2. 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: Higher in women: multiparous, over 40, on estrogen therapy 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 vs Chronic Cholecystitis Which are acute signs; which are chronic? ________ ________ 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 _______ _______ Dull ache Dull ache History of fat intolerance History of fat intolerance Dyspepsia Dyspepsia Increased flatulence Increased flatulence

8. 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

9. 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

10. Cholesterol vs Pigment Stones Which is which & which is more common? ______________ ______________ 4x more prevalent in 4x more prevalent in women women formation incidence formation incidence increased in use of oral increased in use of oral contraceptives, estrogens contraceptives, estrogens _____________ made of other bile components (bile salts, bilirubin, Ca, protein) undissolvable; requires surgery increased risk in: cirrhosis, hemolysis, biliary tree infections

11. Cholesterol stones 1

12. Cholesterol stones 2

13. Pigment stones

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

15. Diagnostic Studies History & physical examination History & physical examination Would these laboratory tests show increased or decreased levels? Would these laboratory tests show increased or decreased levels? * Liver function tests * Liver function tests * WBC count * WBC count * Serum bilirubin * Serum bilirubin * Serum amylase * Serum amylase

16. Diagnostic Tests Abdominal x-rays Abdominal x-rays Ultrasonography – most accurate Ultrasonography – most accurate HIDA scan HIDA scan Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic retrograde cholangiopancreatography (ERCP) Percutaneous transhepatic cholangiography Percutaneous transhepatic cholangiography

17. Treatment & Nursing Care Acute episodes focus on * Pain control – * Pain control – - Morphine - Morphine - Dilaudid (hydromorphone) - Dilaudid (hydromorphone) - Ketorolac (Toradol ) - Ketorolac (Toradol ) - Demerol (Meperidine ) - Demerol (Meperidine ) - NSAIDS, anticholinergics - NSAIDS, anticholinergics * Infection Control - antibiotics * Infection Control - antibiotics

18. Treatment & Nursing Care continued *Fluid and electrolyte balance *Fluid and electrolyte balance - IV fluid - IV fluid - Antiemetics : - Antiemetics : Metoclopramide (Reglan) Metoclopramide (Reglan) Ondansentron (Zofran) Ondansentron (Zofran) Prochlorperazine (Compazine) Prochlorperazine (Compazine) Gastric Decompression – NGT, NPO Gastric Decompression – NGT, NPO *How/what would you monitor to maintain F & E balance? *How/what would you monitor to maintain F & E balance?

19. Treatment and Nursing Care Once attack is over maintain on _____ fat diet _____ fat diet _________ forming foods _________ 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 _______ diet if obese Reduced _______ diet if obese

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

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

22. ERCP with Sphincterectomy

23. Treatment and Nursing Care: Surgical When is one preferred over another? Why? ____________ ____________ Cholecystectomy Cholecystectomy * GB removed * GB removed through through 4 puncture holes 4 puncture holes * CX: injury to CBD * CX: injury to CBD _________Cholecystectomy * removal of GB * removal of GB via right subcostal via right subcostal incision incision * T tube inserted into * T tube inserted into CBD CBD

24. Laparoscopic vs Open Cholestectomy

25. T tube

26. Treatment and Nursing Care: Surgical Transhepatic biliary catheter * to decompress * to decompress obstructed obstructed extrahepatic extrahepatic ducts ducts

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

28. 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

29. 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

30. 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

31. 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

32. The End