Gallbladder Disease – Med/Surg Lewis – Flashcards

Cholelithiasis Stones in the gallbladder Most common disorder of the biliary system Stones may be lodged in the neck of the gallbladder or the cystic duct Affects 8%-10% of adults in the U.S. Cholecystitis Inflammation of the gallbladder Can be acute or chronic. It usually is caused by gallstones that block the tube leading out of your gallbladder. Usually associated with Cholelithiasis

Higher incidence in women, multiparous women, and persons over 40 years old Obesity & diabetes Prolonged fasting Rapid weight loss Sedentary lifestyles Family history High intake of fatty foods and dairy products More common in whites than Asian Americans & African Americans High incidence in the Native Americans, particularly in the Navaho & Pima tribes

Most often associated with obstruction caused by gallstones or biliary sludge Causes not associated with obstruction include: Older adults Trauma, burns, & recent surgery Prolonged immobility Fasting Prolonged parenteral nutrition Diabetes Mellitus Bacteria from E. coli, Streptococci, & Salmonellae Other etiologic factors include adhesions, neoplasms, anesthesia, tumors and narcotics. Inflammation is the major pathophysiologic condition May be confined to the mucous lining or involve the entire wall of the gallbladder During an acute attack, the gallbladder is edematous & hyperemic. The wall of the gallbladder becomes scarred after an acute attack. Decreased functioning occurs if large amounts of tissue are fibrosed. May be distended with bile or pus Cystic duct may become occluded

Cause is unknown Most common gallstones are predominantly cholesterol Develops when cholesterol, bile salts, and calcium are altered and precipitation of these substances occur Immobility, pregnancy, and inflammatory or obstructive lesions of the biliary system decrease bile flow resulting in stasis of bile Stones may remain in the gallbladder or migrate to the cystic or common bile ducts May lodge in the ducts and cause an obstruction

- Spasms - Severe pain that is steady (biliary colic) - Excruciating pain accompanied by tachycardia, diaphoresis, and prostration - Pain may last up to an hour and when it subsides theres residual pain in RUQ - Pain occurs 3-6 hours after a high fat meal or when patient lies down - S/S related to bile blockage (Obstructive jaundice, dark amber urine thats frothy when shaken, no urobilinogen in urine, clay colored stools, pruritus, intolerance of fatty foods, bleeding tendencies, steatorrhea)

May produce severe symptoms or none at all. - Indigestion, moderate to severe pain, jaundice - RUQ pain & tenderness initially which may be referred to the right shoulder and scapula - Pain may be acute & accompanied by N/V, restlessness and diaphoresis - Inflammation may manifest as leukocytosis and fever - Physical findings include abdominal rigidity - Chronic cholecystitis manifests as fat intolerance, dyspepsia, heart burn and flatulence - Pain can occur 2-4 hours after high fat meals lasting 1-3 hours - Murphy's Sign pain with expiration while examiners hand is placed below the costal margin on right side at midclavicular line. Patient then asked to inspire if patient is unable to inspire due to pain, test is positive.

- Gangrenous Cholecystitis - Subphrenic abscess - Pancreatitis - Cholangitis - Biliary cirrhosis - Fistulas - Rupture of gallbladderCan produce bile peritonitis In older patients and those with diabetes, gangrenous cholecystitis and bile peritonitis are the most common complications of cholecystitis. Gangrenous cholecystitis develops when severe inflammation interrupts the blood supply to your gallbladder. Without a constant supply of blood, the tissue of the gallbladder will begin to die. Subphrenic abscess is an abscess that develops on or near the undersurface of the diaphragm. Cholangitis - inflammation of the common bile duct.

Ultrasonography Useful for patients with jaundice because it does not depend on liver function and for patients who are allergic to contrast medium. It is 90%-95% accurate in detecting stones. ERCP Allows visualization of the gallbladder, cystic duct, common hepatic duct, and common bile duct. Can remove stone at the same time. Bile can be sent for culture to identify possible infecting organisms. Percutaneous transhepatic cholangiography Used to diagnose obstructive jaundice and to locate stones within the bile ducts. Laboratory tests: Increased WBC Elevated bilirubin levels Elevated urinary bilirubin level if obstructive process present Elevated Alkaline phosphatase, ALT & AST Increased Serum amylase if pancreatic involvement

ERCP with sphincterotomy (papillotomy) Removes common bile duct stones. Endoscope is passed to the duodenum. With an electrodiathermy knife attached to the endoscope, the sphincter of Oddi is widened by incision of the sphincter muscle. A basket is used to retrieve the stone. Stone may be removed in the basket or passed naturally in the stool. Extracorporeal shock-wave lithotripsy Dissolves stones by using an ultrasound to locate the stones and shock waves are then directed through the abdomen as a water-filled cushion is pressed against the area. Stones pass through the common bile duct and into the small intestine. Minimal side effects include some pain or colic, N&V, and fever -NPO with NG tube, later progressing to low-fat diet -IV fluids - Antiemetics -Fat-soluble vitamins (A,D,E, & K) - Antibiotics (for secondary infection) - NSAIDS (Toradol) are given for pain - Anticholinergics (antispasmodics) to decrease secretions and counteract smooth muscle spasms

Treatment focuses on pain control, control of possible infection with antibiotics and maintenance of fluid & electrolyte balance - NG tube when N/V is severe to decompress the stomach and decrease the stimulation of the gallbladder - Cholecystectomy is use to drain purulent material from obstructed gallbladder - NSAIDS (Toradol) are given for pain - Anticholinergics (antispasmodics) to decrease secretions and counteract smooth muscle spasms -NPO with NG tube, later progressing to low-fat diet -IV fluids - Antiemetics -Fat-soluble vitamins (A,D,E, & K) - Antibiotics (for secondary infection)

Laparoscopic cholecystectomy A laparoscope, which has a camera attached, is inserted into the abdomen. These punctures are used for insertion of the laparoscope and the grasping forceps. Using closed-circuit monitors to view the abdominal cavity, the surgeon retracts and dissects the gallbladder and removes it with grasping forceps. Treatment of choice for symptomatic cholelithiasis Approximately 90% of cholecystectomies are done laparoscopically The main complication is injury to the common bile duct Potential contraindications include: peritonitis, cholangitis, gangrene or perforation of gallbladder, & portal hypertension Laparoscopic cholecystectomy - gallbladder removed through one to four small punctures in the abdomen. Open Cholecystectomy Removal of gallbladder through a right subcostal incision T tube may be inserted into common bile duct when exploration of duct is necessary T tube allows excess bile to drain while the small intestine is adjusting to continuous flow of bile You will need general anesthesia, and the surgery lasts 1 to 2 hours. After removal of the gallbladder, bile flows from the liver (where it is produced) through the common bile duct and into the small intestine. Because the gallbladder is gone, bile no longer is stored between meals. In most people, this has little or no effect on digestion. Complications after surgery you would report to the surgeon are: severe abdominal pain, stomach cramping, jaundice, high fever or chills, and clay-colored stools.

Used preoperatively in biliary obstruction & hepatic dysfunction secondary to obstructive jaundice Can also be inserted when inoperable liver, pancreatic, or bile duct carcinoma obstructs bile flow Used when endoscopic drainage has been unsuccessful Inserted percutaneously & allows for decompression of obstructed extrahepatic bile ducts so bile can flow The patient may be discharged with it in place Note that the bile will drain directly into the duodenum or through the catheter. If patient is discharged with a catheter daily skin care with an antiseptic is needed. If a drainage device is used, it needs to be emptied and the drainage documented appropriately by the nurse.

- Analgesic: Morphine & NSAIDs Gallbladder pain can be very severe in the acute stage therefore strong drugs such as morphine may be used initially. However NSAIDs such as ketorolac (Toradol) has also been effective in treating gallbladder pain. -Anticholinergics (antispasmodics): Atropine Basically relaxes the smooth muscle and keeps the stones from moving and causing additional discomfort. - Fat-soluble vitamins ( A, D, E, and K) Helpful in patients with chronic gallbladder, since dietary fat will aid in their digestion. - Bile salt Substitute for bile. Facilitate digestion & vitamin absorption - Cholestyramine Relieves pruritus by binding to bile salt and remove it from the body.

- Eat smaller, more frequent meals - Diet low in saturated fats, High in fiber and calcium - Avoid dairy products, fried foods & fatty red meats - Full liquid diet postoperatively (laparoscopic cholecystectomy) for rest of day & eat light for the next few days - Reduced caloric intake for obese patients - After an open cholecystectomy patient will progress from liquid to regular diet once normal bowel sounds return - Amount of fat in post op diet depends on tolerance - Low fat diet is indicated when the flow of bile is reduced or if patient if overweight. Fat may be restricted 4-6 weeks - Overall the patient should eat nutritiously and avid excessive fat intake Once the gallbladder is removed the bile that is produced by the liver now drains directly into the duodenum. Smaller more frequent meals has a better chance of receiving bile since the gallbladder is not present to release bile on demand when fatty food reaches the stomach.

Subjective Data Past Medical History Obesity Multi-parity Infection Cancer Extensive fasting Pregnancy Medication Estrogen Oral contraceptive Cognitive Perceptual Pain Pruritus Elimination Clay colored stool Steatorrhea Flatulence Dark urine We know that gallbladder disease is more common in female due to pregnancy, birth control and hormone use. However if the patient is a male it is important to ask about recent weight loss. For religious groups ask about fasting rituals. It is important to assess the stool or ask the patient to describe it for you. Because clay colored stool indicates the absence of bile. Objective Data Fever Restlessness Jaundice Icteric sclera Splinting during respirations Palpable gallbladder Abdominal guarding Abdominal distention Now that the patient is in front of us and we are doing a physical assessment we can observe for the above signs and symptoms. When the flow of bile is obstructed, it accumulates in the liver which will result in obstructive jaundice.

Ineffective self health management related to lack of knowledge of diet and postoperative management. Acute pain related to surgical procedure

Relief of pain and discomfort No complications postoperatively No recurrent attack of cholelithiasis or cholecystitis

Teach patient with chronic cholecystitis the importance of routine follow up because they may not have acute symptoms. Teach the patients at risk like native americans the s/s and to tell their provider if these manifestations occur Early detection in at risk patient is important because they can be monitored closely while on a low fat diet.

Acute Interventions Treating pain Relieving nausea and vomiting Maintaining fluid and electrolyte balance Providing proper nutrition Comfort measures - Give drugs as ordered before pain becomes severe. Asses what medication works and how much of it is needed. Observe for side effects of pain medications. provide nursing comfort measures such as a clean bed, comfortable positioning and oral care - To relive N/V an NG tube with gastric decompression may be used if its severe. NPO status, oral and nasal care. Accurate I/O's and maintenance of suction. For less severe cases antiemetics should be fine. While patient is vomiting provide comfort measures such as frequent mouth rinses. Remove vomit from patients view immediately - Take measures to relive the patients itching - Assess for progression of S/S and prevent complications - Observe for S/S of bile obstruction(Jaundice, clay colored stools, dark foamy urine, steatorrhea, fever and increased WBC) - Observe for bleeding if bile obstruction present (mucous membranes, nose, gums and injection site) - Use small gauge needles to give injections and apply gentle pressure afterwards - Know patients PT time and use it as a baseline for assessment - Asses for infection (monitor VS. Increased temp with chills and jaundice indicate choledocholithiasis) - Care for ERCP with papillon-my patients includes assessing for complications such as pancreatitis, perforation, infection and bleeding. Monitor VS Abdominal pain and fever may indicate pancreatitis. the patient should be on bed rest for the first few hours post op and then NPO until their gag reflex returns. Teach the patient the need for follow up care if the stent is to be removed or changed

Patient will verbalize relief of pain Patient will appear comfortable Patient will verbalize knowledge of activity level Patient will verbalize knowledge of dietary restrictions

Laparoscopic Cholecystectomy Remove dressing to puncture site and shower one day after surgery. Notify MD if: Swelling, pus or bile-colored drainage noted from incision, or severe abdominal pain, fever, nausea, vomiting or chills. Return to work within one week. Open Cholecystectomy Usually discharged in 2 to 3 days Avoid heavy lifting Resume sexual activity as soon as comfortable.

NPO antiemetics nasogastric decompression analgesics avoid gas forming foods surgery cholecystectomy removal of gall bladder monitor for pain and infection at incision site abdominal splinting when coughing T-tube High Fowlers position report drainage >500mL

Primary cancer of gallbladder is uncommon Majority are adenocarcinomas There is a relationship between cancer of the gallbladder & chronic cholecystitis & cholelithiasis

Similar to those of chronic cholecystitis & cholelithiasis Abdominal bloating Fever Jaundice Nausea Restlessness Diaphoresis Loss of appetite Weight loss Later symptoms are usually those of biliary obstruction Right abdominal pain that may radiate to the chest and back, fever, nausea, jaundice, itchiness from accumulation of bile salts, loss of appetite and weight loss. The tumor may cause a blockage preventing bile from flowing into the intestines.

Blood tests Ultrasound CT MRI MRCP (magnetic resonance cholangiopancreatography) Blood tests will be performed to evaluate liver function. Gallbladder cancer is difficult to diagnose because there are no specific signs and symptoms. Because the gallbladder is hidden behind other organs, it makes it easier for the cancer to grow undetected.

Cholecystectomy with lymph node dissection Endoscopic stenting of the biliary tree to reduce obstructive jaundice if surgery is not an option Radiation & chemotherapy depending on the disease state Endoscopic stenting - If the tumor is blocking the bile duct, surgery may be done to put in a stent (a thin, flexible tube) to drain bile that has built up in the area. The stent may be placed through a catheter that drains to the outside of the body or may go around the blocked area and drain the bile into the small intestine. Sometimes a portion of the liver and bile ducts that surround the gallbladder can be surgically removed.

Prognosis Poor - often not detected until disease is advanced When found early, surgery can be curative Surgical outcomes are influenced by: Depth of cancer Extent of liver involvement Presence of venous or lymphatic invasion Lymph node metastasis

Palliative with special attention to: Nutrition Hydration Skin care Pain relief Many of the same measures used for patients with cholecystitis or cholelithiasis Our patient's prognosis and treatment plan will guide our nursing management. It is important to identify family and community support and resources, emphasize ongoing follow-up visits with their medical team (primary care physician, surgeon, oncologist), and assist in pain management and self-care measures.