1. Care of the Client with Disorders of the Gallbladder ACC RNSG 1247

3. Gallbladder Disease Two main disorders: Two main disorders: Cholecystitis Cholecystitis Cholelithiasis Cholelithiasis

4. Risk factors for GB disease Higher in women: multiparous, over 40, on estrogen therapy Higher in women: multiparous, over 40, on estrogen therapy Sedentary lifestyle Sedentary lifestyle Familial tendency Familial tendency Obesity Obesity

5. Etiology of Cholecystitis Acute : Acute : - Calculous: with stone obstruction - Calculous: with stone obstruction - Acalculous: absence of stones - Acalculous: absence of stones Chronic: Chronic: - Repeated attacks, long standing - Repeated attacks, long standing inflammation inflammation

6. Pathophysiology of Cholecystitis Obstruction leads to ischemia of GB mucosa or wall Obstruction leads to ischemia of GB mucosa or wall Inflammation may follow: GB is edematous during acute attack or distended with bile or pus Inflammation may follow: GB is edematous during acute attack or distended with bile or pus Cystic duct may be occluded Cystic duct may be occluded GB becomes scarred GB becomes scarred

7. Clinical Manifestations of Acute Cholecystitis Usually begins with a biliary colic attack Usually begins with a biliary colic attack RUQ pain RUQ pain N/V N/V Usually signs of acute inflammation Usually signs of acute inflammation Possible pus formation  gangrenous Possible pus formation  gangrenous

8. Clinical Manifestations of Chronic Cholecystitis Dull ache Dull ache History of fat intolerance History of fat intolerance Dyspepsia Dyspepsia Increased flatulence Increased flatulence

9. Cholelithiasis Calculi (stones) in the GB Calculi (stones) in the GB May obstruct the cystic or CBD May obstruct the cystic or CBD Choledocholithiasis: stones in the CBD Choledocholithiasis: stones in the CBD Types: Types: Composed primarily of pigment Composed primarily of pigment Composed primarily of cholesterol Composed primarily of cholesterol

10. Pathophysiology of Cholelithiasis Develops when the balance that keeps cholesterol, bile salts and calcium is altered causing precipitation of these substances Develops when the balance that keeps cholesterol, bile salts and calcium is altered causing precipitation of these substances Conditions affecting balance: infection and altered metabolism of cholesterol Conditions affecting balance: infection and altered metabolism of cholesterol Bile in GB and liver become saturated with cholesterol Bile in GB and liver become saturated with cholesterol

11. Cholesterol Stones Mixed cholesterol stones are the most common gallstones Mixed cholesterol stones are the most common gallstones 4x more prevalent in women 4x more prevalent in women Formation incidence increased in use of oral contraceptives, estrogens Formation incidence increased in use of oral contraceptives, estrogens

12. Cholesterol stones 1

13. Cholesterol stones 2

14. Pigment Stones Pigment stones – made of other bile components other than cholesterol (bile salts, bilirubin, calcium, protein) Pigment stones – made of other bile components other than cholesterol (bile salts, bilirubin, calcium, protein) Less common than cholesterol stones Less common than cholesterol stones Surgical removal required; undissolvable Surgical removal required; undissolvable Risk is increased in patients with: Risk is increased in patients with: Cirrhosis Cirrhosis Hemolysis Hemolysis Infections of the biliary tree Infections of the biliary tree

15. Pigment stones

16. Clinical Manifestations of Cholelithiasis “Silent cholelithiasis” “Silent cholelithiasis” Pain and biliary colic Pain and biliary colic Symptoms related to bile obstruction Symptoms related to bile obstruction such as jaundice, pruritus, changes in such as jaundice, pruritus, changes in color of stool and urine, vitamin deficiency, bleeding, steatorrhea color of stool and urine, vitamin deficiency, bleeding, steatorrhea

17. Gallstones On this page: What are gallstones? What causes gallstones? Who is at risk for gallstones? What are the symptoms of gallstones? How are gallstones diagnosed? How are gallstones treated? Do people need their gallbladder? Points to Remember

18. Diagnostic Studies History & physical examination History & physical examination Laboratory tests Laboratory tests * Liver function tests * Liver function tests * WBC count * WBC count * Serum bilirubin * Serum bilirubin * Serum amylase * Serum amylase

19. Diagnostic Tests Abdominal x-rays Abdominal x-rays Ultrasonography Ultrasonography Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic retrograde cholangiopancreatography (ERCP) Percutaneous transhepatic cholangiography Percutaneous transhepatic cholangiography

20. Treatment & Nursing Care Acute episodes focus on * pain control – Morphine * pain control – Morphine * antibiotic treatment * antibiotic treatment * fluid & electrolyte balance – IV fluids * fluid & electrolyte balance – IV fluids Gastric decompression – NGT, NPO Anticholinergics - Bentyl

21. Treatment and Nursing Care Once attack is over maintain on Low fat diet Low fat diet Non-gas forming foods Non-gas forming foods Avoid eggs, whole milk products, cheese, Avoid eggs, whole milk products, cheese, ice cream, fried foods, rich foods, alcohol ice cream, fried foods, rich foods, alcohol Reduced calorie diet if obese Reduced calorie diet if obese

22. Treatment & Nursing Care: Supportive Drug Therapy * Fat soluble vitamin replacement: A,D,E,K * Fat soluble vitamin replacement: A,D,E,K * Bile salts: Decholin, enhance fat absorption * Bile salts: Decholin, enhance fat absorption * Bile acids: Questran and Cholestid, bind * Bile acids: Questran and Cholestid, bind bile salts and treat pruritus bile salts and treat pruritus

23. Treatment and Nursing Care: Non Surgical Stone Approaches for Stone Removal * endoscopic sphincterotomy * endoscopic sphincterotomy * mechanical lithotripsy * mechanical lithotripsy * cholesterol solvents * cholesterol solvents * extracorporeal shock wave lithotripsy * extracorporeal shock wave lithotripsy

24. Treatment and Nursing Care: Surgical Laparoscopic Cholestectomy Laparoscopic Cholestectomy * treatment of choice * treatment of choice * gallbladder removed through 4 puncture * gallbladder removed through 4 puncture holes holes * minimal postoperative pain * minimal postoperative pain * D/C same or next day * D/C same or next day * CX: injury to CBD * CX: injury to CBD

25. Treatment and Nursing Care: Surgical Open cholecystectomy Open cholecystectomy * Removal of GB through right subcostal * Removal of GB through right subcostal incision incision * T tube inserted into CBD * T tube inserted into CBD Transhepatic biliary catheter Transhepatic biliary catheter * to decompress obstructed extrahepatic * to decompress obstructed extrahepatic ducts ducts

26. Laparoscopic vs Open Cholestectomy

27. T tube

28. Treatment and Nursing Care: Post Op Pain Control Pain Control Prevent Complications primarily pulmonary Prevent Complications primarily pulmonary Wound Care Wound Care Dietary modification Dietary modification

29. Gerontologic considerations Gallstones increasingly common Gallstones increasingly common Differing presenting symptoms Differing presenting symptoms Surgical risks due to concurrent conditions Surgical risks due to concurrent conditions Decreased elective surgery and more advanced status at time of surgery Decreased elective surgery and more advanced status at time of surgery Higher risk of complications and shorter hospital stays Higher risk of complications and shorter hospital stays

30. Gallbladder Cancer Uncommon Uncommon Majority are adenocarcinomas Majority are adenocarcinomas Early symptoms similar to chronic cholecystitis and cholelithiasis Early symptoms similar to chronic cholecystitis and cholelithiasis Later symptoms of biliary obstruction Later symptoms of biliary obstruction Poor prognosis Poor prognosis

31. Gallbladder Cancer Diagnosis and staging – EUS, transabdominal US, CT, MRI, MRCP Diagnosis and staging – EUS, transabdominal US, CT, MRI, MRCP If found early – surgery is curative If found early – surgery is curative Extended cholestectomy with lymph node dissection – good outcome Extended cholestectomy with lymph node dissection – good outcome Palliative – stenting of biliary tree, radiation, chemotherapy Palliative – stenting of biliary tree, radiation, chemotherapy

32. Gallbladder Cancer Nursing Management - supportive care Nursing Management - supportive care Nutrition, hydration, skin care, pain relief Nutrition, hydration, skin care, pain relief Similar to care for cholecystitis and cholelithiasis and cancer Similar to care for cholecystitis and cholelithiasis and cancer

33. The End