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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
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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
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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
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Generalized jaundice
Cullen’s sign
Turner’s sign
Bowel sounds
Abdominal tenderness, rigidity, guarding
Pancreatic ascites
Significant changes in vital signs
Laboratory Assessment
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•
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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
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•
•
•
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 highcarbohydrate, 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?
A. Liver function tests
B. Total bilirubin
C. 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 female
C. 45-year-old Caucasian female with a
family history of gallstones
D. 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 relief
D. 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 Hg
C. Respiratory rate 28 breaths/min
D. Serum glucose 136 mg/dL