33

Anatomy of theAnatomy of theGallbladderGallbladder

Pear-shapedPear-shapedhollow sac-likehollow sac-likeorgan;organ;lies in a shallowlies in a shallowdepression on thedepression on theinferior surface of inferior surface of the liverthe liverNormal capacity isNormal capacity is30-50ml30-50ml

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

4/33

Bile FlowBile Flow

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

5/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

6/33

In the fasting state, the Sphincter of In the fasting state, the Sphincter of Oddi offers a high pressure zone:Oddi offers a high pressure zone:

- to prevent reflux of duodenal- to prevent reflux of duodenalcontents into the bile ductscontents into the bile ducts

- to promote bile filling of the- to promote bile filling of thegallbladdergallbladder

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

7/33

CholecystokininCholecystokinin- is released in the duodenal- is released in the duodenal

mucosa in response to the ingestionmucosa in response to the ingestionof fats and amino acids.of fats and amino acids.Contraction of gallbladder Contraction of gallbladder

Decreased resistance of the Sphincter of Decreased resistance of the Sphincter of OddiOddiIncreased hepatic secretion of bileIncreased hepatic secretion of bile

Enhanced flow of biliary contents into theEnhanced flow of biliary contents into theduodenumduodenum

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

8/33

Enterohepatic CirculationEnterohepatic Circulation

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

9/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

10/33

Diseases of theDiseases of the

GallbladderGallbladder

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

11/33

Acute CholecystitisAcute Cholecystitis

Types: calculous (90%) stone Types: calculous (90%) stoneobstructsobstructs bilebileoutflowoutflow

acalculous absence of acalculous absence of obstructionobstruction byby

stonesstones

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

12/33

Cholelithiasis (Gallstones)Cholelithiasis (Gallstones)

Formation of stones in the cystic ductFormation of stones in the cystic duct Types of Stones: Types of Stones:- cholesterol- cholesterol- pigment- pigment

- stones- stones

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

13/33

Risk Factors:Risk Factors:ObesityObesityWomen,especially those who hadWomen,especially those who hadmultiple pregnanciesmultiple pregnancies

Frequent changes in weightFrequent changes in weightRapid weight lossRapid weight loss

Treatment with high dose estrogen Treatment with high dose estrogenIleal resection/ diseaseIleal resection/ diseaseDiabetes MellitusDiabetes Mellitus

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

14/33

PathophysiologyPathophysiology

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

15/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

16/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

17/33

Clinical ManifestationsClinical Manifestations

Pain and Biliary ColicPain and Biliary Colic Jaundice JaundiceChanges in urine and stool colorChanges in urine and stool colorVitamin DeficiencyVitamin Deficiency

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

18/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

19/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

20/33

Diagnostic ProceduresDiagnostic Procedures

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

21/33

A.A. Plain Abdominal X-ray - to rule outPlain Abdominal X-ray - to rule outotherother possible diseasespossible diseases

B.B. US detects gallstones with 95%US detects gallstones with 95%accuracyaccuracy

C.C. Cholescintigraphy biliary tract isCholescintigraphy biliary tract is

scanned afterscanned afteradministration of aadministration of aradioactive agentradioactive agent

D.D. Cholecystography to visualizeCholecystography to visualizebiliarybiliary tract; x-ray istract; x-ray isobtained after anobtained after an oraloralcontrast is administeredcontrast is administered

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

22/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

23/33

Surgical ManagementSurgical Management

Laparoscopic CholecystectomyLaparoscopic CholecystectomyOpen CholecystectomyOpen Cholecystectomy

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

24/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

25/33

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

26/33

Nutritional and SupportiveNutritional and Supportive

Therapy Therapy80% of patients with acute80% of patients with acutecholecystitis achieve remission withcholecystitis achieve remission with

rest, IV fluids, analgesia andrest, IV fluids, analgesia andantibioticsantibioticsLow-fat liquid diet; should avoid hihgLow-fat liquid diet; should avoid hihg

fat dietfat diet

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

27/33

Pharmacologic ManagementPharmacologic Management

Dissolving agentsDissolving agentsUrsodeoxycholic acidUrsodeoxycholic acid

Chenodeoxycholic acidChenodeoxycholic acid*** desaturates bile by inhibiting the*** desaturates bile by inhibiting the

synthesis and secretion of cholesterolsynthesis and secretion of cholesterol

*** taken for 6-12months*** taken for 6-12months

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

28/33

Nonsurgical ManagementNonsurgical Management

Dissolving gallstones infusion of aDissolving gallstones infusion of asolvent in the gallstone (MTBE)solvent in the gallstone (MTBE)

Stone removal by instrumentationStone removal by instrumentationExtracorporeal Shock-waveExtracorporeal Shock-waveLithotripsyLithotripsyIntracorporeal LithotripsyIntracorporeal Lithotripsy

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

29/33

Nursing ManagementNursing Management

AssessmentAssessmentHistory takingHistory taking

Preadmission testingPreadmission testingClient teaching on proceduresClient teaching on proceduresPatients capability to undergoPatients capability to undergo

procedureprocedure

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

30/33

DiagnosisDiagnosisAcute pain and discomfortAcute pain and discomfort

Impaired gas exchange r/t highImpaired gas exchange r/t highabdominal surgical incisionabdominal surgical incisionImpaired skin integrity r/t altered biliaryImpaired skin integrity r/t altered biliary

drainage (T-tube)drainage (T-tube)Imbalance nutritionImbalance nutritionDeficient knowledge about self-careDeficient knowledge about self-careactivities r/t incision care, dietaryactivities r/t incision care, dietarymodifications, medications and follow-modifications, medications and follow-upup

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

31/33

Planning and GoalsPlanning and GoalsRelief of painRelief of painAdequate ventilationAdequate ventilation

Intact skin and improved biliaryIntact skin and improved biliarysecretionsecretionOptimal nutrition intakeOptimal nutrition intake

Absence of complicationsAbsence of complicationsUnderstanding of self-care routinesUnderstanding of self-care routines

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

32/33

Nursing InterventionsNursing InterventionsMonitoring and Managing ComplicationsMonitoring and Managing Complications

Bleeding, infection, leakageBleeding, infection, leakageImproving Nutritional StatusImproving Nutritional StatusLow fat high carbohydrate and proteinLow fat high carbohydrate and protein

Promoting Skin Care and BiliaryPromoting Skin Care and Biliary

DrainageDrainage T-tube care T-tube care

Improving Respiratory StatusImproving Respiratory Status Turning, early ambulation, deep breathing Turning, early ambulation, deep breathing

exercisesexercisesRelieving PainRelieving Pain

Administer analgesics as orderedAdminister analgesics as orderedPillow or binder on the side of incision sitePillow or binder on the side of incision site

8/14/2019 Approach to a Patient With Gallbladder Disease[1]

33/33

EvaluationEvaluationReports decrease in painReports decrease in painDemonstrates appropriate respiratoryDemonstrates appropriate respiratoryfunctionfunctionExhibits normal skin integrityExhibits normal skin integrityObtains relief of dietary intoleranceObtains relief of dietary intolerance

Absence of complicationsAbsence of complications