Biliary and Pancreatic Conditions in Nursing

Cholecystitis

-Inflammation of the gallbladder, often due to gallstones.

Cholesterol stones

-80% or more cholesterol

-appear yellow with a dark spot in the center

-oval

Pigment stones

-less than 20% cholesterol

-they are either black or brown

-form when bile has a high bilirubin concentration

cholelithiasis

stones

choledocholithiasis

stones in the common bile duct

Acalculous cholecystitis

the inflammation of the gallbladder without associated gallstones

-caused from surgery and trauma

Risk factors for Cholelithiasis

-Age >40

-female

-obesity

-multiple pregnancies

-Family history

-rapid weight loss diets

-oral contraceptives/estrogen therapy

-ileal resection or disease

-older adults due to decrease in gallbladder contractility

-native americans and mexicans

-cystic fibrosis

-low cal and low protein diet

-DM2

Diagnostic studies for Cholelithiasis

-abdominal x-ray

-ultrasound

-ERCP (endoscopic retrograde cholangiopancreatography)

-Percutaneous Transheptic Cholangiography (PTC) high risk patients more costly

-Labs

gold standard test for cholelithiasis

ERCP (endoscopic retrograde cholangiopancreatography)

ERCP PROCEDURE

-npo

-moderate sedation

-anticholinergic agents can make it easier for them to see

-during procedure observe for respiratory and CNS depression

-give IVF and position the patient

-After: observe vitals and check for perforation and other complications

-make sure gag reflex return

ULTRASOUND ACCURACY PERCENTAGE

Ultrasonography can detect calculi in the gallbladder or a dilated common bile duct with 90% accuracy

chole CM

-Epigastric distress

-biliary colic

-infection

-jaundice

-changes in urine and stool color

-vitamin deficiency

epigastric distress

◦Fullness, abdominal distention, vague upper right quadrant pain after eating a fatty meal

Vitamin deficiency in Chole

Deficiencies in vitamins A, D, E, K due to malabsorption.

chole infection signs

◦Fever, palpable abdominal mass

jaundice

◦Blockage of the common bile duct

-In black would be in eyes

Biliary colic

◦Severe right abdominal pain that radiates to the back or right shoulder, nausea and vomiting

◦Severe pain usually associated with nausea and vomiting usually several hours after a heavy meal

chole med management

-Nutritional (low fat diet)

-meds

-Nonsurgical removal

-Dissolving gallstones with infusion of solvent

-By instrumentation

-Intracorporeal or extracorporeal lithotripsy

Surgical

-laparoscopic cholecystectomy

-Open Cholecystectomy

laparoscopic cholecystectomy post surgery

-minimally invasive

-3-4 small incision

-carbon dioxide so they need to ambulate

-no heavy lifting

-narcotics will not best manage pain and can cause parylitc ileus

-gag reflex, clear to full to regular liquid diet

chole patients should avoid these foods

-eggs

-cream

-pork

-fried foods

-cheese

-rich dressings

-gas forming veggies

-alcohol

T tube

-non-surgical

-able to drain the fluids and remove the stone

-older adults

Lithotripsy

lasers that pulsate to get rid of the stone

post op chole nursing care

-Manage acute pain

◦Carbon dioxide (4-6L) ingested during surgery

-Improve, monitor respiratory status

-Maintain skin integrity

-Promotion of biliary drainage/monitor for infection, peritonitis

-Improve nutritional status

-Monitor for complications

◦Bleeding

◦GI symptoms r/t biliary leak

how to take care of laparoscopic cholecystectomy wound site

-4-6 weeks no lifting more than 5 lbs

-no baths and swimming

-dont rub just pat dry

-no scented soaps just let water run down

-monitor for infection

Acute pancreatitis

Inflammation of the pancreas, can be life-threatening.

How does the client need to sit post Chloecystectomy

low fowlers

If they are NPO with a nonlaproscopic (open) procedure they may have a

NGT

What else do you need to do postoperative chole

-ambulation

-progressive diet

-care of biliary drainage system

-coughing/deep breathing exercises

-splinting to reduce pain

chole patient and family teaching

-Medications & Activity (anti-inflammatory)

-Diet: at discharge, maintain a nutritious diet

◦Avoid excess fat

Fat restriction is usually lifted in 4–6 weeks.

-Instruct in wound care, dressing changes, care of T-tube

you cant take tylenol and what at the same time

percoset bc you can overdose

-Instruct chole patient and family

◦Report signs of gastrointestinal complications

◦Changes in color of stool

◦Report anorexia, vomiting, pain, abdominal distension, fever

◦Signs of inflammation and infections, such as pain and fever

open cholcystectomy

-JP drain

-fluid should get lighter

-empty drains

-take pain meds short term

-encourage cough and deep breath

-progress diet

-will be in hospital longer

acute pancreatitis

-Ranges from mild to severe & rapidly fatal

—Two types: 1.interstitial

2.necrotizing- pancreas autodigests

—

At risk for:

-hypovolemic shock

-F & E imbalances

-sepsis

—

Pathophysiology

◦Self-digestion of pancreas by it’s own enzymes (trypsin)

◦Activation of enzymes leads to vasodilation, increased vascular permeability, necrosis, erosion and hemorrhage

risk factors for acute pancreatitis

-Biliary tract disease

-Gallstones-bile backs up into pancreas causing it to digest

-History of long-term alcohol abuse

-Bacterial or viral infection

-Blunt abdominal trauma

-ischemia vascular disease

-Hyperlipidemia

-Medications (BCP, diuretics, corticosteroids)

-more common in elderly but can affect all ages

acute pancreatitis CM

-Severe abdominal pain

-Abdominal guarding

-N/V

-Fever, jaundice, confusion

-Ecchymosis in the flank or umbilical area may occur

-Respiratory distress, hypoxia, tachypnea, renal failure, hypovolemia, shock

if they come in with pancreatitis but develop rigid board like abdomen what do you do

tell HCP

-could have developed into peritonitis

ACUTE pancreatitis diagnostics

-History/Physical

-Serum amylase/lipase elevated for 24 hrs after the onset of symptoms, amylase goes down after 48-72 hrs, lypase stays elevated

-Hypocalcemia

-Hyperglycemia, glycosuria, elevated serum bilirubin

-CT/MRI/US

-CBC:high WBC

After 24 hours what changes in labs

amylase goes down

what stays elevated 48-72 hrs

Serum lipase

hypocalcemia happens in

very severe cases

pancreatitis need the following

-IVF

-NPO

-NGT

-BED REST

-TPN so they can have nutrition without triggering digestion

-monitor I/O

-pain management

Ranson Criteria

Scoring system to assess severity of acute pancreatitis.

-6 or more of these is not good

-these criteria say how likely the patient is to die from pancreatitis

on admission to hospital criteria

Age >55 years

White blood cells (WBCs) >16,000 mm3

Serum glucose >200 mg/dL (>11.1 mmol/L)

AST >250 IU/L

acute pancreatitis care

-Oral fluid with-held

-Parenteral/enteral nutrition

-NGT

-Medications: pain meds IV narcotics

-ICU for fluid and blood loss

no eating or ambulation bc it will cause digestion

main problems for pancreatitis

-acute pain

-ineffective breathing

-imbalanced nutrition

-impaired skin integrity

complications for acute pancreatitis

-Fluid /Electrolyte disturbances (I/O)

-Necrosis of the pancreas (rigid abdomen)(sepsis)

-Shock (tachypnea) (low bp)

-Multiple organ dysfunction syndrome

Chronic pancreatitis

-Long-term inflammation leading to pancreatic tissue destruction.

-cells replaced by fibrous tissue

-after recurring acute pancreatitis

-atrophy of pancreatic ducts

chronic pancreatitis etiology

-smoking

-alcohol abuse

-50x more likely in alcoholic patients

CM of chronic pancreatitis

-Severe upper abdominal pain, back pain

-N/V

-Opioids do not provide relief

-Weight loss- anorexia and fear of feeling bad after food

-Malabsorption

-Stools: frothy, fouls smelling (high fat content: steatorrhea)

diagnostic for chronic pancreatitis

-ERCP- looks at ducts to check for blockage

-MRI

-CT

-US

-Elevated serum amylase

-Abnormal glucose tolerance test: unable to make insulin

Steatorrhea

Fatty stools due to malabsorption in chronic pancreatitis.

chronic pancreatitis collaborative care

-Preventing and managing attacks

-Relieving pain

-Managing exocrine and endocrine pancreatic deficiency

-Pancreatic duct stone retrieval via ERCP

-Adjuvant pain management- ibuprophen

-Dietary management

-Manage diabetes

—Surgery (Roux-en-Y)

◦Anastomosis of pancreatic duct to jejunum

◦Whipple

when patient is on TPN what do we monior

glucose 4-6 hrs

Whipple procedure

used for tumor on the ampulla bypass the pancreas so they make an anastamosis from stomach to the jejunum and connect it to the pancreas and bile duct

risks

-leak

-delayed gastric emptying

-blood clots

-should be NPO

-NG tube for suction

-irrigation

-drainage

-liquid to solid progression

-pain control IV narcotics then oral b4 patients discharge

Pancreatic cancer risk factors

-tobacco use

-diabetes

-chronic pancreatitis

-hereditary

-70% occurs in head of the pancreas

-rare before the age of 45

Clinical manifestations of pancreatic cancer

◦Pain

◦Weight loss

◦Anorexia, N/V

◦Ascites

◦Abdominal pain

◦Jaundice

◦Diabetes

◦Clay-colored stools

diagnostic tests for pancreatic cancer

◦CT

-ERCP

◦Percutaneous, fine-needle biopsy

medical management for cancer

-resection

-chemo in late stages

-whipple

-may need to do chemo first to reduce tumor size to do during whipple

-biologic agents: antibodies specifc to person to attack cancer

-total pancreatectomy: remove pancreas

Total pancreatectomy

Surgical removal of the entire pancreas.

Pain management in pancreatitis

Includes opioids and adjunctive medications for relief.

Nutritional management post-surgery

Focus on low-fat diet and gradual reintroduction of foods.