CHOLELITHIASIS Choledocholithiasis (gallstone in the common bile

 Calculi (gallstones) usually form in the duct)

gallbladder from solid constituents of bile Pancreatitis (infection or inflammation of the
and vary greatly in size, shape, and pancreas)
composition. CHOLECYSTITIS
TWO MAJOR TYPES OF GALL STONE  An acute complication of cholelithiasis
 Pigment stones – which contain an excess of  Is an acute infection of the gall bladder
unconjugated pigments in the bile and;  Most patients with cholecystitis have
 Cholesterol stones – (the more common gallstones (calculous cholecystitis)
form), which result from bile supersaturated  A gallstone obstructs bile outflow and bile in
with cholesterol due to increased synthesis the gallbladder initiates a chemical reaction,
of cholesterol and decreased synthesis of resulting in edema, compromise of the
bile acids that dissolve cholesterol vascular supply and gangrene(nephrosis)
SYMPTOMS OF CHOLELITHIASIS  Infection causes:
 Many are asymptomatic  Pain and tenderness
 Others can cause cholecystitis  Rigidity of the upper right abdomen and is
(inflammation of the gallbladder) associated with nausea and vomiting and
 Biliary colic (when stone temporarily lodges the usual signs of inflammation
in the bile duct)  Purulent fluid inside the gallbladder
 Cholangitis – bile duct inflammation indicates an empyema of the gallbladder
 Upper right-side abdominal pain CLINICAL MANIFESTATIONS
 Biliary colic – spasmodic upper abdominal  May be silent, producing no pain and only
pain after a fatty meal mild GI symptoms
 Abdominal discomfort  May be acute or chronic with epigastric
MEDICAL MANAGEMENT distress (fullness, abdominal distention, and
 Supportive measures vague upper right quadrant pain); may
 Bed rest follow a meal rich in fried or fatty foods
 Fluids  If the cystic duct is obstructed;
 Intravenous access  The gall bladder become distended,
 Pain relief inflamed, and eventually infected
 Intravenous analgesics  Fever and palpable abdominal mass
 Narcotic analgesics  Biliary colic with excruciating upper right
 Antipasmodics abdominal pain, radiating to back or right
 Paverine shoulder with nausea and vomiting several
 Atropine hours after a heavy meal
 Metodaradine  Restlessness and constant or colicky pain
 Surgery  Jaundice, accompanied by marked itching
 Cholecystectomy with obstruction of the common bile duct,
TREATMENT TYPES FOR SURGERY in a small percentage of patients
Electrocautery – the use of electricity-current flows  Very dark urine , grayish or clay-colored
through a heating element, which burns the tissue stool
by direct transfer of heat  Deficiencies of vitamins A, D E K (fat-soluble
Cryosurgery – a procedure performed with an vitamins)
instrument that freezes and destroys abnormal ASSESSMENT AND DIAGNOSTIC METHODS
tissues  Cholecystogram x-ray procedure used to
Open surgery – surgical remove of the gall bladder help evaluate the gallbladder
(usually for relief of gallstone pain)  Ultrasonography
Laparoscopic Surgery (keyhole surgery) – surgery  Laparoscopic surgery uses a thin tube with
performed through a small opening into the body, camera attached to it (laparoscope) is
rather than fully opening the body with a large inserted into the abdomen through a small
incision incision which allows a surgeon to view the
Keyhole surgery – also known as minimally invasive inside of the body without major trauma to
surgery or laparoscopic surgery – through small patient
incisions, using a device called a laparoscope to  ERCP – Endoscopic retrograde
transmit images of the inside of the body to a cholanglopancreatography
monitor in the operating room  Insertion of flexible tube (endoscope) into
COMPLICATIONS AND SEQUELAE OF the upper digestive systems. Contrast dye
CHOLELITHIASIS with X-rays is used to allow the doctor to
Acute cholecystitis (sudden inflammation of the see stones, abnormal narrowing or
gallbladder) blockages in the ducts
Cholangitis (an infection or inflammation of the  Serum alkaline phosphatese; gamma-
common bile duct) glutamyl (GGT)/gamma-glutamyl
transpeptidase(GGTP)
  High levels of GGT in the blood may be a  It happens when digestive enzymes start
sign of the disease or damage to the bile digesting the pancreas itself
duct  It can be acute or chronic, either form is
MEDICAL MANAGEMENT serious and can lead to complications
Major objectives of medical theraphy: CAUSES:
 To reduce the incidence of acute episodes  80% of patients with acute pancreatitis have
of gallbladder pain and cholecystitis by biliary tract disease or history of long-term
supportive and dietary management and, if alcohol abuse
possible,  Other less common causes:
 To remove the cause by pharmacotherapy;  Bacterial or viral infection,
endoscopic procedures, or surgical  With pancreatitis occasionally developing as
interventions a complication of mumps virus
NUTRITIONAL AND SUPPORTIVE THERAPY CLINICAL MANIFESTATIONS:
 Achieve remission with  Severe abdominal pain is the major
 Rest symptoms
 IV fluids,  Pain in the midepigastrium may be
 Nasogastric suction accompanied by abdominal distention; a
 Analgesia, and antibiotics poorly defines, palpable abdominal mass;
 Diet immediately after an episode is usually decreased peristalsis and vomiting that fails
low-fat liquids with high protein and to relieve the pain or nausea
carbohydrates followed by solid soft foods  Pain is frequently acute in onset (24-48
as tolerated, avoiding eggs, cream, pork, hours after a heave meal or alcohol
fried foods, cheese, rich dressing, gas- ingestion); may be more severe after meals
forming vegetables and alcohol and unrelieved by antacids
PHARMACOLOGIC THERAPY  Patient appears acutely ill
 Ursodeoxycholic acid (UDCA [Urso, Actigall])  Abdominal guarding, rigid or boardlike
and chenodeoxycholic acid (chenodiol or abdomen (generally an ominous sign,
VDCA [Chenix] are effective in dissolving usually indicating peritonitis)
primarily cholesterol stones  Ecchymosis in the flank or around the
 Patients with significant, frequent umbilicus, which may indicate severe
symptoms, cystic duct occlusion; or hemmorrhagic pancreatitis
pigment stones are not candidates for  Nausea and vomiting fever, jaundice mental
therapy with UDCA confusion, agitation
NONSURGICAL REMOVAL OF GALLSTONES  Hypotension related to hypovolemia and
 Lithotripsy, or shock wave dissolution of shock
gallstone – uses highly focused soundwaves ASSESSMENT/DIAGNOSTIC FINDINGS
to break the stones into tiny particles which  Diagnosis is based on (increased urine
then pass through the cystic duct to the amylase level and white blood cell [WBC]
common duct and into the intestine count;
SURGICAL MANAGEMENT  X-rays of abdomen and chest ultrasound,
 Goals of surgery: and contrast-enhanced computed
 To relieve persistent symptoms tomography (CT) scan may be performed
 To remove the cause of biliary colic, and  Hematocrit and hemoglobin levels are used
 To treat acute cholecystitis to monitor the patient for bleeding
CHOLEDOCHOSTOMY MEDICAL MANAGEMENT
 Incision into the common duct for stone  Oral intake is withheld to inhibit pancreatic
removal stimulation and secretion of pancreatic
CHOLECYSTOSTOMY (surgical or percutaneous) enzymes
 Gallbladder is opened, and the stone, bile or  Parenteral nutrition (PN) is administered to
purulent drainage is removed the debilitated patient
 This is minimally invasive procedure  Nasogastric suction is used to relieve
performed under x-ray or ultrasound. A thin nausea and vomiting and to decrease
tube is placed into the gallbladder to drain painful abdominal distention and paralytic
blocked and infected gallbladder fluid ileus
Laparoscopic cholecystectomy – performed  Histamine – 2 (H2) receptor antagonists
through a small incision or puncture made through (cimetidine, ranitidine) or sometimes,
the abdominal wall in the umbilicus proton pump inhibitors are given to
Open cholecystectomy – the surgeon removes the decrease hydrochloric acid secretion
gallbladder through a single incision in the  Adequate pain medication, such as
abdomen under general anesthesia, and the morphine, is administered antiemetic
surgery lasts 1-2 hours agents may be prescribed to prevent
PANCREATITIS vomiting
 Pathologic inflammation of the pancreas  Correction of fluid, blood loss is necessary
  Antibiotics are administered if infection is  Endoscopic retrograde
present cholanglopancreatography (ERCP) is the
 Insulin is necessary if significant most useful study
hyperglycemia occurs  Various imaging procedures, including
 Aggressive respiratory care is provided for magnetic resonance imaging (MRI) , CT
pulmonary problems scans, and ultrasound
 Surgical interventions may recommend  A glucose tolerance test evaluates
surgery to remove the gallbladder, if pancreatic islet cell function
gallstone causes pancreatitis  Steatorrhea is best confirmed by laboratory
NURSING MANAGEMENT analysis of fecal fat content
 Relieving Pain and Discomfort MEDICAL MANAGEMENT
 Administer analgesics as prescribed. Current  Endoscopy to remove pancreatic duct
recommendation for pain management is stones, correct structures and drain cysts
parenteral opioids, including morphine, may be effective in selected patients to
hydromorphone, or fentanyl via patient manage pain and relieve obstruction
controlled analgesia or bolus  Pain and discomfort are relieved with
 Frequently assess pain and the effectiveness analgesics
of the pharmacologic interventions  Yoga may be an effective nonpharmacologic
 Use nasogastric suctioning to remove gastric method for pain reduction and for relief of
secretions and relieve abdominal distention; other coexisting symptoms
 Provides frequent oral hygiene and care to  Avoid alcohol and foods that produce
decrease discomfort from the nasogastric abdominal pain and discomfort
tube and relieve dryness of the mouth  Diabetes mellitus resulting from dysfunction
 Maintain patient on bed rest to decrease of pancreatic islet cells is treated with diet,
metabolic rate and to reduce secretion of insulin, or oral hypoglycemic agents
pancreatic enzymes  Pancreatic enzyme replacement therapy is
 Report increased pain (may be pancreatic instituted for malabsorption and
hemorrhage or inadequate analgesic steatorrhea
dosage)  Surgery is done to relieve abdominal pain
IMPROVING BREATHING PATTERN and discomfort, restore drainage of
 Maintain patient in semi-fowler’s position to pancreatic secretions and reduce frequency
decrease pressure on diaphragm of attacks (pancreaticojejunostomy)
 Change position frequently to prevent
atelectasis and pooling of respiratory
secretions
 Assess respiratory status frequently (pulse
oximetry, arterial blood gas [ABG] values),
and teach patient techniques of coughing
and deep breathing
PANCREATITIS, CHRONIC
 Chronic pancreatitis is an inflammatory
disorder characterized by progressive
anatomic and functional destruction of the
pancreas
 Cells are replaced by fibrous tissue with
repeated attacks of pancreatitis. The end
result is obstruction of the pancreatic and
common bile ducts and duodenum
 There is atrophy of the epithelium of the
ducts, inflammation, and destruction of the
secreting cells of the pancreas
CLINICAL MANIFESTIONS
 Recurring attacks of severe upper
abdominal and back pain, accompanied by
vomiting; opioids may not provide relief
 Altered digestion (malabsorption) of foods
(proteins and fats) resulting in frequent,
frothy, and foul-smelling stools with a high
fat content (steatorrhea)
 As disease progresses, calcification of the
gland my occur and calcium stones may
form within the ducts
ASSESSMENT/DIAGNOSTIC METHODS