Gallbladder Disease Flashcards
What are the 2 common types?
Cholelithiasis
Cholecystitis
What is Cholelithiasis
Most common disorder of biliary system
Stones in the gallbladder
What is Cholecystitis
- Inflammation of the gallbladder
- Usually associated with cholelithiasis
What causes Cholelithiasis
- Cause of gallstones unknown
- Develops when balance that keeps cholesterol, bile salts, and calcium in solution is altered, leading to precipitation
- Bile secreted by liver supersaturated with cholesterol (lithogenic)
- Stasis of bile → supersaturation and changes in composition of bile (biliary sludge)
- Immobility, pregnancy, and inflammatory or obstructive lesions of biliary system ↓ bile flow
Causes of pain
- Stones may remain in gallbladder or may migrate to cystic or common bile duct
- Cause pain as they pass through ducts
- May lodge in ducts and produce an obstructio•Stones may remain in gallbladder or may migrate to cystic or common bile duct
- Cause pain as they pass through ducts
- May lodge in ducts and produce an obstructionn
What causes Cholecystitis
•Most commonly associated with obstruction from stones or sludge
•Acalculous cholecystitis: Inflammation without stones. Could be critically ill pts, TPN, DM, Ecoli
- Older adults and critically ill
- Prolonged immobility, fasting, parenteral nutrition, diabetes
- Bacteria or chemical irritants
- Adhesions, neoplasms, anesthesia, opioids
Cholecystitis where is the inflammation Inflammation
- Confined to mucous lining or entire wall
- Gallbladder is edematous and hyperemic-increased blood supply
- May be distended with bile or pus
- Cystic duct may become occluded
- Scarring and fibrosis after attack
Clinical manifestations
- Vary from severe to none at all
- Pain more severe when stones moving or obstructing
- Steady, excruciating
- Tachycardia, diaphoresis, prostration: extremely weak
- May be referred to shoulder/scapula
- Residual tenderness in RUQ
- Occur 3–6 hours after high-fat meal or when patient lies down
- Inflammation
- Leukocytosis
- Fever
- Physical examination findings
- RUQ tenderness (Murphy’s sign)
- Abdominal rigidity
Cinical manifestations of Chronic cholecystitis
- Fat intolerance
- Light-colored stools- no bile due to liver obstructed
- Dyspepsia
- Heartburn
- Flatulence
Symptoms of total obstruction
Jaundice: Lack of bile in blood
Dark amber urine-increased water soluble bilirubin
Clay-colored stools
Pruritus- itching due to bile salts in our skin tissue
Intolerance of fatty foods
Bleeding tendencies: Issues with absorption of Vitamin K= decreased production of prothrombin
Steatorrhea- Oily and foul odor in stool
Diagnostic Studies
- Ultrasonography
- Endoscopic Retrograde Cholangio-pancreatography (ERCP): Involves cystic and liver fatty duct and common bile duct. Allows us to look at those structures and do biopsies
- Percutaneous transhepatic cholangiography- insertion of needle int•Ultrasonography
- Endoscopic Retrograde Cholangio-pancreatography (ERCP): Involves cystic and liver fatty duct and common bile duct. Allows us to look at those structures and do biopsies
- Percutaneous transhepatic cholangiography- insertion of needle into gallbladder injects dye into ito gallbladder injects dye into it
Laboratory Tests
↑ WBC count
↑ Serum bilirubin level
↑ Urinary bilirubin level
↑ Liver enzyme levels
↑ Serum amylase level: Pancrease is involved. Secondary pancreatitis
Treatment
- Treatment dependent on stage of disease
- Oral dissolution therapy
- Ursodeozycholic acid (ursodiol [Actigall])
- Chenodeozycholic acid (chenodiol)
- ERCP with sphincterotomy
- Visualization
- Dilation
- Placement of stents
- Open the sphincter of Oddi, if needed
- Endoscope passed to duodenum
- Stones removed with basket or allowed to pass in stool
Collaborative Care
- Pain control
- NSAIDs
- Anticholinergics
- Control infection
- Antibiotic treatment
- Cholecystectostomy
- Maintenance of F&E balance
- NG tube if severe nausea/vomiting
Surgical Therapy
Laparoscopic cholecystectomy
Treatment of choice
Removal of gallbladder through one to four puncture holes
Minimal postoperative pain
Resume normal activities, including work, within 1 week
Few complications
The surgical treatment of choice for the patient with symptomatic gallbladder disease is a
Laparoscopic cholecystectomy
Transhepatic Biliary Catheter
- Preoperative or palliative: when endoscopic drainage fails
- Inserted percutaneously and attached to drainage bag
- Skin care important
- Patient may be discharged home with catheter in place: Need home health to assist or good family dynamics
Drug therapy
- Most common
- Analgesics
- Morphine
- NSAIDs
- Anticholinergics
- Atropine
- Fat-soluble vitamins (A, D, E, K)
- Bile salts to facilitate digestion and vitamin absorption
Cholestyramine (Questran) what is it given for and how?
may be given for pruritus
Given in powdered form, mixed with milk or juice
Monitor for side effects (nausea/vomiting, diarrhea or constipation, skin reactions)
Nutritional therapy
•Small, frequent meals with some fat
•Diet low in saturated fat
- High in fiber and calcium
- Reduced-calorie diet if patient is obese
- Avoidance of rapid weight loss
Nutritional therapy after laparoscopic cholecystectomy
- Liquids first day
- Light meals for several days
Nutritional therapy after incisional cholecystectomy
•Liquids to regular diet after return of bowel sounds
•May need to restrict fats for 4–6 weeks
Nursing Assessment
- Abnormal diagnostic findings
- ↑ Serum liver enzymes
- ↑ Alkaline phosphatase
- ↑ Bilirubin
- Absence of urobilinogen in urine
- ↑ Urinary bilirubin
- Leukocytosis
- Abnormal gallbladder ultrasound findings
Nursing Management:
Planning over all goals
•Relief of pain and discomfort: PCA- Monitor how many times they use. Sign off with next nurse on how many doses are left: Make sure you check their elimination pattern, continuous pulse ox, educate patient to use before pain is severe
- No complications postoperatively
- No recurrent attacks of cholecystitis or cholelithiasis
•Acute interventions
- Monitor for complications
- Obstruction
- Bleeding
Infection
•Postoperative care
- Laparoscopic cholecystectomy
- Monitor for complications
- Patient comfort
•Referred pain to shoulder from CO2
•Sims’ position
•Deep breathing, ambulation, analgesia
- Clear liquids
- Discharged same day if uncomplicated
- Immediate Postoperative care
- Incisional cholecystectomy
- Maintain adequate ventilation
- Prevent respiratory complications
- General postoperative nursing care
- Maintain drainage tubes (T-tube, Penrose tube, or Jackson-Pratt tube), if present
Ambulatory and home care Dietary teaching
•Low-fat diet
- Weight reduction if needed
- Fat-soluble vitamin supplements
- Teach what to report
Follow-up care
Nursing Management:
Nursing Implementation
Ambulatory and home care
Laparoscopic cholecystectomy
- Remove bandages the day after surgery and then can shower
- Report signs of infection
- Gradually resume activities
- Return to work in 1 week
- May need low-fat diet for several weeks
Nursing Management:
Nursing Implementation
Ambulatory and home care
Open-incision cholecystectomy
- Discharged in 2–3 days
- No heavy lifting for 4–6 weeks
- Usual activities when feeling ready
- May need low-fat diet for 4–6 weeks
Expected Outcomes
- Appear comfortable and verbalize pain relief
- Verbalize knowledge of activity level and dietary restrictions
