1. Care of Patients with Problems of the Biliary System and Pancreas
Chapter 62
Mrs. Kreisel MSN, RN
NU130 Adult Health
Summer 2011

2. Hepatobiliary Anatomy

3. Acute Cholecystitis
Acute cholecystitis is the inflammation of the gallbladder.
Calculous cholecystitis.
Cholelithiasis (gallstones) usually accompanies cholecystitis.
Acalculous cholecystitis inflammation can occur in the absence of gallstones.

4. Gallstones

5. Chronic Cholecystitis
Repeated episodes of cystic duct obstruction result in chronic inflammation
Pancreatitis, cholangitis
Jaundice
Icterus
Obstructive jaundice
Pruritus

6. Clinical Manifestations
Flatulence, dyspepsia, eructation, anorexia, nausea and vomiting, abdominal pain
Biliary colic
Murphy’s sign
Blumberg’s sign
Rebound tenderness
Steatorrhea

7. Nonsurgical Management
Nutrition therapy—low-fat diet, fat-soluble vitamins, bile salts
Drug therapy—opioid analgesic such as morphine or hydromorphone, anticholinergic drugs, antiemetic
Extracorporeal shock wave lithotripsy
Percutaneous transhepatic biliary catheter insertion

8. Surgical Management Laparoscopic cholecystectomy
Standard preoperative care
Operative procedure
Postoperative care:
Free air pain result of carbon dioxide retention in the abdomen
Ambulation
Return to activities in 1 to 3 weeks

9. Traditional Cholecystectomy
Standard preoperative care
Operative procedure
Postoperative care:
Opioids via patient-controlled analgesia pump
T-tube
Antiemetics
Wound care

10. Traditional Cholecystectomy (Cont’d)
Care of the T-tube
NPO
Nutrition therapy

11. Cancer of the Gallbladder
Anorexia, weight loss, nausea, vomiting, general malaise, jaundice, hepatosplenomegaly; chronic, progressively severe epigastric or right upper quadrant pain
Poor prognosis
Surgery, radiation, chemotherapy

12. Acute Pancreatitis
Serious and possibly life-threatening inflammatory process of the pancreas
Necrotizing hemorrhagic pancreatitis
Lipolysis
Proteolysis
Necrosis of blood vessels
Inflammation
Theories of enzyme activation

13. Autodigestion

14. Complications of Acute Pancreatitis
Hypovolemia
Hemorrhage
Acute renal failure
Paralytic ileus
Hypovolemic or septic shock
Pleural effusion, respiratory distress syndrome, pneumonia
Multisystem organ failure
Disseminated intravascular coagulation
Diabetes mellitus

15. Clinical Manifestations
Generalized jaundice
Cullen’s sign
Turner’s sign
Bowel sounds
Abdominal tenderness, rigidity, guarding
Pancreatic ascites
Significant changes in vital signs

16. Laboratory Assessment
Lipase
Trypsin
Alkaline phosphatase
Alanine aminotransferase
WBC
Glucose
Calcium

17. Acute Pain Interventions include:
The priority for patient care to provide supportive care by relieving symptoms, decrease inflammation, and anticipate and treat complications
Comfort measures to reduce pain including fasting and drug therapy
Endoscopic retrograde cholangiopancreatography

18. Nonsurgical Management
Fasting and rest
Drug therapy
Comfort measures
Endoscopic retrograde cholangiopancreatography (ERCP)

19. Surgical Management Preoperative care—NG tube may be inserted
Operative procedures
Postoperative care:
Monitor drainage tubes and record output from drain.
Provide meticulous skin care and dressing changes.
Maintain skin integrity.

20. Imbalanced Nutrition: Less Than Body Requirements
Interventions include:
NPO in early stages
Antiemetics for nausea and vomiting
Total parenteral nutrition
Small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals
Avoidance of foods that cause GI stimulation

21. Chronic Pancreatitis
Progressive destructive disease of the pancreas, characterized by remissions and exacerbations
Nonsurgical management includes:
Drug therapy
Analgesic administration
Enzyme replacement
Insulin therapy
Nutrition therapy

22. Pancreatic Abscess
Most serious complication of pancreatitis; always fatal if untreated
High fever
Blood cultures
Drainage via the percutaneous method or laparoscopy
Antibiotic treatment alone does not resolve abscess

23. Pancreatic Pseudocyst
Complications: hemorrhage, infection, bowel obstruction, abscess, fistula formation, pancreatic ascites
May spontaneously resolve
Surgical intervention after 6 weeks

24. Insulinoma Most common type of neuroendocrine pancreatic tumor
Benign tumors of the islets of Langerhans that cause excessive insulin secretion and subsequent hypoglycemia
Management—removal of tumor

25. Pancreatic Carcinoma Nonsurgical management: Drug therapy
Radiation therapy
Biliary stent insertion

26. Surgical Management Preoperative care: NG tube may be inserted
TPN typically begun
Operative procedure may include Whipple procedure

27. Surgical Management (Cont’d)
Postoperative care:
Observe for complications
GI drainage monitoring
Positioning
Fluid and electrolyte assessment
Glucose monitoring

28. Whipple Procedure Three anastomoses that constitute the Whipple procedure: Choledochojejunostomy, pancreaticojejunostomy, & gastrojejunostomy

29. NCLEX TIME

30. Question 1 A patient with chronic cholecystitis is complaining of
pruritus, clay-colored stools, and voiding dark, frothy
urine. Which laboratory analysis is a priority in the
nurse’s assessment of this patient?
Liver function tests
Total bilirubin
Lipase level
White blood cell count
Answer: B
Rationale: Excess circulating bilirubin present with chronic cholecystitis is responsible for pruritus and changes in stool and urine color. Cholecystitis is associated with several risks, to include hepatic disease, pancreatitis, and peritonitis. Thus monitoring liver function and pancreatic laboratory values and white blood cell counts is also very important.

31. Question 2 Which patient is more likely to develop gallstones?
55-year-old African-American male with a history of diabetes mellitus
62-year-old American-Indian female
45-year-old Caucasian female with a family history of gallstones
60-year-old obese, Mexican-American female with a history of diabetes mellitus
Answer: D
Rationale: Risk factors for developing gallstones include: female gender; obesity; family history of gallstones; diabetes mellitus; Mexican-American, American-Indian, and Caucasian descent; rapid change in weight; and advanced age. More risk factors increase the likelihood of developing gallstones.

32. Question 3 The nurse notes jaundice and bluish discoloration of the
abdomen and flank in the patient complaining of
abdominal pain of sudden onset that radiates to the left
shoulder. Based on these symptoms, what intervention
should be the priority for this patient?
Passage of a nasogastric tube
Observation for delirium tremens
Pain relief
Relief from vomiting
Answer: C
Rationale: Symptoms are characteristic of acute pancreatitis. Most often, the patient indicates that he needs relief from abdominal pain.

33. Question 4 About how any Americans are affected by acute pancreatitis?
10,000
30,000
50,000
80,000
Answer: D
Rationale: Acute pancreatitis affects about 80,000 Americans every year. Acute pancreatic attacks are especially common during holidays and vacations when alcohol consumption is usually high. Women are affected most often after cholelithiasis and biliary tract disturbances.
Source:

34. Question 5 In the care of a patient with acute pancreatitis, which
assessment parameter requires immediate nursing
intervention?
Heart rate 105 beats/min
Blood pressure 110/82 mm Hg
Respiratory rate 28 breaths/min
Serum glucose 136 mg/dL
Answer: C
Rationale: The patient with pancreatitis may develop pulmonary complications, pleural effusions, pulmonary infiltrates, and acute respiratory distress syndrome. Increases in respiratory effort is an important assessment variable in the care of a patient with pancreatitis. Patients may also be hyperglycemic and hypovolemic. Thus assessing and treating endocrine function of the pancreas and perfusion variables are also important.