Biliary Disorders Flashcards
- Cholelithiasis - Cholecystitis
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Is the most common disorder of the biliary system
Stones in the gallbladder
Cholelithiasis
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Is inflammation of the gallbladder wall
Usually assoc w/cholelithiasis & occurs together but a person can have cholelithiasis w/o ___
May be present acutely or chronically
Cholecystitis
Gallbladder Disease
- Common health problem
Risk factors
> Female
Multiparity
Age older than 40 yrs
Estrogen therapy; oral contraceptive use
Sedentary lifestyle
Genetics/ethnicity
Obesity [causes inc secretion of cholesterol in bile]
Cholelithiasis
- Cause of gallstones unknown
- Develops when balance that keeps cholesterol, bile salts, & calcium in solution is altered, leading to precipitation
> i.e., d/t infection & disturbances in metabolism of cholesterol
- Bile secreted by liver is supersaturated w/cholesterol (lithogenic bile)
> Other components of bile that precipitate into stones are bile salts, bilirubin, calcium, & protein
Mixed cholesterol stones, which’re predominantly cholesterol, are the most common gallstones
- Stasis of bile > supersaturation & changes in composition of bile (biliary sludge)
- Immobility, pregnancy, & inflammatory or obstructive lesions of biliary system ↓ bile flow
- Stones may remain in GB or may migrate to cystic or CBD
- Cause pain as they pass through ducts
Cholecystitis
- Most commonly assoc w/obstruction from gallstones or biliary sludge
___ cholecystitis [in the absence of obstruction]
> Older adults & critically ill
> Prolonged immobility, fasting, prolonged parenteral nutrition, diabetes
> Bacteria or chemical irritants
> Adhesions, neoplasms, anesthesia, opioids
acalculous (cholecystitis)
Cholecystitis - Inflammation
- Confined to mucous lining or entire wall
- GB is edematous and hyperemic & may be distended w/bile or pus
- Cystic duct may become occluded
- Scarring & fibrosis after attack
Clinical Manifestations
- Vary from severe to none at all
- Pain more severe when stone moving or obstructing
> Steady, excruciating
> Tachycardia, diaphoresis, prostration
> May be referred to shoulder/scapula
> Residual tenderness in RUQ
> Occurs 3-6 hrs after high-fat meal or when pt lies down
When total obstruction occurs:
> Dark amber urine
Clay-colored stools
Pruritus
Intolerance to fatty foods
Bleeding tendencies
Steatorrhea
- If the CBD is obstructed, no bilirubin will reach the SI to be converted to urobilinogen
- Thus bilirubin will be excreted by the kidneys instead, causing dark amber to brown urine
- In addition to pain
> Indigestion
Fever, chills
Jaundice
Pain, tenderness RUQ
- Referred to right shoulder, scapula
> N/V
Restlessness
Diaphoresis
- Inflammation
> Leukocytosis, fever - Physical exam findings
> RUQ or epigastrium tenderness
> Abd rigidity
Chronic cholecystitis Manifestations
> Fat intolerance
Dyspepsia
Heartburn
Flatulence
Cholelithiasis & Cholecystitis - Complications
- Gangrenous cholecystitis
- Subphrenic abscess
- Pancreatitis
- Cholangitis [inflammation of biliary ducts]
- Biliary cirrhosis
- Fistulas
- GB rupture > (bile) peritonitis
- Choledocholithiasis (stone in the CBD > obstruction)
In older pts & those w/diabetes, gangrenous cholecystitis & bile peritonitis are the most common complications of cholecystitis
Diagnostic Studies
- US (to diagnose gallstones; useful for pts w/jaundice & those allergic to contrast medium)
- ERCP
> Visualize GB, cystic duct, common hepatic duct, & CBD
> Bile sent for culture
- Percutaneous transhepatic cholangiography
> Is the insertion of a needle directly into the GB duct, followed by injection of contrast materials
> Generally done >US indicates a bile duct blockage
Laboratory tests
↑ WBC count (d/t inflammation)
↑ serum bilirubin (direct/indirect) & urinary bilirubin [if an obstructive process present]
↑ liver enzymes (alkaline phosphatase, ALT, AST)
↑ serum amylase (if pancreatic involvement)
- Treatment dependent on stage of disease
- Oral dissolution therapy [to dissolve stones]
> Ursodeoxycholic acid (ursodiol) [Actigall]
> Chenodeoxycholic acid (chenodiol) - Gallstones aren’t usually treated w/rx’s, b/c high use & success of laparoscopic cholecystectomy
ERCP w/sphincterotomy (papillotomy)
- Visualization
- Dilation (balloon sphincteroplasty)
- Placement of stents; sphincterotomy
- Open sphincter of Oddi, if needed
- Endoscope passed to duodenum
- Stones removed w/basket or allowed to pass in stool
Endoscopic Sphincterotomy
- An endoscope is advanced through the mouth & stomach until its tip sits in the duodenum opposite the CBD
- After widening the duct mouth by incising the sphincter muscle, the physician advances a basket attachment into the duct & snags the stone
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This is an alternate treatment used when stones cannot be removed by endoscopic approaches
Extracorporeal shock-wave lithotripsy (ESWL)
ESWL
- A lithotriptor produces high-energy shock waves to disintegrate gallstones once they have been located by US
- Usually takes 1-2 hrs for stones to disintegrate
- After they’re broken up, the fragments pass through the CBD & into the SI
- Usually ESWL & oral dissolution therapy are used together
- Control possible infection
> Antibiotic treatment
! Maintenance of F&E balance
- NG tube for severe N/V
- Cholecystostomy (to drain purulent material from obstructed GB)
- Opioids for pain control
- Anticholinergics
> Decrease GI secretions
> Counteract smooth muscle spasms
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- Treatment of choice for symptomatic cholelithiasis
- Removal of GB through 1 to 4 puncture sites
- Minimal postop pain
- Resume normal activities, inc work, within 1 wk
- Few complications (main inj is to CBD)
Laparoscopic cholecystectomy
Contraindications to laparoscopic cholecystectomy include
> Peritonitis
Cholangitis
Gangrene or perforation of the GB
Portal HTN
Serious bleeding disorders
Open (incisional) cholecystectomy
- Removal of GB through right subcostal incision
- T-tube inserted into CBD
> Ensures patency of duct
> Allows excess bile to drain
Transhepatic Biliary Catheter
- Preoperative or palliative
> When endoscopic drainage fails - Inserted percutaneously & attached to drainage bag
- Replace fluids lost w/electrolyte-rich drinks
- Skin care important
Drug Therapy - Most common
- Analgesics (morphine)
> Initially for pain management - Anticholinergics [antispasmodics] (atropine)
> To relax smooth muscle & dec ductal tone
- Fat-soluble vitamins (A, D, E, K)
> For those w/chronic GB dz or any biliary tract obstruction - Bile salts
> To facilitate digestion & vitamin absorption
___ may be given for pruritus
> Given in powdered form, mixed w/milk or juice
Monitor for side effects (n/v/d or constipation, skin reactions)
Check drug-to-drug interactions (b/c it can bind w/other rx’s)
cholestyramine
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This is a resin that binds bile salts in the intestine, increasing their excretion in the feces
cholestyramine
Nutritional Therapy
- Small, frequent meals w/some fat
- Diet low in saturated fat
- High in fiber & calcium
- Reduced-calorie diet if pt is obese
- Avoidance of rapid wt loss (b/c it can promote gallstone formation)
After laparoscopic cholecystectomy
> liquids 1st day
> light meals for several days
After incisional cholecystectomy
> liquids to regular diet after return of bowel sounds
> may need to restrict fats for 4-6 wks [will depend on pt’s tolerance of fats]
Nursing Management - Subjective Data
Past medical history - obesity, multiparity, infection, cancer, extensive fasting, pregnancy
Medication use - estrogen, oral contraceptives
Surgical hx - prev abd surgery
Health perception-health management - positive family hx, sedentary lifestyle
Nutritional-metabolic - wt loss or anorexia, indigestion or fat intolerance, N/V or dyspepsia, chills
Elimination - clay-colored stools, steatorrhea, flatulence, dark urine
Cognitive-perceptual - mod to severe pain in RUQ that may radiate to the back or scapula; pruritus
Objective Data
- Fever, restlessness; jaundice/icteric sclera, diaphoresis; tachypnea, splinting during respirations
- Tachycardia; palpable GB, abd guarding & distention
Abnormal diagnostic findings
↑ serum liver enzymes, alkaline phosphatase, bilirubin
Absence of urobilinogen in urine
↑ urinary bilirubin
Leukocytosis
Abn GB US findings
Nursing Diagnoses
- Acute pain r/t surgical procedure
- Ineffective health management r/t lack of knowledge of diet & postop management
Overall Goals
- Relief of pain & discomfort
- No complications postoperatively
- No recurrent attacks of cholecystitis or cholelithiasis
Health Promotion
- Screen for predisposing factors
- Teaching for at-risk ethnic groups (Native Americans)
- Early detection of chronic cholecystitis
> Manage w/low-fat diet
Acute Care - Nursing Goals
- Treating pain
- Relieve N/V
- Provide comfort & emotional support
- Maintain F&E balance & nutrition
- Accurate assessments
- Monitor for complications
- Pain management
- Administering rx’s
- Assess effectiveness
- Comfort measures
- Clean bed; positioning; oral care
- Manage N/V
- NG tube, gastric decompression
> Oral hygiene, care of nares
> Accurate I&O
> Maintenance of suction - Antiemetics
- Comfort measures (i.e., freq mouth rinses; remove vomitus from view)
- Pruritus relief measures
- Antihistamines
- Baking soda or Alpha Keri baths
- Lotions (i.e., calamine)
- Soft linen
- Control of temperature
- Short, clean nails
- Scratch w/knuckles rather than nails
- Monitor for complications
- Obstruction
- Bleeding
- Infection
Obstruction signs of ducts by stones
- Jaundice
- Clay-colored stools
- Dark, foamy urine
- Steatorrhea
- Fever
- Inc WBC count
- Bleeding from dec prothrombin production by liver
- Look @ the mucous membranes of the mouth, nose, gingivae, & injection sites
> Use a small-gauge needle & apply pressure after injection - Monitor VS to assess for infection
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A temperature elevation w/chills & jaundice may indicate which condition?
choledocholithiasis
Care of the pt >ERCP w/sphincterotomy; ERCP w/papillotomy
> Assess for pancreatitis, perforation, infection, & bleeding
Monitor VS
Abd pain, fever, inc amylase & lipase may indicate pancreatitis
> Pt to be on bedrest for several hrs & on NPO status until gag reflex returns
> Teach need for f/u if stent is to be removed or changed
Postop Care: Laparoscopic cholescystectomy
- Monitor for complications
- Pt comfort
> Referred pain to shoulder pain from CO2
> Sims’ position
> Deep breathing, ambulation, analgesia
- Clear liquids
- Discharged same day
Postop Care: Laparoscopic cholecystectomy
- Monitor for complications (i.e., bleeding)
- Pt comfort
> Referred pain to shoulder from CO2 that’s used to inflate abd cavity during surgery (common!; CO2 can irritate the phrenic nerve & diaphragm, causing some difficulty in breathing) - Place in Sims’ position (left side w/right knee flexed)
> Deep breathing, ambulation, analgesia
- Manage pain (NSAIDs, codeine)
- Clear liquids
- Discharged same day
Postop Care: Incisional cholecystectomy
- Maintain adequate ventilation
- Prevent respiratory complications
- General postop nursing care
- Maintain drainage tubes (T-tube, Penrose, JP tube), if present
> Use a sterile pouching system to protect the skin - Replace F&E
Ambulatory Care
- Dietary teaching
> Low-fat diet
> Wt reduction if needed
> Fat-soluble vitamin supplements
- Teach what to report
> Signs of obstruction include stool & urine changes; jaundice; pruritus - Follow-up care
Ambulatory Care - Laparoscopic cholecystectomy
- Remove bandages day after surgery & then can shower
- Report signs of infection
- Gradually resume activities
- Return to work in 1 week
- May need low-fat diet for several wks
Ambulatory Care - Open-incision cholecystectomy
- No heavy lifting for 4-6 wks
- Usual activities when feeling ready
- May need low-fat diet for 4-6 wks
Ambulatory Care - Open-incision cholecystectomy
- No heavy lifting for 4-6 wks
- Usual activities when feeling ready
- May need low-fat diet for 4-6 wks
Expected Outcomes (for the pt w/GB dz)
- Appear comfortable & verbalize pain relief
- Verbalize knowledge of activity lvl & dietary restrictions
