Care of the Client with Disorders of the Gallbladder

1. Care of the Client with Disorders of the Gallbladder ACC RNSG 1247

2. Two main disorders: Cholecystitis Cholelithiasis Gallbladder Disease

3. Risk factors for GB disease • Higher in women: multiparous, over 40, on estrogen therapy • Sedentary lifestyle • Familial tendency • Obesity

4. Etiology of Cholecystitis • Acute : - Calculous: with stone obstruction - Acalculous: absence of stones • Chronic: - Repeated attacks, long standing inflammation

5. Pathophysiology of Cholecystitis • Obstruction leads to ischemia of GB mucosa or wall • Inflammation may follow: GB is edematous during acute attack or distended with bile or pus • Cystic duct may be occluded • GB becomes scarred

6. _______ Dull ache History of fat intolerance Dyspepsia Increased flatulence Clinical Manifestations of Acutevs Chronic CholecystitisWhich are acute signs; which are chronic? • ________ • Usually begins with a biliary colic attack • RUQ pain • N/V • Usually signs of acute inflammation • Possible pus formationgangrenous

7. Cholelithiasis • Calculi (stones) in the GB • May obstruct the cystic or CBD • Choledocholithiasis: stones in the CBD • Types: • Composed primarily of pigment • Composed primarily of cholesterol

8. Pathophysiology of Cholelithiasis • Develops when the balance that keeps cholesterol, bile salts and calcium is altered causing precipitation of these substances • Conditions affecting balance: infection and altered metabolism of cholesterol • Bile in GB and liver become saturated with cholesterol

9. _____________ made of other bile components (bile salts, bilirubin, Ca, protein) undissolvable; requires surgery increased risk in: cirrhosis, hemolysis, biliary tree infections Cholesterol vs Pigment StonesWhich is which & which is more common? • ______________ • 4x more prevalent in women • formation incidence increased in use of oral contraceptives, estrogens

10. Cholesterol stones 1

11. Cholesterol stones 2

12. Pigment stones

13. Clinical Manifestations of Cholelithiasis • “Silent cholelithiasis” • Pain and biliary colic • Sx RT bile obstruction such as jaundice, pruritus, changes in color of stool and urine, vitamin deficiency, bleeding, steatorrhea

14. Diagnostic Studies • History & physical examination • Would these laboratory tests show increased or decreased levels? * Liver function tests * WBC count * Serum bilirubin * Serum amylase

15. Diagnostic Tests • Abdominal x-rays • Ultrasonography – most accurate • HIDA scan • Endoscopic retrograde cholangiopancreatography (ERCP) • Percutaneoustranshepaticcholangiography

16. Treatment & Nursing Care Acute episodes focus on * Pain control – - Morphine - Dilaudid (hydromorphone) - Ketorolac (Toradol) - Demerol (Meperidine) - NSAIDS, anticholinergics * Infection Control - antibiotics

17. Treatment & Nursing Care continued *Fluid and electrolyte balance - IV fluid - Antiemetics : Metoclopramide (Reglan) Ondansentron (Zofran) Prochlorperazine (Compazine) Gastric Decompression – NGT, NPO • *How/what would you monitor to maintain F & E balance?

18. Treatment and Nursing Care Once attack is over maintain on • _____ fat diet • _________ forming foods • Avoid eggs, whole milk products, cheese, ice cream, fried foods, rich foods, alcohol • Reduced _______ diet if obese

19. Treatment & Nursing Care:Supportive Drug Therapy * Fat soluble vitamin replacement: A,D,E,K * Bile salts: Ex: Decholin; enhance fat absorption * Bile acids: Exs: Questran and Cholestid; bind bile salts and treat pruritus

20. Treatment and Nursing Care:Non Surgical Stone Approaches for Stone Removal * endoscopic sphincterotomy (papillotomy) * mechanical lithotripsy * cholesterol solvents * extracorporeal shock wave lithotripsy

21. ERCP with Sphincterectomy

22. _________ Cholecystectomy * removal of GB via right subcostal incision * T tube inserted into CBD Treatment and Nursing Care: SurgicalWhen is one preferred over another? Why? ____________ Cholecystectomy * GB removed through 4 puncture holes * CX: injury to CBD

23. Laparoscopic vs Open Cholestectomy

24. T tube

25. Treatment and Nursing Care:Surgical Transhepatic biliary catheter * to decompress obstructed extrahepatic ducts

26. Treatment and Nursing Care: Post Op Care &Teachings • Pain Control • Prevent Complications primarily pulmonary • Wound Care • Dietary modification

27. Gerontologic considerations • Gallstones increasingly common • Differing presenting symptoms • Surgical risks due to concurrent conditions • Decreased elective surgery and more advanced status at time of surgery • Higher risk of complications and shorter hospital stays

28. Gallbladder Cancer • Uncommon • Majority are adenocarcinomas • Early symptoms similar to chronic cholecystitis and cholelithiasis • Later symptoms of biliary obstruction • Poor prognosis

29. Gallbladder Cancer • Diagnosis and staging – EUS, transabdominal US, CT, MRI, MRCP • If found early – surgery is curative • Extended cholestectomy with lymph node dissection – good outcome • Palliative – stenting of biliary tree, radiation, chemotherapy

30. Gallbladder Cancer • Nursing Management - supportive care • Nutrition, hydration, skin care, pain relief • Similar to care for cholecystitis and cholelithiasis and cancer

31. The End