Gallbladder

Question 1

Gallbladder

Answer 1

Several disorders affect the normal drainage of bile into the duodenum.

• inflammation (cholecystitis) of the biliary system
• carcinoma (cancer) that obstructs the biliary tree.
• Gallstones (cholilithiasis)

Question 2

Risk Factors

Answer 2

• Incidence increases with age
• Obesity
• fasting
• Frequent changes in weight * Rapid weight loss (leads to development of gallstones)
• Women – over 40, multiple pregnancies (multiparous), * * * Native American or Hispanic ethnicity or european
• Four times more women than men
• Treatment with high dose estrogen (prostate cancer) Low-dose estrogen therapy – oral contraceptives increase biliary cholesterol saturation
• Cystic fibrosis

Question 3

Symptoms

Answer 3

• Gallstones may be silent, producing no pain and only mild gastrointestinal symptoms. Such * Stones may be detected incidentally during surgery or evaluation for unrelated problems
• With gallbladder disease from gallstones may develop two types of symptoms:
  
  • -Those due to disease of the gall bladder itself
  • Those due to obstruction of the bile passages by a gallstone. Symptoms may be acute or chronic:

Question 4

Pain (Gallbladder)

Answer 4

• The patient develops a fever and may have a palpable abdominal mass.
• Biliary colic is caused by contraction of the gallbladder, which cannot release bile because of obstruction by the stone. When distended, the fundus of the gallbladder comes in contact with the abdominal wall in the region of the right ninth and tenth costal cartilages. This produces marked tenderness in the right upper quadrant on deep inspiration and prevents full inspiratory excursion. Positive murphy’s sign -pause breathing due to palpate
• May have biliary colic with excruciating upper right abdominal quadrant pain
• Epigastric distress such as fullness, abdominal distention and vague pain.
• Some pain is constant rather than colicky that radiates to the midsternal areas, back or right shoulder, usually associated with nausea and vomiting and is noticeable several hours after a heavy meal.
• This pain may follow a meal rich in fried or fatty foods * Pain of acute cholecystitis may be so severe that analgesics are required – morphine is thought to increase spasm of the sphincter of Oddi and may be avoided in many cases in favor of meperidine(demerol)
• If the gallstone is dislodged and no longer obstructs the cystic duct, the gall bladder drains and the inflammatory process subsides after a relatively short time. If the gallstone continues to obstruct the duct, abscess, necrosis, empyema and perforation of the gallbladder with generalized peritonitis may result.

Question 5

Jaundice

Answer 5

• Occurs in a few patients with gallbladder disease and usually occurs with obstruction of the common bile duct
• The bile, which no longer carried to the duodenum, is absorbed by the blood and gives the skin and mucous membranes a yellow color.
• This is frequently accompanied by marked itching of the skin
• The excretion of bile pigments by the kidney gives the urine a very dark color (because the bile is absorbed by the blood and not drained into the intestine)
• The feces, no longer colored with bile pigments are greyish, like putty, and usually described as clay-colored

Question 6

Vitamin deficiency

Answer 6

Obstruction of the bile flow also interferes with absorption of the fat soluble vitamins –if the obstruction has been prolonged

A

D

E

K – may experience bleeding due to deficiency. Preoperatively administer Vit K if the prothrombin level is low

Question 7

Diagnosis

Answer 7

• Abdominal x-ray – only 15% to 20% of gallstones are calcified sufficiently to be visible on x-rays
• Utrasonography
  
  • Procedure of choice
  • No ionizing radiation
  • Most accurate if fast overnight so that the
  • gallbladder is distended -Based on reflected sound waves
  • Can detect calculi in the gallbladder or a dilated common bile duct -Detects gallstones with 95% accuracy

Question 8

Goals

Answer 8

• To reduce the incidence of acute episodes of gallbladder pain and cholecystitis by supportive and dietary management
• To remove the cause of cholecystitis by pharmacologic therapy, endoscopic procedures, or surgical intervention

Question 9

Non surgical approaches

Answer 9

• Nonsurgical approaches:
  
  • eliminate risks associated with surgery but are associated with persistent symptoms or recurrent stone formation.
  • Approximately 80% of the patients with acute gallbladder inflammation achieve remission with rest, IV fluids, nasogastric suction, analgesia, and antibiotic agents,NPO.
  • Diet: Fatty foods may bring on a episode
    
    • Diet immediately after an episode is usually limited to low fat liquids.
    • Avoid eggs, cream, pork, fried foods, cheese and rich dressings, gas-forming vegetables, and alcohol.

Question 10

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Answer 10

Endoscopic Retrograde Cholangiopancreatography (ERCP) with Sphincterotomy (can remove gallstone from bile duct, but not from the gallbladder itself)

• If the common bile duct is thought to be obstructed by a gallstone, an ERCP with sphincterotomy may be performed to explore the duct before laparoscopy
• permits direct visualization of structures
• Examination of the hepatobiliary system via a side viewing flexible fiberoptic endoscope inserted into the esophagus to the duodenum. Insertion of a catheter through the endoscope into the common bile duct (sphincterotomy- division of the muscles of the biliary sphincter) for gallstone extraction
• Multiple position changes are required during the procedure, beginning in the left semi prone position to pass the endoscope
• Fluoroscopy and multiple x-rays are used during ERCP to evaluate the presence and location of ductal stones
  
  • Pre test:
    
    • NPO several hours ,6-8 hrs
  • During test:
    
    • mild sedation - Observe for respiratory and CNS depression, hypotension, over sedation and vomiting (if glucagon is given)
  • Post test:
    
    • Monitor for signs of perforation or infection - Assess return of gag reflex and cough reflex after the use of local anesthetics

Question 11

Extracorporeal Shock-Wave Lithotripsy (ESWL) and Intracorporeal Lithotripsy

Answer 11

• Extracorporeal Shock-Wave Lithotripsy (ESWL) (breaks stone into pieces so it can pass out) Repeated shock waves, through fluid filled bags or submerged in water, to remove fragments of the stones in the gallbladder and CBD. The fragmented stones pass from the gallbladder or CBD spontaneously. Laparscopic cholecystectomy has reduced the use of this procedure.
• Intracorporeal Lithotripsy –stones are fragmented by the use of laser pulse technology. Can distinguish between stones and tissue. This allows time for improvement in the patient’s clinical condition until gallstones are cleared endoscopically, percutaneously, or surgically.(uses energy to break the stone)

Question 12

Surgical management

Answer 12

Surgical intervention is delayed until the acute symptoms subside and a complete evaluation can be carried out- unless the patient’s condition deteriorates. - laparoscopic or open cholecystectomy Types :

• Removal of the gallbladder (cholecystectomy)
• Laparoscopic cholecystectomy
• Percutaneous Cholecystostomy

Question 13

(cholecystectomy)

Answer 13

Removal of the gallbladder (cholecystectomy) – the gallbladder is removed through an abdominal incision (usually right subcostal) after the cystic duct and artery are ligated.

• A drain may be inserted in the incisional area if there is leakage of bile- a small leak should close spontaneously in a few days with the drain preventing accumulation of bile.
• Usually only a small amount of serosanguinous fluid will drain in the initial 24 hours after surgery, then the drain will be removed - Use of a T-tube into the CBD is Uncommo - it is used only in the setting of a complication (i.e. retained common bile duct stone). The T-tube will be left in place for up to several weeks. Before your tube can be removed, an X-ray will be done to make sure that your duct has healed and that there are no stones present.
• Bile duct injury is a serous complication of this procedure
• This procedure has largely been replaced by laparoscopic cholecystectomy

Question 14

Laparoscopic cholecystectomy

Answer 14

Laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus).

• The abdominal cavity is insufflated with carbon dioxide (pneumoperitoneum) to assist in inserting the laparoscope and to visualize the abdominal organs. Post op pain may occur in the right shoulder of scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure) – heating pad for 15-20 minutes hourly, walking, and sitting up when in bed/chair may ease discomfort until CO2 is absorbed
• The most serious complication after laparoscopic cholecystectomy is a bile duct injury
• Post op nursing care:
  
  • Drive a car after 3-4 days
  • Avoid lifting objects exceeding 5 pounds after surgery for 1 week
  • Allow special adhesive strips on the puncture site to fall off – DO NOT pull them off
  • Gradually add fat back into diet in small increments

Question 15

Percutaneous Cholecystostomy

Answer 15

Percutaneous Cholecystostomy

• Used in treatment and diagnosis of acute cholecytitis in patients who are poor risks for any surgical procedure. (manages)
• A fine needle/catheter is inserted through the abdominal wall into the gallbladder to decompress the biliary tract.
• Antibiotics are administered before, during and after the procedure

Question 16

Pre Operative preparation

Answer 16

• May administer Vit K if prothrombin is low
• Nutritional supplements if nutritional status is suboptimal
• Avoid aspirin and other agents (OTC and herbal remedies) that alter coagulation and other biochemical processes

Question 17

Post operative Preparation

Answer 17

Post Operative

• Fasten tubes to gown
• Diet: low in fats and high in CHO and proteins immediately after surgery then just avoid excessive fats with no other dietary limitations. The fat restriction is usually lifted 4-6 weeks when the biliary ducts dilate to accommodate the volume of bile once held by the gallbladder and when the ampulla of Vater (end of CBD) again functions effectively. After this when the patient eats fat, adequate bile will be released into the digestive tract to emulsify the fats and allow their digestion. This is in contrast to before surgery when fats may not be digested completely or adequately, and flatulence may occur. ****one purpose of gallbladder surgery is to allow a normal diet*

Question 18

Post operative complication

Answer 18

Potential Post op complications:

• Observe for indications of infection, leakage of bile into the peritoneal cavity and obstruction of bile drainage.
• Puncture or nick of major blood vessel – assess patient for increased tenderness and rigidity of the abdomen –report these signs to the surgeon
• After laparoscopic cholecystectomy, assess for loss of appetite, nausea, vomiting, pain, distention, and elevation of temperature, redness, tenderness, swelling heat or drainage at incisional site – may indicate infection or disruption of the GI tract
• Some patients report one to three bowel movements a day. This is the result of a continual trickle of bile through the choledochoduodenal junction after cholecystectomy. Usually, such frequency diminishes over a period of a few weeks to several months.

Question 19

Obstruction

Answer 19

• If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream – jaundice, yellow sclera, dark urine, pruritus, (pale)clay-colored stools
• Report right upper quadrant (not shoulder) pain, nausea, vomiting, bile drainage around any drainage tube, (pale)clay-colored stools and a change in vital signs

Question 20

Inflammation (cholecystitis)

Answer 20

• Bile remaining in the gallbladder initiates a chemical reaction, autolysis and edema occur and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene(dead tissue)of the gall bladder with perforation may result.
• If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute cholecystitis).

Question 21

Causes (Cholecystitis)

Answer 21

• Calculous cholecystitis is the cause of more that 90% of cases of acute cholecystitis. A gallstone obstructs bile outflow.
• Acalculous cholecystitis –acute gallbladder inflammation in the absence of obstruction by gallstones. Occurs after major surgical procedures, severe trauma, burns, torsion, cystic duct obstruction, bacterial infections of the gallbladder, and multiple blood transfusions, alterations in F&E balances and blood flow, bile stasis (lack of gallbladder contraction) and increased viscosity of the bile.
• Bacteria- frequently cause acute cholecystitis. Infection of bile with E Coli, Klebsiella and other enteric organisms occurs in about 60% of patients.