Gallbladder Disease PDF

blood glucose level are glucagon, epinephrine, adrenocorticosteroids, growth hormone, and thyroid hormone. The endocrine and exocrine functions of the pancreas are interrelated. The major exocrine function is to facilitate digestion through secretion of enzymes into the proximal duodenum. Secreti...

blood glucose level are glucagon, epinephrine, adrenocorticosteroids, growth hormone, and thyroid hormone. The endocrine and exocrine functions of the pancreas are interrelated. The major exocrine function is to facilitate digestion through secretion of enzymes into the proximal duodenum. Secretin and CCK are hormones from the GI tract that aid in the digestion of food substances by controlling the secretions of the pancreas. Neural factors also influence pancreatic enzyme secretion. Considerable dysfunction of the pancreas must occur before enzyme secretion decreases and protein and fat digestion becomes impaired. Pancreatic enzyme secretion is normally 1500 to 3000 mL/day (Doherty, 2015; Papadakis & McPhee, 2016). Gerontologic Considerations There is little change in the size of the pancreas with age. However, there is an increase in fibrous material and some fatty deposition in the normal pancreas in people older than 70 years. Some localized arteriosclerotic changes occur with age. There is also a decreased rate of pancreatic enzyme secretion (i.e., amylase, lipase, and trypsin) and decreased bicarbonate output in older adults. Some impairment of normal fat absorption occurs with increasing age, possibly because of delayed gastric emptying and pancreatic insufficiency (Eliopoulos, 2018; Papadakis & McPhee, 2016). Decreased calcium absorption may also occur. These changes require care in interpreting diagnostic test results in the normal older patient and in providing dietary counseling. DISORDERS OF THE GALLBLADDER Several disorders affect the biliary system and interfere with normal drainage of bile into the duodenum. These disorders include inflammation of the biliary system and carcinoma that obstructs the biliary tree. Gallbladder disease with stones is the most common disorder of the biliary system. Not all occurrences of cholecystitis are related to stones (calculi) in the gallbladder (cholelithiasis) or stones in the common bile duct (choledocholithiasis). However, most of the 15 million Americans with gallstones have no pain and are unaware of the presence of stones (Bope & Kellerman, 2015). 3776 Cholecystitis Cholecystitis (inflammation of the gallbladder which can be acute or chronic) causes pain, tenderness, and rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with nausea, vomiting, and the usual signs of an acute inflammation. An empyema of the gallbladder develops if the gallbladder becomes filled with purulent fluid (pus). Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis (Feldman et al., 2015; Rakel & Rakel, 2015). In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute cholecystitis; however, secondary infection of bile occurs in approximately 50% of cases. The organisms involved are generally enteric (normally live in the GI tract) and include Escherichia coli, Klebsiella species, and Streptococcus. Bacterial contamination is not believed to stimulate the actual onset of acute cholecystitis (Feldman et al., 2015). Acalculous cholecystitis describes acute gallbladder inflammation in the absence of obstruction by gallstones. Acalculous cholecystitis occurs after major surgical procedures, orthopedic procedures, severe trauma, or burns. Other factors associated with this type of cholecystitis include torsion, cystic duct obstruction, primary bacterial infections of the gallbladder, and multiple blood transfusions. It is speculated that acalculous cholecystitis is caused by alterations in fluids and electrolytes and alterations in regional blood flow in the visceral circulation. Bile stasis (lack of gallbladder contraction) and increased viscosity of the bile are also thought to play a role. The occurrence of acalculous cholecystitis with major surgical procedures or trauma makes its diagnosis difficult (Doherty, 2015). Cholelithiasis Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition (see Fig. 50-2). They are uncommon in children and young adults but become more prevalent with increasing age. It is estimated that the prevalence of gallstones ranges from 5% to 20% in women between the ages of 20 and 3777 55 years and from 25% to 30% in women older than 50 years. Cholelithiasis affects approximately 50% of women by the age of 70 years. Pathophysiology There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for about 10% to 25% of cases in the United States (Feldman et al., 2015; Kumar, Abbas, Fausto, et al., 2014). The risk of developing such stones is increased in patients with cirrhosis, hemolysis, and infections of the biliary tract. Pigment stones cannot be dissolved and must be removed surgically. Cholesterol stones account for most of the remaining 75% of cases of gallbladder disease in the United States. Cholesterol, which is a normal constituent of bile, is insoluble in water. Its solubility depends on bile acids and lecithin (phospholipids) in bile (Hall, 2015). In gallstone-prone patients, there is decreased bile acid synthesis and increased cholesterol synthesis in the liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form stones (Hall, 2015; Kumar et al., 2014). The cholesterol-saturated bile predisposes to the formation of gallstones and acts as an irritant that produces inflammatory changes in the mucosa of the gallbladder (Feldman et al., 2015; Lee, Keane, & Pereira, 2015). 3778 Figure 50-2 Examples of cholesterol gallstones (left) made up of a coalescence of multiple small stones and pigment gallstones (right) composed of calcium bilirubinate. From Strayer, D. S., & Rubin, E. (2015). Rubin’s pathology: Clinicopathologic foundations of medicine (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Two to three times more women than men develop cholesterol stones and gallbladder disease; affected women are usually older than 40 years, multiparous, and obese (Feldman et al., 2015; Goldman & Schafer, 2015; Greenberger, Blumberg, & Burakoff, 2015; Lee et al., 2015). Stone formation is more frequent in people who use oral contraceptives, estrogens, or clofibrate (Atromid-S); these medications are known to increase biliary cholesterol saturation (Feldman et al., 2015; Kumar et al., 2014). The incidence of stone formation increases with age as a result of increased hepatic secretion of cholesterol and decreased bile acid synthesis (Greenberger et al., 2015; Kumar et al., 2014). In addition, there is an increased risk because of malabsorption of bile salts in patients with GI disease or T-tube fistula and in those who have undergone ileal resection or bypass. The incidence is also greater in people with diabetes (see Chart 50-1). 3779 Clinical Manifestations Gallstones may be silent, producing no pain and only mild GI symptoms. Such stones may be detected incidentally during surgery or evaluation for unrelated problems (Doherty, 2015; Greenberger et al., 2015; Lee et al., 2015). The patient with gallbladder disease resulting from gallstones may develop two types of symptoms: those due to disease of the gallbladder itself and those due to obstruction of the bile passages by a gallstone. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. This distress may follow a meal rich in fried or fatty foods (Feldman et al., 2015; Greenberger et al., 2015; Lee et al., 2015). Pain and Biliary Colic If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute cholecystitis). The patient develops a fever and may have a palpable abdominal mass. The patient may have biliary colic with excruciating upper right abdominal pain that radiates to the back or right shoulder. Biliary colic is usually associated with nausea and vomiting, and it is noticeable several hours after a heavy meal. The patient moves about restlessly, unable to find a comfortable position. In some patients, the pain is constant rather than colicky (Greenberger et al., 2015; Lee et al., 2015; Townsend, Beauchamp, Evers, et al., 2016). Chart 50-1 RISK FACTORS Cholelithiasis Cystic fibrosis Diabetes Frequent changes in weight Ileal resection or disease Low-dose estrogen therapy—carries a small increase in the risk of gallstones Obesity Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease) Treatment with high-dose estrogen (e.g., in prostate cancer) 3780  Women, especially those who have had multiple pregnancies or who are of Native American or U.S. southwestern Hispanic ethnicity Adapted from Lee, J. Y. J., Keane, M. G., & Pereira, S. (2015). Diagnosis and treatment of gallstone disease. Practitioner, 259(1783), 15–19; Greenberger, N. J., Blumberg, R. S., & Burakoff, R. (Eds.). (2015). Current diagnosis and treatment: Gastroenterology, hepatology & endoscopy. New York: McGraw-Hill. Such a bout of biliary colic is caused by contraction of the gallbladder, which cannot release bile because of obstruction by the stone. When distended, the fundus of the gallbladder comes in contact with the abdominal wall in the region of the right 9th and 10th costal cartilages. This produces marked tenderness in the right upper quadrant on deep inspiration and prevents full inspiratory excursion. The pain of acute cholecystitis may be so severe that analgesic medications are required. The use of morphine has traditionally been avoided because of concern that it could cause spasm of the sphincter of Oddi, and meperidine (Demerol) has been used instead. This is controversial, because morphine is the preferred analgesic agent for management of acute pain, and some metabolites of meperidine are toxic to the central nervous system (CNS). Furthermore, all opioids stimulate the sphincter of Oddi to some degree (Emmanuel & Lee, 2014; Papadakis & McPhee, 2016). If the gallstone is dislodged and no longer obstructs the cystic duct, the gallbladder drains and the inflammatory process subsides after a relatively short time. If the gallstone continues to obstruct the duct, abscess, necrosis, and perforation with generalized peritonitis may result. Jaundice Jaundice occurs in a few patients with gallbladder disease, usually with obstruction of the common bile duct. The bile, which is no longer carried to the duodenum, is absorbed by the blood and gives the skin and mucous membranes a yellow color. This is frequently accompanied by marked pruritus (itching) of the skin. Changes in Urine and Stool Color The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. 3781 Vitamin Deficiency Obstruction of bile flow interferes with absorption of the fat-soluble vitamins A, D, E, and K. Patients may exhibit deficiencies of these vitamins if biliary obstruction has been prolonged. For example, a patient may have bleeding caused by vitamin K deficiency (vitamin K is necessary for normal blood clotting). Assessment and Diagnostic Findings A wide range of diagnostic studies may be performed in patients with biliary disorders. Table 50-1 identifies various procedures and their diagnostic uses. The nurse should educate the patient about the purpose, what to expect, and any possible side effects related to these examinations prior to testing. The nurse should note trends in results because they provide information about disease progression as well as the patient’s response to therapy. TABLE 50-1 Studies Used in the Diagnosis of Biliary Tract and Pancreatic Disease 3782 Abdominal X-Ray If gallbladder disease is suspected, an abdominal x-ray may be obtained to exclude other causes of symptoms. However, only 10% to 15% of gallstones are calcified sufficiently to be visible on such x-ray studies (Rakel & Rakel, 2015; Townsend et al., 2016). 3783 Ultrasonography Ultrasonography is the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation. The procedure is most accurate if the patient fasts overnight so that the gallbladder is distended. Ultrasonography can detect calculi in the gallbladder or a dilated common bile duct with 90% accuracy (Rakel & Rakel, 2015; Townsend et al., 2016). Radionuclide Imaging or Cholescintigraphy Cholescintigraphy is used successfully in the diagnosis of acute cholecystitis or blockage of a bile duct (Goldman & Schafer, 2015; Greenberger et al., 2015; Lee et al., 2015; Rakel & Rakel, 2015). During this procedure, a radioactive agent is administered intravenously (IV) which is taken up by the hepatocytes and excreted rapidly through the biliary tract. The biliary tract is then scanned, and images of the gallbladder and biliary tract are obtained. This test is more expensive than ultrasonography, takes longer to perform, and exposes the patient to radiation. It is often used when ultrasonography is not conclusive, such as in acalculous cholecystitis (Feldman et al., 2015; Goldman & Schafer, 2015; Greenberger et al., 2015; Lee et al., 2015). Oral Cholecystography Oral cholecystography is used if ultrasound equipment is not available or if the ultrasound results are inconclusive. This study may be performed to detect gallstones and to assess the ability of the gallbladder to fill, concentrate its contents, contract, and empty. If the patient is not allergic to iodine or seafood, an iodide-containing contrast agent that is excreted by the liver and concentrated in the gallbladder is given 10 to 12 hours before the x-ray study (Feldman et al., 2015; Marx et al., 2013). The normal gallbladder fills with this radiopaque substance. If gallstones are present, they appear as shadows on the x-ray image. Oral cholecystography may be used as part of the evaluation of patients who have been treated with gallstone dissolution therapy (the use of medications to break up/dissolve gallstones) or lithotripsy (disintegration of gallstones by shock waves). Endoscopic Retrograde Cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) permits 3784 direct visualization of structures that previously could be seen only during laparotomy. This procedure examines the hepatobiliary system via a side- viewing flexible fiberoptic endoscope inserted through the esophagus to the descending duodenum (see Fig. 50-3). Multiple position changes are required to pass the endoscope during the procedure, beginning in the left semiprone position. Fluoroscopy and multiple x-rays are used during ERCP to evaluate the presence and location of ductal stones. Careful insertion of a catheter through the endoscope into the common bile duct is the most important step in sphincterotomy (division of the muscles of the biliary sphincter) for gallstone extraction via this technique (see later discussion). ERCP is not recommended for the evaluation of suspected common bile duct stones but can be used to treat confirmed choledocholithiasis before or during laparoscopic cholecystectomy (Lee et al., 2015). Nursing Implications An ERCP requires a cooperative patient to permit insertion of the endoscope without damage to the GI tract structures, including the biliary tree. Before the procedure, the patient is educated about the procedure and their role in it. The patient takes nothing by mouth for several hours before the procedure. Moderate sedation is used, and the sedated patient must be monitored closely. It may be necessary to administer medications, such as glucagon or anticholinergic agents, to make cannulation easier by decreasing duodenal peristalsis. The nurse observes closely for signs of respiratory and CNS depression, hypotension, oversedation, and vomiting (if glucagon is given). During ERCP, the nurse monitors IV fluids, administers medications, and positions the patient. After the procedure, the nurse monitors the patient’s condition, observing vital signs and assessing for signs of perforation or infection. The nurse also monitors the patient for side effects of any medications received during the procedure and for return of the gag and cough reflexes after the use of local anesthetic agents. 3785 Figure 50-3 Endoscopic retrograde cholangiopancreatography. A fiberoptic duodenoscope, with side-viewing apparatus, is inserted into the duodenum. The ampulla of Vater is catheterized, and the biliary tree is injected with contrast agent. The pancreatic ductal system is also assessed, if indicated. This procedure is of special value in visualizing neoplasms of the ampulla area and extracting a biopsy specimen. Percutaneous Transhepatic Cholangiography Percutaneous transhepatic cholangiography (PTC) is rarely used for diagnostic purposes alone due to the multitude of other less invasive and reliable imaging studies. PTC is reserved for those patients in whom an 3786 ERCP may be unsafe due to previous surgery involving the biliary tract (Doherty, 2015; Feldman et al., 2015). The use of PTC has mainly been replaced by ERCP and magnetic resonance cholangiopancreatography (MRCP). PTC involves the injection of dye directly into the biliary tract. Because of the relatively large concentration of dye that is introduced into the biliary system, including the hepatic ducts within the liver, the entire length of the common bile duct, the cystic duct, and the gallbladder is outlined clearly. This procedure can be carried out even in the presence of liver dysfunction and jaundice. It is useful for (1) distinguishing jaundice caused by liver disease (hepatocellular jaundice) from that caused by biliary obstruction, (2) investigating the GI symptoms of a patient whose gallbladder has been removed, (3) locating stones within the bile ducts, and (4) diagnosing cancer involving the biliary system (Miller, Eriksson, Fleisher, et al., 2014). This sterile procedure is performed under moderate sedation on a patient who has been fasting; the patient also receives local anesthesia. Coagulation parameters and platelet count should be normal to minimize the risk of bleeding. Broad-spectrum antibiotics are given during the procedure because of the high prevalence of bacterial colonization from obstructed biliary systems (Feldman et al., 2015; Miller et al., 2014). After infiltration with a local anesthetic agent has occurred, a flexible needle is inserted into the liver from the right side in the midclavicular line immediately beneath the right costal margin. Successful entry of a duct is noted when bile is aspirated or on injection of a contrast agent. Ultrasound can be used to guide puncture of the duct. Bile is aspirated, and samples are sent for bacteriology and cytology (Feldman et al., 2015; Rakel & Rakel, 2015). A water-soluble contrast agent is injected to fill the biliary system. The fluoroscopy table is tilted and the patient is repositioned to allow x-rays to be taken in multiple projections. Delayed x-ray views can identify abnormalities of more distant ducts and determine the length of a stricture or multiple strictures. Before the needle is removed, as much dye and bile as possible are aspirated to forestall subsequent leakage into the needle tract and eventually into the peritoneal cavity, thus minimizing the risk of bile peritonitis. Nursing Implications Although the complication rate after this procedure is low, the nurse must 3787 closely observe the patient for symptoms of bleeding, peritonitis, and sepsis. The nurse assesses the patient for pain and indications of these complications and reports them promptly to the primary provider, takes measures to reassure the patient, and ensures patient comfort. Antibiotic agents are often prescribed to minimize the risk of sepsis and septic shock. Medical Management The major objectives of medical therapy are to reduce the incidence of acute episodes of gallbladder pain and cholecystitis by supportive and dietary management and, if possible, to remove the cause of cholecystitis by pharmacologic therapy, endoscopic procedures, or surgical intervention. Although nonsurgical procedures eliminate risks associated with surgery, these approaches are associated with persistent symptoms or recurrent stone formation. Most of the nonsurgical approaches, including lithotripsy and dissolution of gallstones, provide only temporary solutions to gallstone problems and are infrequently used in the United States. In some instances, other treatment approaches may be indicated; these are described later. Removal of the gallbladder (cholecystectomy) through traditional surgical approaches has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. In relatively rare instances, a standard surgical procedure may be necessary. Nutritional and Supportive Therapy Approximately 80% of the patients with acute gallbladder inflammation achieve remission with rest, IV fluids, nasogastric suction, analgesia, and antibiotic agents. Unless the patient’s condition deteriorates, surgical intervention is delayed just until the acute symptoms subside (usually within a few days). At this time, the patient undergoes a laparoscopic cholecystectomy (Goldman & Schafer, 2015; Michetti, Griffen, Tran, et al., 2015). The diet immediately after an episode is usually low-fat liquids. These can include powdered supplements high in protein and carbohydrate stirred into skim milk. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non–gas-forming vegetables, bread, coffee, or tea may be added as tolerated. The patient should avoid eggs, cream, pork, fried foods, 3788 cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the patient that fatty foods may induce an episode of cholecystitis. Dietary management may be the major mode of therapy in patients who have had only dietary intolerance to fatty foods and vague GI symptoms (Rakel & Rakel, 2015). Pharmacologic Therapy Ursodeoxycholic acid (UDCA [Urso, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol (Comerford, 2015). UDCA has fewer side effects than chenodiol and can be given in smaller doses to achieve the same effect. It acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating bile. Treatment with UDCA can reduce the size of existing stones, dissolve small stones, and prevent new stones from forming. Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient for recurrence of symptoms or the occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time. The effective dose of medication depends on body weight. This method of treatment is generally indicated for patients who refuse surgery or for whom surgery is contraindicated. The success rate of this therapy is low as the recurrence following it is high (Lee et al., 2015). Patients with significant, frequent symptoms, cystic duct occlusion, or pigment stones are not candidates for pharmacologic therapy. Laparoscopic or open cholecystectomy is more appropriate for symptomatic patients with acceptable operative risk (Lee et al., 2015). Nonsurgical Removal of Gallstones Dissolving Gallstones Several methods have been used to dissolve gallstones by infusion of a solvent (mono-octanoin or methyl tertiary butyl ether [MTBE]) into the gallbladder. The solvent can be infused through the following routes: through a tube or catheter inserted percutaneously directly into the gallbladder, through a tube or drain inserted through a T-tube tract to dissolve stones not removed at the time of surgery, endoscopically with ERCP; or via a transnasal biliary catheter (a rarely used procedure due to its lack of success, potential side effects, and rates of recurrence rate of up to 50% (Lee et al., 2015; Townsend et al., 2016). 3789  Laparoscopic cholecystectomy is the standard for management. Dissolution therapies are used for those patients who may not be candidates for the procedure due to safety concerns regarding general anesthesia (Lee et al., 2015; Townsend et al., 2016). Figure 50-4 A–F. Nonsurgical techniques for removing gallstones. Stone Removal by Instrumentation Several nonsurgical methods are used to remove stones that were not removed at the time of cholecystectomy or have become lodged in the common bile duct (see Fig. 50-4A,B). A catheter and instrument with a basket attached are threaded through the T-tube tract or fistula formed at the time of T-tube insertion; the basket is used to retrieve and remove the stones lodged in the common bile duct. A second procedure involves the use of the ERCP endoscope (see Fig. 50-4C). After the endoscope is inserted, a cutting instrument is passed 3790 through the endoscope into the ampulla of Vater of the common bile duct. It may be used to cut the submucosal fibers, or papilla, of the sphincter of Oddi, enlarging the opening, which may allow the lodged stones to pass spontaneously into the duodenum. Another instrument with a small basket or balloon at its tip may be inserted through the endoscope to retrieve the stones (see Fig. 50-4D–F). The patient is observed closely for bleeding, perforation, and the development of pancreatitis (see later discussion) or sepsis. The ERCP procedure is particularly useful in diagnosis and treatment of patients who have symptoms after biliary tract surgery, patients with intact gallbladders, and patients for whom surgery is particularly hazardous. Intracorporeal Lithotripsy Stones in the gallbladder or common bile duct may be fragmented by means of laser pulse technology. A laser pulse is directed under fluoroscopic guidance with the use of devices that can distinguish between stones and tissue. The laser pulse produces rapid expansion and disintegration of plasma on the stone surface, resulting in a mechanical shock wave. Electrohydraulic lithotripsy uses a probe with two electrodes that deliver electric sparks in rapid pulses, creating expansion of the liquid environment surrounding the gallstones. This results in pressure waves that cause stones to fragment. This technique can be used percutaneously with a basket or balloon catheter system or by direct visualization through an endoscope. Repeated procedures may be necessary because of stone size, local anatomy, bleeding, or technical difficulty. A nasobiliary tube can be inserted to allow for biliary decompression and to prevent stone impaction in the common bile duct. This approach allows time for improvement in the patient’s clinical condition until gallstones are cleared endoscopically, percutaneously, or surgically. Extracorporeal Shock Wave Lithotripsy Extracorporeal shock wave therapy (lithotripsy or ESWL) has been used for nonsurgical fragmentation of gallstones. Lithotripsy, which is a noninvasive procedure, uses repeated shock waves directed at the gallstones in the gallbladder or common bile duct to fragment the stones. The waves are transmitted to the body through a fluid-filled bag or by immersing the patient in a water bath. After the stones are gradually broken up, the stone fragments can be spontaneously passed from the 3791 gallbladder or common bile duct, removed by endoscopy, or dissolved with oral bile acid or solvents. Because the procedure requires no incision and no hospitalization, patients are usually treated as outpatients, but usually several sessions are necessary. This procedure has largely been replaced by laparoscopic cholecystectomy. ESWL is used in some centers for a small percentage of suitable patients (those with common bile duct stones who may not be surgical candidates), sometimes in combination with dissolution therapy (Feldman et al., 2015; Lee et al., 2015; Rakel & Rakel, 2015). Surgical Management Surgical treatment of gallbladder disease and gallstones is carried out to relieve persistent symptoms, to remove the cause of biliary colic, and to treat acute cholecystitis. Surgery may be delayed until the patient’s symptoms have subsided, or it may be performed as an emergency procedure, if necessitated by the patient’s condition. Preoperative Measures Chest x-ray, electrocardiogram, and liver function tests may be performed in addition to imaging studies of the gallbladder. Vitamin K may be given if the prothrombin level is low. Nutritional requirements are considered, and, if the nutritional status is suboptimal, it may be necessary to provide IV glucose with protein supplements to aid wound healing and help prevent liver damage. Patient education for gallbladder surgery is similar to that for any upper abdominal laparotomy or laparoscopy. Instructions and explanations are given before surgery about turning and deep breathing. Postoperative pneumonia and atelectasis can be avoided by deep-breathing exercises, frequent turning, and early ambulation. The patient should be informed that drainage tubes and a nasogastric tube and suction might be required during the immediate postoperative period if an open cholecystectomy is performed. Laparoscopic Cholecystectomy Laparoscopic cholecystectomy (see Fig. 50-5) is the standard of therapy for symptomatic gallstones. Approximately 700,000 patients in the United States require surgery each year for removal of the gallbladder, and 80% to 90% of them are candidates for laparoscopic cholecystectomy (Doherty, 2015; Feldman et al., 2015). If the common bile duct is thought to be 3792 obstructed by a gallstone, an ERCP with sphincterotomy may be performed to explore the duct before laparoscopy (Goldman & Schafer, 2015; Lee et al., 2015). Before the procedure, the patient is educated that an open abdominal procedure may be necessary, and general anesthesia is given. Laparoscopic cholecystectomy is performed through a small incision or puncture made through the abdominal wall at the umbilicus. The abdominal cavity is insufflated with carbon dioxide (pneumoperitoneum) to assist in inserting the laparoscope and to aid in visualizing the abdominal structures. The fiberoptic scope is inserted through the small umbilical incision. Several additional punctures or small incisions are made in the abdominal wall to introduce other surgical instruments into the operative field. A camera attached to the laparoscope permits the surgeon to view the intra- abdominal field and biliary system on a television monitor. After the cystic duct is dissected, the common bile duct can be visualized by ultrasound or cholangiography to evaluate the anatomy and identify stones. The cystic artery is dissected free and clipped. The gallbladder is separated from the hepatic bed and removed from the abdominal cavity after bile and small stones are aspirated. Stone forceps also can be used to remove or crush larger stones. With the laparoscopic procedure, the patient does not experience the paralytic ileus that occurs with open abdominal surgery and has less postoperative abdominal pain. The patient is often discharged from the hospital on the same day of surgery or within 1 or 2 days and resumes full activity and employment within 1 week after the procedure. Conversion to a traditional abdominal surgical procedure occurs in 2.2% of cases in the United States and 3.6% to 8.2% of cases internationally. Conversion to an open procedure occurs if there is inflammation in and around the gallbladder, making safe dissection of the porta hepatis difficult (Feldman et al., 2015). (The porta hepatis is the fissure of the liver where the portal vein and the hepatic artery enter and the hepatic ducts exit the liver.) Careful screening of patients and identification of those at low risk for complications limit the frequency of conversion to an open abdominal procedure. However, with increasing use of laparoscopic procedures, the number of such conversions may increase. 3793 Figure 50-5 In laparoscopic cholecystectomy (A), the surgeon makes four small incisions (less than one half inch each) in the abdomen and inserts a laparoscope with a miniature camera through the umbilical incision (B). The camera apparatus displays the gallbladder and adjacent tissues on a screen, allowing the surgeon to visualize the sections of the organ for removal. The most serious complication after laparoscopic cholecystectomy is a bile duct injury, which may be identified and corrected at the time of the procedure. Patients with a postoperative bile leak may not develop symptoms until several days after the procedure, and some have an even more prolonged period before injury to the bile duct becomes apparent (Doherty, 2015; Michetti et al., 2015). A bile leak may result in fluid collections, which can usually be managed by endoscopic stent placement. Bile peritonitis, a rare complication, may result in serious illness or death. Because of the short length of hospital stay with uncomplicated laparoscopic cholecystectomies, it is important to provide patient education about managing postoperative pain and reporting signs and symptoms of intra-abdominal complications, including loss of appetite, vomiting, pain, distention of the abdomen, and temperature elevation. 3794 Although recovery from laparoscopic cholecystectomy is rapid, patients are drowsy afterward. The patient must have assistance at home during the first 24 to 48 hours. If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend a heating pad for 15 to 20 minutes hourly. Cholecystectomy In cholecystectomy, the gallbladder is removed through an abdominal incision (usually right subcostal) after the cystic duct and artery are ligated. The procedure is performed for acute and chronic cholecystitis. In some patients, a drain is placed close to the gallbladder bed and brought out through a puncture wound if there is a bile leak. The drain type is chosen based on the surgeon’s preference. A small leak should close spontaneously in a few days, with the drain preventing accumulation of bile. Usually, only a small amount of serosanguineous fluid drains in the initial 24 hours after surgery; afterward, the drain is removed. The drain is typically maintained if there is excess oozing or bile leakage. Insertion of a T-tube into the common bile duct during the open procedure is now uncommon; it is used only in the setting of a complication (i.e., retained common bile duct stone). Bile duct injury is a serious complication of cholecystectomy, but it occurs less frequently than with the laparoscopic approach, which has largely replaced traditional surgical cholecystectomy. Small-Incision Cholecystectomy Small-incision cholecystectomy is a surgical procedure in which the gallbladder is removed through a small abdominal incision, as the name implies. If needed, the surgical incision is extended to remove larger gallbladder stones. Drains may or may not be used. The short length hospital stay has been identified as a major advantage of this type of procedure (Doherty, 2015; Goldman & Schafer, 2015). The procedure is controversial because it limits exposure to all involved biliary structures. Choledochostomy Choledochostomy is reserved for the patient with acute cholecystitis who may be too ill to undergo a surgical procedure. This procedure involves making an incision in the common duct, usually for removal of stones. After the stones have been evacuated, a tube is usually inserted into the 3795 duct for drainage of bile until edema subsides. This tube is connected to gravity drainage tubing; the patient is monitored closely, and a laparoscopic cholecystectomy is planned for a future date after acute inflammation has resolved. Surgical Cholecystostomy Cholecystostomy is performed when the patient’s condition precludes more extensive surgery or when an acute inflammatory reaction is severe. The gallbladder is surgically opened, stones and the bile or the purulent drainage are removed, and a drainage tube is secured with a purse-string suture. The drainage tube is connected to a drainage system to prevent bile from leaking around the tube or escaping into the peritoneal cavity. After recovery from the acute episode, the patient may return for subsequent laparoscopic cholecystectomy. Despite its lower risk, surgical cholecystostomy has a high mortality rate (reported to be as high as 10% to 30%) because of the underlying infectious disease process (Feldman et al., 2015; Goldman & Schafer, 2015). Percutaneous Cholecystostomy Percutaneous cholecystostomy has been used in the treatment and diagnosis of acute cholecystitis in patients who are poor risks for any surgical procedure or for general anesthesia. This at risk population may include patients with sepsis or severe cardiac, renal, pulmonary, or liver failure (Doherty, 2015; Gurusamy, Rossi & Davidson, 2013; Nikfarjam, Shen, Fink, et al., 2013). Under local anesthesia, a fine needle is inserted through the abdominal wall and liver edge into the gallbladder under the guidance of ultrasound or computed tomography (CT). Bile is aspirated to ensure adequate placement of the needle, and a catheter is inserted into the gallbladder to decompress the biliary tract. Almost immediate relief of pain and resolution of signs and symptoms of sepsis and cholecystitis have been reported with this procedure. Antibiotic agents are given before, during, and after the procedure. Gerontologic Considerations Surgical intervention for disease of the biliary tract is the most common operative procedure performed in the older adult. Cholesterol saturation of bile increases with age because of increased hepatic secretion of cholesterol and decreased bile acid synthesis. Although the incidence of gallstones increases with age, the older 3796 patient may not exhibit the typical symptoms of fever, pain, chills, and jaundice. Symptoms of biliary tract disease in the older adult may be accompanied or preceded by those of septic shock, which include oliguria, hypotension, changes in mental status, tachycardia, and tachypnea. Although surgery in the older adult presents a risk because of pre- existing associated diseases, the mortality rate from serious complications of biliary tract disease itself is also high. The risk of death and complications is increased in the older patient who undergoes emergency surgery for life-threatening disease of the biliary tract. Despite the presence of chronic illness in many older patients, elective cholecystectomy is usually well tolerated and can be carried out with low risk if expert assessment and care are provided before, during, and after the surgical procedure (Doherty, 2015; Rao, Polanco, Qiu, et al., 2013). Because of changes in reimbursement for health care expenses, there are fewer elective surgical procedures performed, including cholecystectomies. As a result, patients requiring the procedure are seen in later stages of disease. At the same time, patients undergoing surgery are increasingly older than 60 years and may have complicated acute cholecystitis (de Mestral, Rotstein, Laupacis, et al., 2014). The higher risk of complications and shorter length of hospital stay make it essential that older patients and their family members receive specific information about signs and symptoms of complications and measures to prevent them. 3797 NURSING PROCESS The Patient Undergoing Surgery for Gallbladder Disease Assessment The patient undergoing surgical treatment of gallbladder disease is often admitted to the hospital or same-day surgery unit on the morning of surgery. Preadmission testing is often completed a week or longer before admission. At that time, the nurse educates the patient about the need to avoid smoking, to enhance pulmonary recovery postoperatively, and to avoid respiratory complications. The need to avoid aspirin, nonsteroidal medications, and other agents (over-the-counter medications and herbal remedies) that can alter coagulation and other biochemical processes is also emphasized. Assessment should focus on the patient’s respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The nurse notes a history of smoking, previous respiratory problems, shallow respirations, a persistent or ineffective cough, and the presence of adventitious breath sounds. Nutritional status is evaluated through a dietary history and a general examination performed at the time of preadmission testing. The nurse also reviews previously obtained laboratory results to obtain information about the patient’s nutritional status. Diagnosis NURSING DIAGNOSES Based on the assessment data, major postoperative nursing diagnoses may include the following: Acute pain and discomfort related to surgical incision Impaired gas exchange related to the high abdominal surgical incision (if traditional surgical cholecystectomy was performed) 3798  Impaired skin integrity related to altered biliary drainage after surgical intervention (if a T-tube was inserted because of retained stones in the common bile duct or another drainage device was employed) Imbalanced nutrition: less than body requirements related to inadequate bile secretion Deficient knowledge about self-care activities related to incision care, dietary modifications (if needed), medications, and reportable signs or symptoms (e.g., fever, bleeding, vomiting) COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Bleeding GI symptoms (may be related to biliary leak or injury to the bowel) Planning and Goals The goals for the patient include relief of pain, adequate ventilation, intact skin and improved biliary drainage, optimal nutritional intake, absence of complications, and understanding of self-care routines. Nursing Interventions After recovery from anesthesia, the patient is placed in the low Fowler position. Fluids may be administered IV, and nasogastric suction (a nasogastric tube was probably inserted immediately before surgery for a nonlaparoscopic procedure) may be instituted to relieve abdominal distention. Water and other fluids are given within hours after laparoscopic procedures. A soft diet is started after bowel sounds return, which is usually the next day if the laparoscopic approach is used. RELIEVING PAIN The location of the subcostal incision in nonlaparoscopic gallbladder surgery often causes the patient to avoid turning and moving, to splint the affected site, and to take shallow breaths to prevent pain. Because full expansion of the lungs and gradually increased activity are necessary to prevent postoperative complications, the nurse administers analgesic agents as prescribed to relieve the pain and to help the patient turn, cough, breathe deeply, and ambulate as indicated. The use of a pillow or binder over the incision may reduce pain during these maneuvers. 3799 IMPROVING RESPIRATORY STATUS Patients undergoing biliary tract surgery are especially prone to pulmonary complications, as are all patients with upper abdominal incisions. Therefore, the nurse reminds the patient to take deep breaths and cough every hour to expand the lungs fully and prevent atelectasis. The early and consistent use of incentive spirometry also helps improve respiratory function. Early ambulation prevents pulmonary complications as well as other complications, such as venous thromboembolism (VTE) formation. Pulmonary complications are more likely to occur in patients who are older, those who are obese, and those with pre-existing pulmonary disease. MAINTAINING SKIN INTEGRITY AND PROMOTING BILIARY DRAINAGE In patients who have undergone a cholecystostomy or choledochostomy, the drainage tube must be connected immediately to a drainage receptacle. The nurse should fasten the tubing to the dressings or to the patient’s gown, with enough leeway for the patient to move without dislodging or kinking the tube. Because a drainage system remains attached when the patient is ambulating, the drainage bag may be placed in a bathrobe pocket or fastened so that it is below the waist or common duct level. If a Penrose drain is used, the nurse changes the dressings as required. After these surgical procedures, the patient is observed for indications of infection, leakage of bile into the peritoneal cavity, and obstruction of bile drainage. If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream. Because jaundice may result, the nurse should assess the color of the sclerae. The nurse should note and report right upper quadrant abdominal pain, nausea and vomiting, bile drainage around any drainage tube, clay-colored stools, and a change in vital signs. Bile may continue to drain from the drainage tract in considerable quantities for some time, necessitating frequent changes of the outer dressings and protection of the skin from irritation (bile is corrosive to the skin). To prevent total loss of bile, the surgeon may want the drainage tube (T-tube) or collection receptacle elevated above the level of the abdomen so that the bile drains externally only if pressure develops in the duct system. Every 24 hours, the nurse measures the bile collected and records 3800 the amount, color, and character of the drainage. After several days of drainage, the T-tube may be clamped for 1 hour before and after each meal to deliver bile to the duodenum to aid in digestion (Townsend et al., 2016). Within 7 days to 3 weeks, the drainage tube is removed (Townsend et al., 2016). The patient who goes home with a drainage tube in place requires instruction and reassurance about the function and care of the T-tube (Townsend et al., 2016). In all patients with biliary drainage, the nurse (or the patient, if at home) observes the color of stools daily. Urine and stool specimens may be sent to the laboratory for examination for bile pigments. In this way, it is possible to determine whether the bile pigment is disappearing from the blood and is draining again into the duodenum. Maintaining a careful record of fluid intake and output is important. IMPROVING NUTRITIONAL STATUS The nurse encourages the patient to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. At the time of hospital discharge, there are usually no special dietary instructions other than to maintain a healthy diet and avoid excessive fats. Fat restriction usually is lifted in 4 to 6 weeks, when the biliary ducts dilate to accommodate the volume of bile once held by the gallbladder and when the ampulla of Vater again functions effectively. After this time, when the patient eats fat, adequate bile will be released into the GI tract to emulsify the fats and allow their digestion. This is in contrast to the condition before surgery, when fats may not have been digested completely or adequately and flatulence may have occurred. One purpose of gallbladder surgery is to allow a normal diet. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Bleeding may occur as a result of inadvertent puncture or injury to a major blood vessel. Postoperatively, the nurse closely monitors vital signs and inspects the surgical incisions and any drains for bleeding. The nurse also assesses the patient for increased tenderness and rigidity of the abdomen. If these signs and symptoms occur, they are reported to the surgeon. The nurse instructs the patient and family to report any change in the color of stools, because this may indicate complications. GI symptoms, although not common, may occur with manipulation of the intestines during surgery. After laparoscopic cholecystectomy, the nurse assesses the patient for 3801 anorexia, vomiting, pain, abdominal distension, and temperature elevation. These may indicate infection or disruption of the GI tract and should be reported to the surgeon promptly. Because the patient is discharged soon after laparoscopic surgery, the patient and family are instructed verbally and in writing about the importance of reporting these symptoms promptly. PROMOTING HOME, COMMUNITY-BASED CARE, AND TRANSITIONAL CARE Educating Patients About Self-Care. The nurse educates the patient about the medications that are prescribed (vitamins, anticholinergic and antispasmodic agents) and their actions. The nurse also informs the patient and family about symptoms that should be reported to the primary provider, including jaundice, dark urine, pale-colored stools, pruritus, and signs of inflammation and infection such as pain or fever. Some patients report one to three bowel movements a day, which is a result of a continual trickle of bile through the choledochoduodenal junction after cholecystectomy. Usually, such frequency diminishes over a period of a few weeks to several months. If a patient is discharged from the hospital with a drainage tube still in place, the patient and family need education about its management. The nurse educates them in proper care of the drainage tube and the importance of reporting promptly any changes in the amount or characteristics of drainage. Assistance in securing the appropriate dressings reduces the patient’s anxiety about going home with the drain or tube still in place. Chart 50-2 provides additional details about self- care after laparoscopic cholecystectomy. Continuing and Transitional Care. With sufficient support at home, most patients recover quickly from a cholecystectomy. However, older or frail patients and those who live alone may require a referral for transitional or home care. The hospital nurse can help ease the unpredictability of the postoperative and postdischarge experience for patients by providing relevant patient education, prompt pain relief, and an attentive approach to the nursing care (Lindseth & Denny, 2014). During home visits, the nurse assesses the patient’s physical status, especially wound healing, and progress toward recovery. Assessing the patient for adequacy of pain relief and pulmonary exercises is also important. If the patient has a drainage system in place, the nurse assesses it for patency and appropriate management by the patient and 3802 family. Assessing for signs of infection and educating the patient about the signs and symptoms of infection are also important nursing interventions. The patient’s understanding of the therapeutic regimen (medications, gradual return to normal activities) is assessed, and previous education is reinforced. The nurse emphasizes the importance of keeping follow-up appointments and reminds the patient and family of the importance of participating in health promotion activities and recommended health screening. Chart 50-2 PATIENT EDUCATION Managing Self-Care After Laparoscopic Cholecystectomy The nurse instructs the patient about pain management, activity and exercise, wound care, nutrition, and follow-up care as described below. Managing Pain You may experience pain or discomfort from the gas used to inflate your abdominal area during surgery. Sitting upright in bed or a chair, walking, or using a heating pad may ease the discomfort. Take analgesic medications as needed and as prescribed. Report to your surgeon if pain is unrelieved even with analgesic use. Resuming Activity Begin light exercise (walking) immediately. Take a shower or bath after 1 or 2 days. Drive a car after 3 or 4 days. Avoid lifting objects exceeding 5 pounds after surgery, usually for 1 week. Resume sexual activity when desired. Caring for the Wound Check puncture site daily for signs of infection. Wash puncture site with mild soap and water. Allow special adhesive strips on the puncture site to fall off. Do not pull them off. Resuming Eating 3803  Resume your normal diet. If you had fat intolerance before surgery, gradually add fat back into your diet in small increments. Managing Follow-Up Care Make an appointment with your surgeon for 7–10 days after discharge. Call your surgeon if you experience any signs or symptoms of infection at or around the puncture site: redness, tenderness, swelling, heat, or drainage. Call your surgeon if you experience a fever of 37.7°C (100°F) or more for 2 consecutive days. Call your surgeon if you develop nausea, vomiting, or abdominal pain. Evaluation Expected patient outcomes may include: 1. Reports decrease in pain a. Splints abdominal incision to decrease pain b. Avoids foods that cause pain c. Uses postoperative analgesia as prescribed 2. Demonstrates appropriate respiratory function a. Achieves full respiratory excursion, with deep inspiration and expiration b. Coughs effectively, using pillow to splint abdominal incision c. Uses postoperative analgesia as prescribed d. Exercises as prescribed (e.g., turns, ambulates) 3. Exhibits normal skin integrity around biliary drainage site (if applicable) a. Is free of fever; abdominal pain; change in vital signs; and presence of bile, foul-smelling drainage, or pus around drainage tube b. Demonstrates correct management of drainage tube (if applicable) c. Identifies signs and symptoms of biliary obstruction to be noted and reported d. Has serum bilirubin level within normal range 4. Obtains relief from dietary intolerance a. Maintains adequate dietary intake and avoids foods that cause GI 3804