Gastrointestinal System Part VIII: the biliary system & pancreas Mrs. April Page, MSN ARNP FNPC Gulf Coast State College Intermediate Adult Care

Lesson Objectives Identify the structure and function of the biliary tract and pancreas. Compare approaches to management of cholelithiasis. Illustrate the nursing process in providing care of patients with cholelithiasis and those undergoing laparoscopic or open cholecystectomy. Differentiate between acute and chronic pancreatitis. Illustrate the nursing process in providing care of patients with acute pancreatitis. Describe the nutritional and metabolic effects of surgical treatment of tumors of the pancreas.

Identify the structure and function of the biliary tract and pancreas. Lesson Objective: ONE

Review of Anatomy and Physiology Gallbladder Bile Pancreas Insulin Glucagon Somatostatin

Liver, Biliary System, and Pancreas

Compare approaches to management of cholelithiasis. Lesson Objective: TWO

Cholelithiasis Pathophysiology Pigment stones Cholesterol stones

Cholesterol Gallstones and Pigment Gallstones

Cholelithiasis: RISK FACTORS Obesity  Women, especially those who have had multiple pregnancies or who are of Native American or U.S. southwestern Hispanic ethnicity  Frequent changes in weight  Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease)  Treatment with high-dose estrogen (e.g., in prostate cancer)  Low-dose estrogen therapy—carries a small increase in the risk of gallstones  Ileal resection or disease  Cystic fibrosis  Diabetes

Clinical Manifestations of Cholelithiasis None or minimal symptoms, acute or chronic Pain Biliary colic Jaundice Changes in urine or stool color Vitamin deficiency, fat soluble (vitamins A, D, E, and K)

Diagnostic Studies Used in the Diagnosis of Biliary Tract and Pancreatic Disease Diagnostic Uses Magnetic resonance cholangiopancreatography (MRCP) Visualizes the biliary tree and capable of detecting biliary tract obstruction Cholecystogram, cholangiogram Visualize gallbladder and bile duct Celiac axis arteriography Visualize liver and pancreas Laparoscopy Visualize anterior surface of liver, gallbladder, and mesentery through a trocar Ultrasonography Show size of abdominal organs and presence of masses Helical computed tomography and magnetic resonance imaging Detect neoplasms; diagnose cysts, pseudocysts, abscess, and hematomas Endoscopic retrograde cholangiopancreatography Visualize biliary structures and pancreas via endoscopy Endoscopic ultrasound Identify small tumors and facilitate fine-needle aspiration biopsy of tumors or lymph nodes for diagnosis Serum alkaline phosphatase In absence of bone disease, to measure biliary tract obstruction Gamma-glutamyl, gamma-glutamyl transpeptidase, lactate dehydrogenase Markers for biliary stasis; also elevated in alcohol abuse Cholesterol levels Elevated in biliary obstruction; decreased in parenchymal liver disease

Medical Management of Cholelithiasis ERCP Dietary management Medications: ursodeoxycholic acid and chenodeoxycholic acid Laparoscopic cholecystectomy Nonsurgical removal By instrumentation Intracorporeal or extracorporeal lithotripsy

Nonsurgical Removal of Gallstones

Laparoscopic Cholecystectomy

Lesson Objective: THREE Illustrate the nursing process in providing care of patients with cholelithiasis and those undergoing laparoscopic or open cholecystectomy. Lesson Objective: THREE

Nursing Process: The Care of the Patient With Cholelithiasis—Assessment Patient history Knowledge and education needs Respiratory status and risk factors for respiratory complications postoperative Nutritional status Monitor for potential bleeding GI symptoms: after laparoscopic surgery, assess for loss of appetite, vomiting, pain, distention, fever—potential infection or disruption of GI tract

Nursing Process: The Care of the Patient With Cholelithiasis — Diagnosis Acute pain Impaired gas exchange Impaired skin integrity Imbalanced nutrition Deficient knowledge

Collaborative Problems and Potential Complications Bleeding GI symptoms Complications related to surgery in general: atelectasis, thrombophlebitis

Nursing Process: The Care of the Patient With Cholelithiasis — Planning Goals may include relief of pain, adequate ventilation, intact skin, improved biliary drainage Optimal nutritional intake Absence of complications Understands self-care routines

Nursing Process: The Care of the Patient With Cholelithiasis—Interventions Low Fowler’s position NG or NPO until bowel sounds return; then a soft, low-fat, high-carbohydrate diet Care of biliary drainage system Analgesics, pain management Turn, cough, and deep breathing; splinting to reduce pain Ambulation

SELF CARE EDUCATION: S/P lap CHOLE (Laparascopic choleCYSTECTOMY) . SELF CARE EDUCATION: S/P lap CHOLE (Laparascopic choleCYSTECTOMY) Managing Pain  You may experience pain or discomfort in your right shoulder from the gas used to inflate your abdominal area during surgery. Sitting upright in bed or a chair, walking, or using a heating pad may ease the discomfort.  Take analgesic medications as needed and as prescribed. Report to your surgeon if pain is unrelieved even with analgesic use

SELF CARE EDUCATION: S/P lap CHOLE (Cont SELF CARE EDUCATION: S/P lap CHOLE (Cont.) (Laparascopic choleCYSTECTOMY) Resuming Activity  Begin light exercise (walking) immediately.  Take a shower or bath after 1 or 2 days.  Drive a car after 3 or 4 days.  Avoid lifting objects exceeding 5 pounds after surgery, usually for 1 week.  Resume sexual activity when desired.

SELF CARE EDUCATION: S/P lap CHOLE (Cont SELF CARE EDUCATION: S/P lap CHOLE (Cont.) (Laparascopic choleCYSTECTOMY) Caring for the Wound  Check puncture site daily for signs of infection.  Wash puncture site with mild soap and water.  Allow special adhesive strips on the puncture site to fall off. Do not pull them off. Resuming Eating  Resume your normal diet.  If you had fat intolerance before surgery, gradually add fat back into your diet in small increments.

SELF CARE EDUCATION: S/P lap CHOLE (Cont SELF CARE EDUCATION: S/P lap CHOLE (Cont.) (Laparascopic choleCYSTECTOMY) Managing Follow-Up Care  Make an appointment with your surgeon for 7 to 10 days after discharge.  Call your surgeon if you experience any signs or symptoms of infection at or around the puncture site: redness, tenderness, swelling, heat, or drainage.  Call your surgeon if you experience a fever of 37.7°C (100°F) or more for 2 consecutive days.  Call your surgeon if you develop nausea, vomiting, or abdominal pain.

Differentiate between acute and chronic pancreatitis. Lesson Objective: FOUR

Pancreatitis Acute Chronic pancreatic duct becomes obstructed, and enzymes back up, causing autodigestion and inflammation of the pancreas Chronic progressive inflammatory disorder with destruction of the pancreas; cells are replaced by fibrous tissue; pressure within the pancreas increases, obstructing the pancreatic and common bile ducts

Criteria for Predicting Severity of Pancreatitis Criteria on Admission to Hospital Age >55 years White blood cells (WBCs) >16,000 mm3 Serum glucose >200 mg/dL (>11.1 mmol/L) Serum lactose dehydrogenase (LDH) >350 IU/L (>350 U/L) AST >250 IU/L Criteria Within 48 Hours of Hospital Admission Fall in hematocrit >10% (>0.10) Blood urea nitrogen (BUN) increase >5 mg/dL (>1.7 mmol/L) Serum calcium <8 mg/dL (<2 mmol/L) Base deficit >4 mEq/L (>4 mmol/L) Fluid retention or sequestration >6 L Partial pressure of oxygen (PO2) <60 mm Hg Two or fewer signs, 1% mortality; 3 or 4 signs, 15% mortality; 5 or 6 signs, 40% mortality; >6 signs, 100% mortality. * Note: The more risk factors a patient has, the greater the severity and likelihood of complications or death.

Illustrate the nursing process in providing care of patients with acute pancreatitis. Lesson Objective: FIVE

Ineffective breathing pattern Imbalanced nutrition Nursing Process: The Care of the Patient With Acute Pancreatitis—Diagnosis Acute pain Ineffective breathing pattern Imbalanced nutrition Impaired skin integrity

Collaborative Problems and Potential Complications Fluid and electrolyte disturbances Necrosis of the pancreas Shock Multiple organ dysfunction syndrome DIC

Describe the nutritional and metabolic effects of surgical treatment of tumors of the pancreas. Lesson Objective: SIX

Tumors of the Pancreas Pancreatic cysts Pancreatic cancer Chemotherapy Risk factors Sites of lesions Treatment may be palliative Chemotherapy Radiation (limited) Surgery

Pancreatoduodenectomy (Whipple’s Procedure)

Multiple Sumps After Pancreatic Surgery

THE END CHAPTER 59