Care of the Client with Care of the Client with Disorders of the Disorders of the

GallbladderGallbladder

ACC RNSG 1247ACC RNSG 1247

Gallbladder DiseaseGallbladder Disease

Two main disorders:Two main disorders: CholecystitisCholecystitis CholelithiasisCholelithiasis

Risk factors for GB diseaseRisk factors for GB disease

Higher in women: Higher in women:

multiparous, over 40, on estrogen therapy multiparous, over 40, on estrogen therapy Sedentary lifestyleSedentary lifestyle Familial tendencyFamilial tendency ObesityObesity

Etiology of CholecystitisEtiology of Cholecystitis

Acute :Acute :

- Calculous: with stone obstruction- Calculous: with stone obstruction

- Acalculous: absence of stones- Acalculous: absence of stones Chronic:Chronic:

- Repeated attacks, long standing - Repeated attacks, long standing

inflammation inflammation

Pathophysiology of CholecystitisPathophysiology of Cholecystitis

Obstruction leads to ischemia of GB mucosa Obstruction leads to ischemia of GB mucosa or wall or wall

Inflammation may follow: GB is edematous Inflammation may follow: GB is edematous during acute attack or distended with bile or during acute attack or distended with bile or puspus

Cystic duct may be occludedCystic duct may be occluded GB becomes scarredGB becomes scarred

Clinical Manifestations of Clinical Manifestations of AcuteAcute vs Chronic Cholecystitisvs Chronic CholecystitisWhich are acute signs; which are chronic?Which are acute signs; which are chronic?

________________ Usually begins with a Usually begins with a

biliary colic attackbiliary colic attack RUQ pain RUQ pain N/VN/V Usually signs of acute Usually signs of acute

inflammationinflammation Possible pus Possible pus

formationformationgangrenousgangrenous

______________ Dull acheDull ache History of fat History of fat

intoleranceintolerance DyspepsiaDyspepsia Increased flatulenceIncreased flatulence

CholelithiasisCholelithiasis

Calculi (stones) in the GBCalculi (stones) in the GB May obstruct the cystic or CBDMay obstruct the cystic or CBD Choledocholithiasis: stones in the CBDCholedocholithiasis: stones in the CBD Types:Types:

Composed primarily of pigmentComposed primarily of pigment Composed primarily of cholesterolComposed primarily of cholesterol

Pathophysiology of CholelithiasisPathophysiology of Cholelithiasis

Develops when the balance that keeps Develops when the balance that keeps cholesterol, bile salts and calcium is altered cholesterol, bile salts and calcium is altered causing precipitation of these substancescausing precipitation of these substances

Conditions affecting balance: infection and Conditions affecting balance: infection and altered metabolism of cholesterolaltered metabolism of cholesterol

Bile in GB and liver become saturated with Bile in GB and liver become saturated with cholesterolcholesterol

Cholesterol vs Pigment StonesCholesterol vs Pigment StonesWhich is which & which is more common?Which is which & which is more common?

____________________________ 4x more prevalent in 4x more prevalent in

womenwomen formation incidence formation incidence

increased in use of oral increased in use of oral

contraceptives, estrogenscontraceptives, estrogens

_____________ made of other bile

components (bile salts, bilirubin, Ca, protein)

undissolvable; requires surgery

increased risk in: cirrhosis, hemolysis, biliary tree infections

Cholesterol stones 1Cholesterol stones 1

Cholesterol stones 2Cholesterol stones 2

Pigment stonesPigment stones

Clinical Manifestations of Clinical Manifestations of CholelithiasisCholelithiasis

““Silent cholelithiasis”Silent cholelithiasis” Pain and biliary colicPain and biliary colic Sx RT bile obstructionSx RT bile obstruction

such as jaundice, pruritus,such as jaundice, pruritus,

changes in color of stool changes in color of stool

and urine, vitamin and urine, vitamin

deficiency, bleeding, deficiency, bleeding,

steatorrheasteatorrhea

Diagnostic StudiesDiagnostic Studies History & physical examinationHistory & physical examination Would these laboratory tests show increased or Would these laboratory tests show increased or

decreased levels? decreased levels?

* Liver function tests* Liver function tests

* WBC count* WBC count

* Serum bilirubin* Serum bilirubin

* Serum amylase* Serum amylase

Diagnostic TestsDiagnostic Tests

Abdominal x-raysAbdominal x-rays Ultrasonography – most accurate Ultrasonography – most accurate HIDA scan HIDA scan Endoscopic retrograde Endoscopic retrograde

cholangiopancreatography (ERCP)cholangiopancreatography (ERCP) Percutaneous transhepatic cholangiographyPercutaneous transhepatic cholangiography

Treatment & Nursing CareTreatment & Nursing CareAcute episodes focus on Acute episodes focus on * Pain control – * Pain control – - Morphine- Morphine - Dilaudid (hydromorphone)- Dilaudid (hydromorphone)

- Ketorolac (Toradol- Ketorolac (Toradol) ) - - Demerol (MeperidineDemerol (Meperidine) ) - - NSAIDS, anticholinergicsNSAIDS, anticholinergics

* Infection Control - antibiotics * Infection Control - antibiotics

Treatment & Nursing Care Treatment & Nursing Care continuedcontinued

*Fluid and electrolyte balance*Fluid and electrolyte balance - IV fluid- IV fluid - Antiemetics : - Antiemetics : Metoclopramide (Reglan) Metoclopramide (Reglan) Ondansentron (Zofran)Ondansentron (Zofran) Prochlorperazine (Compazine)Prochlorperazine (Compazine) Gastric Decompression Gastric Decompression – NGT, NPO– NGT, NPO

• *How/what would you monitor to maintain F & E *How/what would you monitor to maintain F & E balance?balance?

Treatment and Nursing CareTreatment and Nursing Care

Once attack is over maintain onOnce attack is over maintain on _____ fat diet _____ fat diet _________ forming foods_________ forming foods Avoid eggs, whole milk products, cheese,Avoid eggs, whole milk products, cheese,

ice cream, fried foods, rich foods, alcoholice cream, fried foods, rich foods, alcohol Reduced _______ diet if obese Reduced _______ diet if obese

Treatment & Nursing Care:Treatment & Nursing Care:Supportive Drug TherapySupportive Drug Therapy

* Fat soluble vitamin replacement: A,D,E,K* Fat soluble vitamin replacement: A,D,E,K

* Bile salts: Ex: Decholin; enhance fat * Bile salts: Ex: Decholin; enhance fat

absorptionabsorption

* Bile acids: Exs: Questran and Cholestid; * Bile acids: Exs: Questran and Cholestid;

bind bile salts and treat pruritus bind bile salts and treat pruritus

Treatment and Nursing Care:Treatment and Nursing Care:Non Surgical Stone Approaches for Non Surgical Stone Approaches for

Stone RemovalStone Removal

* endoscopic sphincterotomy (papillotomy)* endoscopic sphincterotomy (papillotomy) * mechanical lithotripsy * mechanical lithotripsy * cholesterol solvents* cholesterol solvents * extracorporeal shock wave lithotripsy * extracorporeal shock wave lithotripsy

ERCP with Sphincterectomy

Treatment and Nursing Care: Treatment and Nursing Care: SurgicalSurgical

When is one preferred over another? Why?When is one preferred over another? Why?

________________________

CholecystectomyCholecystectomy * GB removed * GB removed

through through

4 puncture holes4 puncture holes

* CX: injury to CBD * CX: injury to CBD

__________________

CholecystectomyCholecystectomy * removal of GB * removal of GB

via right subcostal via right subcostal

incision incision

* T tube inserted into * T tube inserted into

CBDCBD

Laparoscopic vs Open Laparoscopic vs Open Cholestectomy Cholestectomy

T tubeT tube

Treatment and Nursing Care:Treatment and Nursing Care:Surgical Surgical

Transhepatic Transhepatic

biliary catheterbiliary catheter * to decompress * to decompress

obstructed obstructed

extrahepatic extrahepatic

ducts ducts

Treatment and Nursing Care: Treatment and Nursing Care: Post Op Care &TeachingsPost Op Care &Teachings

Pain ControlPain Control Prevent Prevent

Complications Complications primarily primarily pulmonarypulmonary

Wound CareWound Care Dietary Dietary

modificationmodification

Gerontologic considerationsGerontologic considerations

Gallstones increasingly commonGallstones increasingly common Differing presenting symptomsDiffering presenting symptoms Surgical risks due to concurrent conditionsSurgical risks due to concurrent conditions Decreased elective surgery and more advanced Decreased elective surgery and more advanced

status at time of surgerystatus at time of surgery Higher risk of complications and shorter Higher risk of complications and shorter

hospital stayshospital stays

Gallbladder Cancer Gallbladder Cancer

UncommonUncommon Majority are adenocarcinomasMajority are adenocarcinomas Early symptoms similar to chronic Early symptoms similar to chronic

cholecystitis and cholelithiasischolecystitis and cholelithiasis Later symptoms of biliary obstructionLater symptoms of biliary obstruction Poor prognosisPoor prognosis

Gallbladder CancerGallbladder Cancer

Diagnosis and staging – EUS, transabdominal Diagnosis and staging – EUS, transabdominal US, CT, MRI, MRCPUS, CT, MRI, MRCP

If found early – surgery is curativeIf found early – surgery is curative Extended cholestectomy with lymph node Extended cholestectomy with lymph node

dissection – good outcomedissection – good outcome Palliative – stenting of biliary tree, radiation, Palliative – stenting of biliary tree, radiation,

chemotherapy chemotherapy

Gallbladder CancerGallbladder Cancer

Nursing Management - supportive careNursing Management - supportive care Nutrition, hydration, skin care, pain reliefNutrition, hydration, skin care, pain relief Similar to care for cholecystitis and Similar to care for cholecystitis and

cholelithiasis and cancer cholelithiasis and cancer

The EndThe End