Chapter 62

Care of Patients with Problems of the Biliary System and Pancreas

Mrs. Kreisel MSN, RNNU130 Adult HealthSummer 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 ProcedureThree 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?

A. Liver function tests B. Total bilirubinC. Lipase level D. White blood cell count

Question 2

Which patient is more likely to develop gallstones?

A. 55-year-old African-American male with a history of diabetes mellitus

B. 62-year-old American-Indian femaleC. 45-year-old Caucasian female with a

family history of gallstonesD. 60-year-old obese, Mexican-American

female with a history of diabetes mellitus

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?

A. Passage of a nasogastric tube B. Observation for delirium tremens C. Pain reliefD. Relief from vomiting

Question 4

About how any Americans are affected by acute

pancreatitis?

A. 10,000 B. 30,000 C. 50,000 D. 80,000

Question 5

In the care of a patient with acute pancreatitis, which

assessment parameter requires immediate nursing

intervention?

A. Heart rate 105 beats/min B. Blood pressure 110/82 mm HgC. Respiratory rate 28 breaths/minD. Serum glucose 136 mg/dL