1. Care of Patients with Problems of the Biliary System and Pancreas
Chapter 62
Care of Patients with Problems of the Biliary System and Pancreas
Organs of the biliary system and the pancreatic ducts.

2. GI Tract
Anatomic relationships of the large intestine.

3. Gallstones
Gallstones within the gallbladder and obstructing the common bile and cystic ducts.

4. Acute vs. Chronic Cholecystitis
Underlying cause
Signs/symptoms
Risk factors
Role of diet

5. Gallstones

6. Cholecystectomy Laparoscopic vs. traditional
Preoperative, intraoperative, postoperative similarities and differences

7. Traditional Cholecystectomy
Standard preoperative care
Operative procedure
Postoperative care
Opioids via PCA pump
T-tube (and care of)
Antiemetics
Wound care
NPO
Nutrition therapy

8. 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

9. Acute Pancreatitis Laboratory and diagnostic tests
Clinical manifestations
Contributing factors
Roles of collaborative health care team
Priority of care
Priority nursing interventions
Patient and family teaching
Resources

10. Acute Pancreatitis
Acute pancreatitis. Axial CT image demonstrates peripancreatic stranding (arrow), a finding of pancreatitis. There are multiple gallstones in the gallbladder, which were the cause of this patient's pancreatitis.

11. Autodigestion
The process of autodigestion in acute pancreatitis.

12. Complications of Acute Pancreatitis
Hypovolemia
Hemorrhage
Acute kidney failure
Paralytic ileus
Hypovolemic or septic shock

13. Complications of Acute Pancreatitis
Pleural effusion, respiratory distress syndrome, pneumonia
Multisystem organ failure
Disseminated intravascular coagulation
Diabetes mellitus

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

15. Chronic Pancreatitis
Chronic calcific pancreatitis. Axial unenhanced CT image demonstrates multiple pancreatic calcifications, which are a common finding in chronic pancreatitis. The pancreatic duct is also dilated, although that is generally better delineated on postcontrast images.

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

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

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

19. Pancreatic Cancer
Carcinoma of the pancreas. A cross-section through the head of the pancreas and adjacent common bile duct showing both an ill-defined mass in the pancreatic substance (arrowheads) and the green discoloration of the duct resulting from total obstruction of bile flow.

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

21. Surgical Management Postoperative care: Observe for complications
GI drainage monitoring
Positioning
Fluid and electrolyte assessment
Glucose monitoring

22. Whipple Procedure
Whipple procedure, or radical pancreaticoduodenectomy. This surgical procedure involves resection of the proximal pancreas, adjoining duodenum, distal portion of the stomach, and distal portion of the common bile duct. The pancreatic duct, common bile ducts, and stomach are anastomosed to the jejunum.

23. Whipple Procedure
The three anastomoses that constitute the Whipple procedure: choledochojejunostomy, pancreaticojejunostomy, and gastrojejunostomy.

24. Case Study
A 68-year-old patient presents to the ED the day after Thanksgiving, stating that he has “eaten and drunk quite a bit.” He states that about 1 hour ago he experienced a sudden onset of pain in the left upper quadrant that radiates to his left flank. He rates the pain as an 8 on a 0-to-10 scale. The patient is admitted with acute pancreatitis.
Which laboratory finding corroborates the diagnosis of acute pancreatitis?
Serum lipase, 150 U/L
Serum amylase, 200 U/L
White blood cells, 6000 mcL
Serum glucose, 80 mg/dL
ANS: B
A serum amylase of 200 U/L is elevated (normal range is approx. 23 to 85 U/L). Lipase normal range is U/L, WBC normal range is ,800 ccm, and glucose normal range is mg/dL. Amylase, lipase, WBC, and glucose are often higher than normal in patients with acute pancreatitis.

25. Case Study
In preparing to care for the patient, which conditions does the nurse recognize as potential complications of acute pancreatitis? (Select all that apply.)
Pancreatic infection
Pleural effusion
Diabetes mellitus
Acute kidney failure
Hemorrhage
Pneumonia
ANS: A, B, C, D, E, F
All are potential complications of acute pancreatitis.

26. Case Study
When the patient is asked about pain, he says that it is intense and continuous. He states that sometimes when he curls up in a fetal position the pain eases.
Which intervention should be implemented for pain relief?
PCA morphine sulfate
PCA meperidine (Demerol)
Oral hydromorphone (Dilaudid)
IM fentanyl (Sublimaze)
ANS: A
Meperidine is not a good choice because it can cause seizures, especially in older adults. While hydromorphone is a good choice with acute pancreatitis pain, IV is the best route. Fentanyl is a good alternative, but the route chosen should be IV or transdermal. Another option is epidural analgesia.

27. Case Study The patient has been NPO but is now tolerating food.
Which nutrition teaching point should the nurse be sure to include?
Expect to experience nausea and vomiting as you begin to consume foods.
Small and frequent meals are best.
Low-carbohydrate, high-protein, and high-fat foods should be consumed.
Use of alcohol and caffeine should be consumed in moderation.
ANS: B
Patients may experience nausea and vomiting but should not expect this to happen. High-carbohydrate, high-protein, and low-fat foods should be included in the diet. Alcohol and caffeine should be avoided.

28. Case Study
The patient is being discharged to home. What instructions would the nurse tell the patient about when to call the provider?
The patient should be instructed to notify the health care provider if acute abdominal pain occurs. Also, jaundice, clay-colored stools, or dark urine should be reported, because these are signs of biliary tract disease that may indicate complications as the disease progresses.

29. Audience Response System Questions
Chapter 62
Audience Response System Questions 29

30. Question 1
A patient with chronic cholecystitis reports 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 including hepatic disease, pancreatitis, and peritonitis. Monitoring liver function, 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 Hispanic/Latino female with a history of irritable bowel syndrome
45-year-old Caucasian female with a family history of gallstones
60-year-old obese, American-Indian 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, American-Indian and Caucasian descent, rapid change in weight, and advanced age. More risk factors increase the likelihood of developing gallstones.

32. Question 3 In the care of a patient with acute pancreatitis, which
assessment parameter requires immediate nursing
intervention?
Heart rate of 105 beats/min
Blood pressure of 102/76 mm Hg
Respiratory rate of 28 breaths/min
Serum glucose of 136 mg/dL
Answer: C
Rationale: The patient with pancreatitis may develop pulmonary complications, pleural effusions, pulmonary infiltrates, and acute respiratory failure or ARDS. Increases in respiratory effort is an important assessment variable in the care of a patient with pancreatitis. Patients may also be hyperglycemic and hypovolemic. Assessing and treating endocrine function of the pancreas and perfusion variables are also important.