Biliary Disorders Chapter PDF

**Chapter 44: Biliary Disorders** **Terms:** - **KNOW Amylase**: pancreatic enzyme, which aids in the digestion of carbohydrates - **KNOW Lipase**: pancreatic enzyme, which aids in the digestion of fats **Cholelithiasis/gallstones, pg. 3815** - Pigment or cholesterol stones -...

**Chapter 44: Biliary Disorders** **Terms:** - **KNOW Amylase**: pancreatic enzyme, which aids in the digestion of carbohydrates - **KNOW Lipase**: pancreatic enzyme, which aids in the digestion of fats **Cholelithiasis/gallstones, pg. 3815** - Pigment or cholesterol stones - Cannot resolve and must be surgically removed - Cholesterol stones: - 75% of stones formed; Women more than me - **Risk of developing gallstones in increased in those who have cirrhosis, hemolysis, and infections of the biliary tract (book)** - **KNOW RF, chart 44-1: CF, DM, weight changes, rapid weight loss, obesity, women, high dose estrogen therapy, women with multiple pregnancies, ileal resection** - **Usually affects women who are older than 40 years, multiparous, and have obesity (book)** - Manifestations - Gallstones may be silent, producing no pain or mild GI s/s - Epigastric distress, fullness, abdominal distention, and vague pain in the RUQ (book) - RUQ pain radiates to back/right shoulder, Biliary colic (pain, N/V after heavy meal) - Jaundice and pruritus, Changes in urine or stool color (steatorrhea, gray colored stool) - Vitamin deficiency, fat soluble (vitamins A, D, E, and K) - Assessment and Diagnostics, table 44-1 - Patient history - Knowledge and education needs - Respiratory status and risk factors for respiratory complications postoperative - Nutritional status - Post Operative Care: - What would you assess as the RN? - Turn, cough, deep breath; encourage them to get up and get out of bed, **maintain a low fat diet "Go lean with cholelithiasis"** - Ex foods: fruits, veggies, lean proteins (chicken or fish) - Potential Post op complications? - Assess for bleeding, VS - Dx: - **KNOW Endoscopic Retrograde Cholangiopancreatography (ERCP)** - **Procedure using fiberoptic technology to visualize the biliary system (gallbladder and biliary ducts)** - **NPO several hrs prior, receive moderate sedation** - **Post: s/sx of perforation and infection** - US, cholangiogram, laparoscopy, cholesterol levels (elevated) - **NOTE: if a pt is receiving dye for any diagnostic, you need to look at BUN levels to ensure proper secretion post test** - Medical Management - ERCP - **Nutritional Therapy: low fat diet** - Medications: ursodeoxycholic acid and chenodeoxycholic acid (given to try and dissolve gallstones) - By instrumentation (followed with T-tube insertion) - **Intracorporeal or extracorporeal lithotripsy (shockwaves that break up the stones)** - **Post op: will have bruises at the spot of shock waves** - Nonsurgical approaches: lithotripsy and dissolution of gallstones - Surgical Management - Pre-op: X Rays, labs, nutrition, education - **MC treatment is Laparoscopic Cholecystectomy, pg 3827** - The standard for medical management of cholelithiasis - General anesthesia - Small puncture at the umbilicus - The abdominal cavity is insufflated with carbon dioxide to assist in insertion of the laparoscopy - **KNOW POST OP: Laparoscopic cholecystectomy pg 3836, chart 44-2** - **Teaching:** - May drive after 3-4 days if not taking narcotic pain relievers - Splint a pillow over abdomen while coughing and breathing deeply - **Sitting upright in bed or a chair,** walking, or using a heating pad may ease the discomfort - If pain occurs in the right shoulder or scapular area, the nurse may recommend a heating pad for 15 to 20 minutes hourly. - Monitor for s/s of infection, wash puncture site with mild soap and water - Call your surgeon if you experience a fever of 37.7°C (100°F) or more for 2 consecutive days. - Do not pull off adhesive strips from surgery, Pain management (analgesics) - No lifting \> 5 lbs for 1 week, **Cholecystitis (only one slide on this)** - RF: Women, Obesity, DM, oral contraceptive/estrogen, rapid weight loss - **Fat, Forty, Fertile, Female** - S/sx: N/V after fatty foods, pain and rigidity of RUQ that may radiate to midsternal area or right shoulder, Murphy\'s Sign, fatty stools, dyspepsia, belching, flatulence, jaundice, clay stools, dark urine, pruritus - Diseases like HIV/AIDs increase risk - If it ruptured: check CBC; can turn into sepsis (low BP, high HR) - Treatment: remove gallbladder via laparoscopy - **KNOW Nursing care:** supportive and dietary management (low fat diet), encourage fluids, and pharmacological therapy - Ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (chenodiol or CDCA) have been used to dissolve small, radiolucent gallstones **Acute Pancreatitis, pg. 3839** - Pancreatic duct becomes obstructed, and enzymes back up, causing auto digestion and inflammation of the pancreas - Self digestion from its own enzymes (trypsin) after obstruction of flow from pancreas (gallstones, infection) - RF: gallstones and alcohol use - Pain is acute in onset and is unrelieved by antacids - **KNOW S/sx:** Severe abdominal pain, abdominal tenderness, back pain, decreased peristalsis, N/V, fever, jaundice, mental confusion, epigastric pain, **rigid or boardlike abdomen**, ecchymosis in the flank area, and agitation - Dx, pg. 3841: - **Two out of the 3 criteria**: - History of upper abdominal pain - Amylase and lipase \> 3 times the high normal - Typical findings on imaging (CT, MRI, US) - Serum amylase and lipase levels are elevated within 24 hours of onset - Labs to obtain: Amylase, lipase, H/H (CBC), WBC, (CBC), UA - **Criteria on Admission to Hospital** - Age \>55 year - White blood cells (WBCs) \>16,000 mm3 - Serum glucose \>200 mg/dL (\>11.1 mmol/L) - Serum lactate dehydrogenase (LDH) \>350 IU/L (\>350 U/L) Aspartate aminotransferase (AST) \>250 IU/L - Medical Management - NPO, NGT: decompress the stomach/remove bile to avoid ulcer - Glycemic control (want it near normal levels), Respiratory (enlarged pancreas can push on diaphragm; can cause atelectasis), Biliary drainage, Bed rest - Pain management: opioids is suggested (Morphine, fentanyl, hydromorphone) - Turn and repostion PRN - Administer H2 antagonist (Cimetidine) - **KNOW Nursing Management** - Monitor: Amylase and Lipase, VS, I's and O's (fluid and electrolyte disturbances) - Improve Breathing by keeping them in semi-fowlers b/c it decrease pressure on diaphragm - Turn, cough and deep breath - Relieve pain and discomfort, improve nutritional status, maintain skin integrity due to bed rest - **Education/discharge teaching:** avoid high-fat foods, heavy meals, and ETOH; utilize the teach-back methods - Potential problems: - Fluid and electrolyte disturbances - Serum amylase and lipase levels are elevated, Necrosis of the pancreas, Shock - Hematemesis: Monitor Vital Signs frequently, Multiple organ dysfunction syndrome, DIC **Chronic Pancreatitis** - Progressive inflammatory disorder with destruction of the pancreas; cells are replaced by fibrous tissue; pressure within the pancreas increases, obstructing the pancreatic and common bile ducts - **RF:** alcoholism, malnutrition, smoking - S/sx: frequent attacks of severe upper abdominal and back pain accompanied by vomiting, weight loss - **KNOW Steatorrhea: frothy, foul-smelling stools with a high fat content; results from impaired digestion of proteins and fats due to a lack of pancreatic juice in the intestine** - **"Chronic can\'t digest fats"** - Patients with chronic pancreatitis usually do not receive relief from opioids - Diagnostics: ERCP, CT scan (will show calcifications or pancreatic ductal changes), MRI, Analyze fecal fat content - Medical Management (surgery is not common but can be performed) - Nonsurgical: 3 step ladder for chronic pain - Surgical: Pancreaticojejunostomy + Whipple resection **Pancreatic Cancer, pg 3863** - 4th leading cause of cancer death in men in the US and 5th in women, Risk greater in smokers and high alcohol intake; Can also be a site of metastasis - Manifestations (may be nonspecific): pain, jaundice, weight loss, ascites, hyperglycemia - Diagnostics: Spiral CT, MRI, ERCP - Medical Management - Radiation, chemo, biliary stent, specificity mattress, pain control, end of life care, and hospice referral - Nursing Management: Pain management, nutrition, end-of-life discussions, skin care, **Pancreaticoduodenectomy (Whipple procedure) "Will require lots of follow-up"** - **Very extensive surgery for pancreatic cancer** - **Complications: Bleeding, Infection, Change in bowel habits** - Use for resectable cancer of the head of the pancreas - Surgical oncologists will remove the cancerous tissue, remove portions of the pancreas, bile duct, small intestine and stomach, and perform immediate reconstruction. - Post operative Care: - ICU post operative - Intense management of hemodynamics, fluid volume, blood replacement - Malabsorption and diabetes are likely post operative