Care of the Client with Disorders of the Gallbladder

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Care of the Client with Disorders of the
Gallbladder

• ACC RNSG 1247

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Gallbladder Disease

• Two main disorders
• Cholecystitis
• Cholelithiasis

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Risk factors for GB disease

• Higher in women multiparous, over 40, on
  estrogen therapy
• Sedentary lifestyle
• Familial tendency
• Obesity

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Etiology of Cholecystitis

• Acute
• - Calculous with stone obstruction
• - Acalculous absence of stones
• Chronic
• - Repeated attacks, long standing
• inflammation

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Pathophysiology of Cholecystitis

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

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Clinical Manifestations of Acute Cholecystitis

• Usually begins with a biliary colic attack
• RUQ pain
• N/V
• Usually signs of acute inflammation
• Possible pus formation?gangrenous

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Clinical Manifestations of Chronic Cholecystitis

• Dull ache
• History of fat intolerance
• Dyspepsia
• Increased flatulence

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Cholelithiasis

• Calculi (stones) in the GB
• May obstruct the cystic or CBD
• Choledocholithiasis stones in the CBD
• Types
• Composed primarily of pigment
• Composed primarily of cholesterol

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Pathophysiology of Cholelithiasis

• 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
• Bile in GB and liver become saturated with
  cholesterol

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Cholesterol Stones

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

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Cholesterol stones 1
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Cholesterol stones 2
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Pigment Stones

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

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Pigment stones
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Clinical Manifestations of Cholelithiasis

• Silent cholelithiasis
• Pain and biliary colic
• Symptoms related to bile obstruction
• such as jaundice, pruritus, changes in
• color of stool and urine, vitamin deficiency,
  bleeding, steatorrhea

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Diagnostic Studies

• History physical examination
• Laboratory tests
• Liver function tests
• WBC count
• Serum bilirubin
• Serum amylase

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Diagnostic Tests

• Abdominal x-rays
• Ultrasonography
• Endoscopic retrograde cholangiopancreatography
  (ERCP)
• Percutaneous transhepatic cholangiography

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Treatment Nursing Care

• Acute episodes focus on
• pain control Morphine
• antibiotic treatment
• fluid electrolyte balance IV fluids
• Gastric decompression NGT, NPO
• Anticholinergics - Bentyl

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Treatment and Nursing Care

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

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Treatment Nursing CareSupportive Drug Therapy

• Fat soluble vitamin replacement A,D,E,K
• Bile salts Decholin, enhance fat
  absorption
• Bile acids Questran and Cholestid, bind
  
• bile salts and treat pruritus

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Treatment and Nursing CareNon Surgical Stone
Approaches for Stone Removal

• endoscopic sphincterotomy
• mechanical lithotripsy
• cholesterol solvents
• extracorporeal shock wave lithotripsy
  

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Treatment and Nursing CareSurgical

• Laparoscopic Cholestectomy
• treatment of choice
• gallbladder removed through 4 puncture
• holes
• minimal postoperative pain
• D/C same or next day
• CX injury to CBD

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Treatment and Nursing CareSurgical

• Open cholecystectomy
• Removal of GB through right subcostal
• incision
• T tube inserted into CBD
• Transhepatic biliary catheter
• to decompress obstructed extrahepatic
• ducts

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Laparoscopic vs Open Cholestectomy
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T tube
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Treatment and Nursing Care Post Op

• Pain Control
• Prevent Complications primarily pulmonary
• Wound Care
• Dietary modification

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Gerontologic considerations

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

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Gallbladder Cancer

• Uncommon
• Majority are adenocarcinomas
• Early symptoms similar to chronic cholecystitis
  and cholelithiasis
• Later symptoms of biliary obstruction
• Poor prognosis

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Gallbladder Cancer

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

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Gallbladder Cancer

• Nursing Management - supportive care
• Nutrition, hydration, skin care, pain relief
• Similar to care for cholecystitis and
  cholelithiasis and cancer

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The End