Care of Patients with Problems of the Biliary System and Pancreas Chapter 62 Mrs. Kreisel MSN, RN NU130 Adult Health Summer 2011

Hepatobiliary Anatomy

Acute Cholecystitis Acute cholecystitis is the inflammation of the gallbladder. Calculous cholecystitis. Cholelithiasis (gallstones) usually accompanies cholecystitis. Acalculous cholecystitis inflammation can occur in the absence of gallstones.

Gallstones

Chronic Cholecystitis Repeated episodes of cystic duct obstruction result in chronic inflammation Pancreatitis, cholangitis Jaundice Icterus Obstructive jaundice Pruritus

Clinical Manifestations Flatulence, dyspepsia, eructation, anorexia, nausea and vomiting, abdominal pain Biliary colic Murphy’s sign Blumberg’s sign Rebound tenderness Steatorrhea

Nonsurgical Management Nutrition therapy—low-fat diet, fat-soluble vitamins, bile salts Drug therapy—opioid analgesic such as morphine or hydromorphone, anticholinergic drugs, antiemetic Extracorporeal shock wave lithotripsy Percutaneous transhepatic biliary catheter insertion

Surgical Management Laparoscopic cholecystectomy Standard preoperative care Operative procedure Postoperative care: Free air pain result of carbon dioxide retention in the abdomen Ambulation Return to activities in 1 to 3 weeks

Traditional Cholecystectomy Standard preoperative care Operative procedure Postoperative care: Opioids via patient-controlled analgesia pump T-tube Antiemetics Wound care

Traditional Cholecystectomy (Cont’d) Care of the T-tube NPO Nutrition therapy

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

Acute Pancreatitis Serious and possibly life-threatening inflammatory process of the pancreas Necrotizing hemorrhagic pancreatitis Lipolysis Proteolysis Necrosis of blood vessels Inflammation Theories of enzyme activation

Autodigestion

Complications of Acute Pancreatitis Hypovolemia Hemorrhage Acute renal failure Paralytic ileus Hypovolemic or septic shock Pleural effusion, respiratory distress syndrome, pneumonia Multisystem organ failure Disseminated intravascular coagulation Diabetes mellitus

Clinical Manifestations Generalized jaundice Cullen’s sign Turner’s sign Bowel sounds Abdominal tenderness, rigidity, guarding Pancreatic ascites Significant changes in vital signs

Laboratory Assessment Lipase Trypsin Alkaline phosphatase Alanine aminotransferase WBC Glucose Calcium

Acute Pain Interventions include: The priority for patient care to provide supportive care by relieving symptoms, decrease inflammation, and anticipate and treat complications Comfort measures to reduce pain including fasting and drug therapy Endoscopic retrograde cholangiopancreatography

Nonsurgical Management Fasting and rest Drug therapy Comfort measures Endoscopic retrograde cholangiopancreatography (ERCP)

Surgical Management Preoperative care—NG tube may be inserted Operative procedures Postoperative care: Monitor drainage tubes and record output from drain. Provide meticulous skin care and dressing changes. Maintain skin integrity.

Imbalanced Nutrition: Less Than Body Requirements Interventions include: NPO in early stages Antiemetics for nausea and vomiting Total parenteral nutrition Small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals Avoidance of foods that cause GI stimulation

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

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

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

Insulinoma Most common type of neuroendocrine pancreatic tumor Benign tumors of the islets of Langerhans that cause excessive insulin secretion and subsequent hypoglycemia Management—removal of tumor

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

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

Surgical Management (Cont’d) Postoperative care: Observe for complications GI drainage monitoring Positioning Fluid and electrolyte assessment Glucose monitoring

Whipple Procedure Three anastomoses that constitute the Whipple procedure: Choledochojejunostomy, pancreaticojejunostomy, & gastrojejunostomy

NCLEX TIME

Question 1 A patient with chronic cholecystitis is complaining of 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, to include hepatic disease, pancreatitis, and peritonitis. Thus monitoring liver function and pancreatic laboratory values and white blood cell counts is also very important.

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 American-Indian female 45-year-old Caucasian female with a family history of gallstones 60-year-old obese, Mexican-American 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; Mexican-American, American-Indian, and Caucasian descent; rapid change in weight; and advanced age. More risk factors increase the likelihood of developing gallstones.

Question 3 The nurse notes jaundice and bluish discoloration of the abdomen and flank in the patient complaining of abdominal pain of sudden onset that radiates to the left shoulder. Based on these symptoms, what intervention should be the priority for this patient? Passage of a nasogastric tube Observation for delirium tremens Pain relief Relief from vomiting Answer: C Rationale: Symptoms are characteristic of acute pancreatitis. Most often, the patient indicates that he needs relief from abdominal pain.

Question 4 About how any Americans are affected by acute pancreatitis? 10,000 30,000 50,000 80,000 Answer: D Rationale: Acute pancreatitis affects about 80,000 Americans every year. Acute pancreatic attacks are especially common during holidays and vacations when alcohol consumption is usually high. Women are affected most often after cholelithiasis and biliary tract disturbances. Source: www.gastro.org/wmspage.cfm?parm1=855

Question 5 In the care of a patient with acute pancreatitis, which assessment parameter requires immediate nursing intervention? Heart rate 105 beats/min Blood pressure 110/82 mm Hg Respiratory rate 28 breaths/min Serum glucose 136 mg/dL Answer: C Rationale: The patient with pancreatitis may develop pulmonary complications, pleural effusions, pulmonary infiltrates, and acute respiratory distress syndrome. Increases in respiratory effort is an important assessment variable in the care of a patient with pancreatitis. Patients may also be hyperglycemic and hypovolemic. Thus assessing and treating endocrine function of the pancreas and perfusion variables are also important.