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

2. 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.

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

4. Review of Anatomy and Physiology
Gallbladder
Bile
Pancreas
Insulin
Glucagon
Somatostatin

5. Liver, Biliary System, and Pancreas

6. Compare approaches to management of cholelithiasis.
Lesson Objective:
TWO

7. Cholelithiasis
Pathophysiology
Pigment stones
Cholesterol stones

8. Cholesterol Gallstones and Pigment Gallstones

9. 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

10. 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)

11. 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

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

13. Nonsurgical Removal of Gallstones

14. Laparoscopic Cholecystectomy

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

16. 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

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

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

19. 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

20. 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

21. 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

22. 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.

23. 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.

24. 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.

25. Differentiate between acute and chronic pancreatitis.
Lesson Objective:
FOUR

26. 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

27. 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.

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

29. 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

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

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

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

33. Pancreatoduodenectomy (Whipple’s Procedure)

34. Multiple Sumps After Pancreatic Surgery

35. THE END
CHAPTER 59