Gallbladder Disorders: Cholecystitis and Biliary System

Disorders of the Gallbladder

• Learning objectives are to review the anatomy and physiology of the biliary system and explain the pathophysiology, clinical manifestations, diagnostic tests, medical-surgical management, and complications of cholelithiasis and cholecystitis.

The Biliary System

• Consists of the liver, gallbladder, and bile ducts.
• The liver produces bile.
• The gallbladder stores bile from the liver.
• Bile ducts are thin tubes that connect the liver, gallbladder, and duodenum.

The Gallbladder

• A pear-shaped, hollow, saclike organ that is 3 to 4 inches long.
• Found in a shallow depression on the inferior surface of the liver.
• Stores 30 to 50 mL of bile; functions as a reservoir for bile.

Enterohepatic Circulation

• Pathway moves bile from hepatocytes, to the intestine, and back to the hepatocytes.

Cholecystitis

• Is an inflammation of the gallbladder that can be acute or chronic.

Cholecystitis Classifications

• Calculous cholecystitis, 90% of acute cases, occurs when a gallbladder stone obstructs bile outflow.
• Vascular supply can be compromised.
• Acalculous cholecystitis occurs in the absence of stone obstruction.
• Acalculous can occur after surgery, orthopedic procedures, trauma, and burns and can result from bacterial infections, bile stasis, and increased bile viscosity.

Clinical Manifestations of Cholecystitis

• RUQ distress and a positive Murphy's Sign (pain radiates to the back & right shoulder/midsternal area).
• Indigestion, nausea, vomiting, and flatulence.
• Other manifestations include leukocytosis, elevated temperature, dark urine, and clay-colored stool.

Cholelithiasis

• Is the formation of calculi, or gallstones, often forming in the gallbladder from bile's solid constituents.
• Choledocholithiasis is the presence of stones in the common bile duct (CBD).
• Pigment and cholesterol stones are the two types of stones.

Risk Factors for Gallbladder Issues

• Include cystic fibrosis, diabetes, frequent weight changes or weight loss, low-fiber and high-fat diets, ileal resection/disease, low-dose estrogen therapy, treatment with high-dose estrogen, obesity, and multiple pregnancies or Native American/Hispanic ethnicity.

Classification of Stones

• Cholesterol stones appear chalk white or greenish-yellow because of increased cholesterol synthesis in the liver; account for about 75% of cases and are associated with oral contraceptives/estrogens.
• Pigment stones are dark brown or black caused by unconjugated pigments in the bile precipitate; account for about 10-25%, and are associated with cirrhosis, hemolysis, and infections of the biliary tract.
• Mixed gallstones are a mixture of cholesterol and pigment stones and have a sticky mud-like appearance.

Clinical Manifestations of Cholelithiasis

• Often present with none to minimal symptoms as well as pain.
• Can present with biliary colic and jaundice.
• Changes in urine or stool color along with a vitamin deficiency.

Pain and Biliary Colic

• Pain manifests as upper right abdominal pain at the 9th & 10th costal cartilage and can radiate to the back or right shoulder, usually associated with nausea and vomiting, noticeable hours after a heavy meal.

Jaundice

• Jaundice is usually connected with obstruction of the common bile duct.
• Often accompanied by pruritus (itching) of the skin

Changes in Urine and Stool Color

• Urine becomes dark, and stool becomes grayish

Diagnostic Findings

Vitamin Deficiency

• Obstruction of bile flow interferes with absorption of the fat-soluble vitamins A, D, E, and K.

• Magnetic resonance cholangiopancreatography (MRCP) visualizes the biliary tree and is capable of detecting biliary tract obstruction.

• A Cholangiogram visualizes the gallbladder and bile duct

• Ultrasonography shows the size of abdominal organs and the presence of masses.

• Endoscopic ultrasound (EUS) identifies small tumors and other abnormalities and facilitates fine-needle aspiration biopsy of tumors or lymph nodes for diagnosis.

• Helical computed tomography and magnetic resonance imaging can detect neoplasms, diagnose cysts, pseudocysts, and abscess, determine the severity of pancreatitis based on the presence of necrosis

Other Diagnostic Tests

• An abdominal X-ray shows gallstones that are calcified sufficiently to be visible, accounting for 10% to 15% of them.
• Ultrasonography is rapid and accurate.
• Patients should be NPO overnight so the gallbladder is distended.
• Radionuclide Imaging or Cholescintigraphy detects acute cholecystitis or a blockage of a bile duct.
• Oral Cholecystography detects gallstones and to assess the ability of the gallbladder to fill, concentrate its contents, contract, and empty.
• Endoscopic Retrograde Cholangiopancreatography examines the hepatobiliary system via a side-viewing flexible fiberoptic endoscope inserted through the esophagus to the descending duodenum.

Nursing Implications Before ERCP

• NPO for several hours.
• Requires IV sedation and monitored anesthesia care.
• Administer such medications like glucagon or anticholinergic agents, to decrease duodenal peristalsis.
• Close observation for signs of respiratory and CNS depression, hypotension, oversedation, and vomiting (if glucagon is given).

Nursing Implications During ERCP

• Nurse monitors IV fluids, administers medications, and positions the patient.

Nursing Implications After ERCP

• Nurse monitors the patient's condition, observing vital signs and assessing for signs of perforation or infection.

Medical Management Goals of Treatment

• Reducing the incidence of acute episodes of gallbladder pain and cholecystitis as well as removing the cause of cholecystitis.

Medical Managment

• Can include dietary management, ursodeoxycholic acid and chenodeoxycholic acid.
• Possible solutions include Laparoscopic cholecystectomy, and/or Nonsurgical removal by instrumentation or intracorporeal or extracorporeal lithotripsy.

Nutritional and Supportive Therapy

• Low-fat liquids include powdered supplements high in protein and carbohydrate stirred into skim milk.
• Cooked fruits, rice or tapioca, lean meats, and mashed potatoes.
• Non-gas-forming vegetables, bread, coffee, or tea may be added as tolerated.
• Foods to avoid include eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol.

Pharmacologic Therapy

• Ursodeoxycholic acid (UDCA)
• Chenodeoxycholic acid (CDCA) which Inhibits the synthesis and secretion of cholesterol.

Nonsurgical Removal of Gallstones

• Includes dissolving gallstones by infusing a solvent (mono-octanoin or methyl tertiary butyl ether [MTBE]) into the gallbladder.
• This is rarely used due to its lack of success, potential side effects, and recurrence rates of up to 50%.

Nonsurgical Removal

• T-tube tract used to remove the stone with a basket to catheter threaded through the T-tube tract
• ERCP endoscope is inserted into the duodenum.
• Papillotome is inserted into the common bile duct . Retrieval and removal of stone with basket inserted through endoscope after enlarging opening of the sphincter of Oddi.

Intracorporeal Lithotripsy

• Stones in the gallbladder or CBD may be fragmented by means of laser pulse technology as well as mechanical shock wave.

Extracorporeal Shock Wave Lithotripsy (ESWL)

• Repeated shock waves are directed at the gallstones in the gallbladder or CBD to fragment the stones.
• Waves are transmitted to the body through a fluid-filled bag or by immersing the patient in a water bath.
• Once broken, stone fragments can be spontaneously passed from the gallbladder.

Surgical Interventions

• percutaneous cholangioscopy, lithotripsy and gallbladder removal and laparoscopic cholecystectomy
• Choledochostomy is the incision in the common duct, usually for a stone removal, and a tube is usually inserted into the duct for bile until the edema subsides.

Surgical Cholecystostomy

• Gallbladder is surgically opened and stones and bile/purulent drainage are removed. A drainage tube is secured with a purse-string suture.

Percutaneous Cholecystostomy

• a fine needle is inserted through the abdominal wall and liver edge into the gallbladder. Bile is aspirated to ensure adequate placement of the needle, and a catheter is inserted into the gallbladder.
• Antibiotics are given before, during, and after the procedure.

Postoperative Complications

• Include Atelectasis & Pneumonia, Deep Vein Thrombosis (DVT) & Pulmonary Embolism (PE), Bile Leakage & Bile Peritonitis and Paralytic ileus.

Prevention & Management of Complications

• Early Mobilization can reduce risks of DVT and ileus.
• Pain Control, Antibiotics & Aseptic Techniques, Respiratory Support (Incentive Spirometry), Bile Leak Signs all assist with management.

Nursing Diagnosis

• Can include acute pain and discomfort, as well as, impaired skin integrity associated with altered biliary drainage and lack of knowledge about self-care activities associated with incision care, dietary modifications, medications, and reportable signs or symptoms
• Can also include impaired gas exchange associated with the high abdominal surgical incision and impaired nutritional status associated with inadequate bile secretion.

Patient Education After Laparoscopic Cholecystectomy

• Managing pain by sitting upright in bed or a chair, walking, or using a heating pad may ease the discomfort.

• Resuming activity by beginning light exercise (walking) immediately.

• Take a shower or bath after 1 or 2 days, drive a car after 3 or 4 days, and avoid lifting objects exceeding 5 lb after surgery.

• Special care for the wound inclues check puncture site daily for signs of infection, washing with mild soap and water and Allow special adhesive strips on the puncture siteto fall off.

• Resume normal diet.

• Gradually add fat if you had intolerance

Managing Follow-Up Care

• Make an appointment with the surgeon 7 to 10 days after discharge.call surgeon if any signs of infection.

Disorders of the Pancreas

• The pancreas has enzymes and hormones
• The learning objective is to review the anatomy and physiology of pancreas and to describe the pathophysiology, manifestations, complications and acute management.
• Pancreatitis is an inflammation of the pancreas which can be acute or chronic.

Etiology of Pancreatitis

• Include alcohol abuse, blunt abdominal trauma, peptic ulcer disease, hyperlipidemia, drugs, abnormal organ structure/congenital abnormality

Pathophysiology

• Triggering factor causes Premature Activation of Pancreatic Enzymes (Trypsin) Inside the Pancreas.
• This causes Autodigestion of Pancreatic Tissue, which causesInflammatory Response & Edema Formation with Increased Vascular Permeability.
• This can cause Fluid Leakage into Interstitial Spaces and Hypovolemia which leads to mild Interstitial Edematous Pancreatitis or severe Necrotizing Pancreatitis.

Acute Pancreatitis Classifications

• Mild Interstitial Edematous causes an inflamed pancrease
• Severe Necrotizing has pancreatic tissue that is necrosed

Chronic Pancreatitis

• Is a progressive fibro-inflammatory disease in which functioning pancreatic tissue is replaced with fibrotic tissue because of inflammation.

Clinical Manifestations

• Severe abdominal pain – Sharp, and constant in the Midepigastrium and back
• Often occurs 24-48 hours after a heavy meal or alcohol intake with fever and chills.
• Also presents with vomiting and nausea, decreased peristalsis and Abdominal distension.
• Palpable mass may suggest a pseudocyst or fluid collection.
• Symptoms include Jaundice and Hypotension.

Neurological Symptoms

• Confusion, Agitation, or Altered Mental Status may be present due to sepsis, hypoxia, or metabolic imbalances.

Skin Manifestations

• Cullen's Sign – Bluish discoloration around the umbilicus indicating internal bleeding and Grey Turner's Sign – Bluish discoloration on the flanks, suggesting retroperitoneal hemorrhage.

Diagnostic Studies

• Elevated Amylase & lipase levels, hematocrit, Increased WBC count and Complete chemistry panel.
• Diagnostic scans include X-ray, MRI, US, CT scans
• Also includes ERCP

Medical Management

• NPO, Enteral Nutrition, and Parenteral Nutrition
• Meds can include H2 blockers (cimetidine) or PPIs (pantoprazole).
• Also Nasogastric Suction.

Pain Management

• Opioids (Morphine, Fentanyl, Hydromorphone).
• NSAIDs (Cautiously Used), Avoided in patients that are at risk of bleeding.
• Antiemetics can also be given to prevent Vomiting

Respiratory Care

• The following must be done: Assess for the lung sounds, cough and deep breathing every 2 hours, close monitoring of arterial blood gases, use of humidified oxygen, and incentative spirometer as well as position in high-Fowlers position as well as potential mechanical ventilation is needed.

Surgical Intervention

• Indications: Necrosis, infected pancreatic tissue, or persistent complications.

Diagnostic Laparotomy

• For Drainage & Debridement (Removes necrotic tissue; multiple drains may be placed).

Potential Follow Up

• Includes Gradual Oral Intake: Low-fat and protein diet and no Alcohol/Caffeine. Also should discontinue triggering Medications and potential Follow-Up Imaging.

Potential Nursing Diagnosis

• May include acute pain, fluid and electrolyte disturbances and ineffective breathing pattern as well as imbalance nutrition.