Gallbladder Disorders

A. Cholelithiasis and Cholecystitis

 1. Definitions
 a. Cholelithiasis: formation of stones (calculi) within
the gallbladder or biliary duct system
 b. Cholecystitis: inflammation of gall bladder
 c. Cholangitis: inflammation of the biliary ducts
 2. Pathophysiology
 a.Gallstones form due to
 1.Abnormal bile composition
 2.Biliary stasis
 3.Inflammation of gallbladder
 Gallbladder Disorders
 b. Most gallstones are composed primarily of bile
(80%); remainder are composed of a mixture of bile
components
 c. Excess cholesterol in bile is associated with
obesity, high-cholesterol diet and drugs that lower
cholesterol levels
 d. If stones from gallbladder lodge in the cystic duct
 1. There can be reflux of bile into the gallbladder and
liver
 2. Gallbladder has increased pressure leading to
ischemia and inflammation
 3. Severe ischemia can lead to necrosis of the gall
bladder
 4. If the common bile duct is obstructed, pancreatitis
can develop
Common locations of gallstones
Gallbladder Disorders
Risk factors for cholelithiasis
 a. Age
 b. Family history, also Native Americans and
persons of northern European heritage
 c. Obesity, hyperlipidemia
 d. Females, use of oral contraceptives
 e. Conditions which lead to biliary stasis:
pregnancy, fasting, prolonged parenteral
nutrition
 f. Diseases including cirrhosis, ileal disease
or resection, sickle-cell anemia, glucose
intolerance
Gallbladder Disorders
Manifestations of cholelithiasis
 a. Many persons are asymptomatic
 b. Early symptoms are epigastic fullness
after meals or mild distress after eating a
fatty meal
 c. Biliary colic (if stone is blocking cystic or
common bile duct): steady pain in epigastric
or RUQ of abdomen lasting up to 5 hours
with nausea and vomiting
 d. Jaundice may occur if there is
obstruction of common bile duct
Gallbladder Disorders

Manifestations of acute cholecystitis

 a. Episode of biliary colic involving RUQ
pain radiating to back, right scapula, or
shoulder; the pain may be aggravated by
movement, or deep breathing and may
last 12 – 18 hours
 b. Anorexia, nausea, and vomiting
 c. Fever with chills
Gallbladder Disorders
Complications of cholecystitis
 a. Chronic cholecystitis occurs after
repeated attacks of acute cholecystitis; often
asymptomatic
 b. Empyema: collection of infected fluid
within gallbladder
 c. Gangrene of gall bladder with perforation
leading to peritonitis, abscess formation
 d. Pancreatitis, liver damage, intestinal
obstruction
Gallbladder Disorders
Collaborative Care
 a. Treatment depends on the acuity of symptoms and
client’s health status
 b. Clients experiencing symptoms are usually treated
with surgical removal of the stones and gallbladder
Diagnostic Tests
 a. Serum bilirubin: conjugated bilirubin is elevated with
bile duct obstruction
 b. CBC reveals elevation in the WBC as with infection
and inflammation
 c. Serum amylase and lipase are elevated, if obstruction
of the common bile duct has caused pancreatitis
 d. Ultrasound of gallbladder: identifies presence of
gallstones
 e. Other tests may include flat plate of the abdomen, oral
cholecytogram, gall bladder scan
Gallbladder Disorders
Treatment
 a. Treatment of choice is laparoscopic cholecystectomy
 b. If surgery is inappropriate due to client condition
 1. May attempt to dissolve the gallstones with
medications
 2. Medications are costly, long duration
 3. Stones reoccur when treatment is stopped
Laparoscopic cholecystectomy
 a. Minimally invasive procedure with low risk of
complications; required hospital stay< 24 hours.
 b. Learning needs of client and family/caregiver include
pain control, deep breathing, mobilization, incisional care
and nutritional/fluids needs
 c. Client is given phone contact for problems
T-tube placement in the common bile duct
Placement of a T-tube
Biliary lithotripsy
Cholendoscopic removal of gallstones
Gallbladder Disorders
Some clients require a surgical laparotomy (incision inside the
abdomen) to remove gall bladder
 a. client will have nasogastric tube in place post-
operatively and require several days of hospitalization
 b. If exploration of the common bile duct is done with the
cholecystectomy, the client may have a T-tube inserted
which promotes bile passage to the outside as area heals

Clients with cholelithiasis and cholecystitis prior to surgery can

avoid future attacks by limiting fat intake

Nursing Diagnoses
 a. Pain
 b. Imbalanced Nutrition: Less than body requirements
 c. Risk for Infection
Liver Disorders

A. Hepatitis
 1. Definition: inflammation of the liver due
to virus, exposure to alcohol, drugs, toxins;
may be acute or chronic in nature
 2. Pathophysiology: metabolic functions
and bile elimination functions of the liver
are disrupted by the inflammation of the
liver.
Liver Disorders
Viral Hepatitis
 1. Types (causative agents)
a. Hepatitis A virus (HAV) Infectious
hepatitis
 1. Transmission: fecal-oral route, often
contaminated foods, water or direct contact
 2. Contagious through stool up to 2 weeks before
symptoms occur; abrupt onset
 3. Benign, self limited; symptoms last up to 2
months
Liver Disorders
Hepatitis B virus (HBV)
 1. Transmission: infected blood and body
fluids
 2. Liver cells damaged by immune
response; increased risk for primary liver
cancer; causes acute and chronic hepatitis,
fulminant hepatitis and carrier state
 3. High risk to health care workers, injection
drug users, men who have sex with men,
persons with multiple sexual partners,
persons exposed to blood products
(hemodialysis clients)
Liver Disorders

Hepatitis C virus (HCV)

 1. Transmission: infected blood and body
fluids; injection drug use is primary factor
 2. Initial manifestations are mild,
nonspecific
 3. Primary worldwide cause of chronic
hepatitis, cirrhosis, liver cancer
Liver Disorders
Hepatits B-associated delta virus (HDV)
 1. Transmission: infected blood and body
fluids; causes infection in people who are
also infected with hepatitis B
 2. Causes acute or chronic infection

Hepatitis E virus (HEV)

 1. Transmission: fecal-oral route,
contaminated water supplies in developing
nations; rare in U.S.
 2. Affects young adults; fulminant in
pregnant women
Liver Disorders
Disease Pattern Associated with hepatitis (all types)
 A .Incubation Phase (period after exposure to virus): no
symptoms
 B Prodromal Phase (preicteric – before jaundice)
 1. “Flu” symptoms: general malaise, anorexia, fatigue, muscle and
body aches
 2. Nausea, vomiting, diarrhea, constipation, and mild RUQ
abdominal pain
 3. Chills and fever
 c.Icteric (jaundiced) Phase
 1 5 – 10 days after prodromal symptoms
 2. Jaundice of the sclera, skin and mucous membranes occurs
 3. Elevation of serum bilirubin
 4. Pruritis
 5. Stool become light brown or clay colored
 6. Urine is brownish colored
Liver Disorders

Convalescent Phase
 1. In uncomplicated cases, symptoms
improve and spontaneous recovery occurs
within 2 weeks of jaundice
 2. Lasts several weeks; continued
improvement and liver enzymes improve
Liver Disorders
 Chronic Hepatitis
 a. Chronic hepatitis: chronic infection from viruses: HBV, HBC,
HBD
 1.Few symptoms (fatigue, malaise, hepatomegaly)
 2.Primary cause of cirrhosis, liver, cancer, liver transplants
 3.Liver enzymes are elevated

b.Fulminant hepatitis; rapidly progressive disease with liver failure

developing within 2 – 3 week of onset of symptoms; rare, but
usually due to HBV with HBD infections

 c.Toxic hepatitis
 1.Hepatocellular damage results from toxic substances
 2.Includes alcoholic hepatitis, acute toxic reaction or chronic
use
Liver Disorders
Chronic Hepatitis
 a. Chronic hepatitis: chronic infection from viruses: HBV,
HBC, HBD
 1. Few symptoms (fatigue, malaise, hepatomegaly)
 2. Primary cause of cirrhosis, liver, cancer, liver
transplants
 3. Liver enzymes are elevated

 b. Fulminant hepatitis; rapidly progressive disease with

liver failure developing within 2 – 3 week of onset of
symptoms; rare, but usually due to HBV with HBD
infections

 c. Toxic hepatitis
 1. Hepatocellular damage results from toxic substances
 2. Includes alcoholic hepatitis, acute toxic reaction or
chronic use
 Liver Disorders
Collaborative Care: Focus is on determination of cause,
treatment and support, and prevention future liver
damage
Diagnostic Tests
a. Liver function tests
 1. Alanine aminotransferase (ALT): specific to liver
 2. Aspartate aminotransferase (AST): heart and liver
cells
 3. Alkaline phosphatase (ALP): liver and bone cells
 4. Gamma-glutamyltransferase (GGT): present in cell
membranes; rises with hepatitis and obstructive biliary
disease
 5. Lactic dehydrogenase (LDH): present in many body
tissues; isoenzyme, LDH5 is specific to the liver
 6. Serum bilirubin levels: total, conjugated,
unconjugated
Liver Disorders
b. Lab tests for viral antigens and antibodies associated with
types of viral hepatitis
c. Liver biopsy: tissue examined to detect changes and make
diagnosis
 1. Preparation: signed consent; NPO 4 – 6 hours before
 2. Prothrombin time and platelet count results; may need
Vitamin K first to correct
 3. Client voids prior to procedure, supine position
 4. Local anesthetic; client instructed to hold breath during
needle insertion
 5. Direct pressure applied to site after sample obtained;
client placed on right side to maintain site pressure
 6. Vital signs monitored frequently for 2 hours
 7. No coughing, lifting, straining 1 – 2 weeks afterward
Liver Disorders
Medications for prevention of hepatitis
 a. Vaccines available for Hepatitis A and B
 b. Vaccine for Hepatitis B recommended for high-
risk groups
 c. Post exposure prophylaxis recommended for
household and sexual contacts of persons with HAV
or HBV
 d. Hepatitis A prophylaxis: single dose of immune
globulin within 2 weeks of exposure
 e. Hepatitis B prophylaxis: Hepatitis B immune
globulin (HBIG) for short-term immunity; HBV
vaccine may be given at the same time
Liver Disorders
Treatment
 a. Medications
1. Medication for acute hepatitis C:
interferon alpha to prevent chronic hepatitis
2. Chronic Hepatitis B: interferon alpha
intramuscular or subcutaneously or
lamivudine
3. Chronic Hepatitis C: interferon alpha with
ribavirin (Rebetol) oral antiviral drug
Liver Disorders
b. Acute hepatitis treatment
 1. As needed bedrest
 2. Adequate nutrition
 3. Avoid substances toxic to the liver especially
alcohol
c. Complementary therapies: Milk thistle (silymarin)
8. Nursing Care: Teaching about prevention by
stressing
 a. Hygiene
 b. Handwashing, especially for food handlers
 c. Blood and body fluids precautions
 d. Vaccines for persons at high risk
Liver Disorders
Nursing Diagnoses
 a. Risk for Infection
 1.Standard precautions, proper hand washing at all times
 2.Reporting of contagious disease to health department to
control spread of disease
 b. Fatigue
 1.Scheduling planned rest periods
 2.Gradual increase of activity with improvement
 c. Imbalanced Nutrition: Less than body requirements
 1.High caloric diet with adequate carbohydrates
 2.Small frequent meals; nutritional supplements
 d. Body Image Disturbance

Home care must include proper infection control measures;

continuing medical care
 Cirrhosis
Definition
 a. End state of chronic liver disease
 b. Progressive and irreversible
 c. Tenth leading cause of death in U.S.

Pathophysiology
 a. Functional liver tissue gradually destroyed and
replaced with fibrous scar tissue
 b. As hepatocytes are destroyed, metabolic
functions are lost
 c. Blood and bile flow within liver is disrupted
 d. Portal hypertension develops
Pathophysiology Illustrated: Esophageal
varices
Cirrhosis
Alcoholic cirrhosis (Laennec’s cirrhosis)
 a. Alcohol causes metabolic changes in liver
leading to fatty infiltration (stage in which
abstinence from alcohol could allow liver to
heal)
 b. With continued alcohol abuse, inflammatory
cells infiltrate liver causing necrosis, fibrosis
and destruction of liver tissue
 c. Regenerative nodules form, liver shrinks
and is nodular
 d. Malnutrition commonly present
Cirrhosis

Biliary cirrhosis: Bile flow is obstructed and

is retained within liver causing
inflammation, fibrosis and regenerative
nodules to form
Posthepatic cirrhosis: Chronic hepatitis B or
C and unknown cause leads to liver
shrinkage and nodule formation with
extensive liver cell loss and fibrosis
Cirrhosis
Manifestations
 a. Early: liver enlargement and tenderness,
dull ache in RUQ, weight loss, weakness,
anorexia, diarrhea or constipation
 b. Progresses to impaired metabolism
causing bleeding, ascites, gynecomastia in
men, infertility in women, jaundice,
neurological changes, ascites, peripheral
edema, anemia, low WBC and platelets
Cirrhosis
Complications
 a.Portal hypertension: shunting of blood to collateral blood
vessels leading to engorged veins in esophagus, rectum and
abdomen, ascites
 b.Splenomegaly: anemia, leucopenia, thrombocytopenia
 c.Ascites: accumulation of abdominal fluid rich in protein;
hypoalbuminemia, sodium and water retention
 d.Esophageal varices: thin walled dilated veins in esophagus
which may rupture leading to massive hemorrhage
 e.Hepatic encephalopathy: from accumulated neurotoxins in
blood; ammonia produced in gut is not converted to urea and
accumulates in blood; medications may not be metabolized
and add to mental changes including personality changes,
slowed mentation, asterixis (liver flap); progressing to
confusion, disorientation and coma
 f. Hepatorenal syndrome: renal failure with azotemia
Cirrhosis
Collaborative Care: Holistic care to client and family addressing
physiologic, psychosocial, spiritual needs

Diagnostic Tests
 a. Liver function tests (ALT, AST, alkaline phosphatase,
GGT); elevated, but not as high as with acute hepatitis
 b. CBC and platelets: anemia, leucopenia, thrombocytopenia
 c. Prothrombin time: prolonged (impaired coagulation due to
lack of Vitamin K)
 d. Serum electrolytes: deficiencies in sodium, potassium,
phosphate, magnesium
 e. Bilirubin: elevated
 f. Serum albumin: hypoalbuminemia
 g. Serum ammonia: elevated
 h. Serum glucose and cholesterol
Cirrhosis

 i. Abdominal ultrasound: evaluation of

liver size and nodularity, ascites
 j. Upper endoscopy: diagnose and
possibly treat esophageal varices
 k. Liver biopsy: may be done to diagnose
cirrhosis; may be deferred if bleeding
times are elevated
Cirrhosis
 Medications
 a. Medications are used to treat complications and effects of
cirrhosis; all liver toxic drugs (sedatives, hypnotics,
acetaminophen) and alcohol must be avoided
 b. Diuretics: Spironolactone (Aldactone) (works against
increased aldosterone levels), furosemide (Lasix)
 c. Medications to decrease manifestations of hepatic
encephalopathy by reducing number of ammonia forming
bacteria in bowel and to convert ammonia to ammonium which
is excreted in stool; Lactulose, Neomycin
 d. Beta-blocker nadolol (Corgard) with isosorbide
mononitrate (Ismo, Imdur) used to prevent esophageal varices
from rebleeding
 e. Ferrous sulfate and folic acid to treat anemia
 f. Vitamin K to reduce risk of bleeding
 g. Antacids to decrease risk of acute gastritis
 h. Oxazepam (Serax) benzodiazepine antianxiety/sedative
drug not metabolized by liver; used to treat acute agitation
Cirrhosis
Treatment: Dietary and fluid management
 a. Fluid and sodium restrictions based on response
to diuretic therapy, urine output, electrolyte values
 b. Protein: 75 – 100 grams per day; unless client
has hepatic encephalopathy (elevated ammonia
levels),then 60 – 80 gm/day
 c. Diet high in carbohydrates, moderate in fats or
as total parenteral nutrition (TPN)
 d. Vitamin and mineral supplements; deficiencies
often include B vitamins, and A, D, E, magnesium
Cirrhosis
Treatment: Complication management
 a. Ascites and associated respiratory distress;
Paracentesis
 b. For bleeding esophageal varices
 1. Restore hemodynamic stability with fluids, blood
transfusion and fresh frozen plasma (contains clotting
factors)
 2. Control bleeding with vasoconstrictive medications:
somatostatin or octreotide, vasopressin
 3. Upper endoscopy to treat varices with banding
(variceal ligation or endoscopic sclerosis)
 4. Balloon tamponade, if bleeding not controlled or
endoscopy unavailable as short term measure:
Cirrhosis
 multiple-lumen naso-gastric tube such as
Sengstaken-Blakemore tube or Minnesota tube
which have gastric and esophageal balloons to
apply tension to control bleeding
 c. Insertion of transjugular intrahepatic
portosystemic shunt (TIPS), a short-term measure to
control portal hypertension (varices and ascites);
using a stent to channel blood between portal and
hepatic vein and bypassing liver (increases risk for
hepatic encephalopathy)
 d. Surgery: liver transplant; contraindications
include malignancy, active alcohol or drug abuse,
poor surgical risk
Triple-lumen nasogastric tube
(Sengstaken-Blakemore)
Transjugular intrahepatic portosystemic
shunt (TIPS)
Cirrhosis

Nursing Care
 a. Health promotion includes education
about relationship of alcohol and drug
abuse with liver disorders; avoidance of
viral hepatitis
 b. Home care includes teaching family to
participate in disease management,
possible hospice care
Cirrhosis
Nursing Diagnoses
 a. Excess Fluid Volume
 b. Disturbed Thought Processes: Early
identification of encephalopathy and appropriate
interventions, i.e. client safety, avoidance of
hepatoxic medications, low-protein diet, medications
to treat
 c. Ineffective Protection: Risks associated with
impaired coagulation, esophageal varices, acute
gastritis
 d. Impaired Skin Integrity: Bile deposits on skin
cause severe pruritis; topical treatments
 e. Imbalanced Nutrition: Less than body
requirements
Disorder of the Exocrine Pancreas

Pancreatitis
1. Definition
 a. Inflammation of pancreas characterized by
release of pancreatic enzymes into pancreatic tissue
itself leading to hemorrhage and necrosis
 b. Mortality rate is 10%;
 c. Occurs as acute or chronic in form

2. Risk factors
 a. Alcoholism
 b. Gallstones
Disorder of the Exocrine Pancreas
Pathophysiology
 1. Interstitial pancreatitis: milder form leading to
inflammation and edema of pancreatic tissue; often
self-limiting
 2. Necrotizing pancreatitis: inflammation,
hemorrhage, and necrosis of pancreatic tissue
 3. Exact cause is unknown; gallstones can cause bile
reflux activating pancreatic enzymes; alcohol causes
duodenal edema, obstructing pancreatic outflow
 4. Other factors are trauma, surgery, tumors,
infectious agents
 5. With pancreatitis, large volume of fluid shifts from
circulation into retroperitoneal space, peripancreatic
space, abdominal cavity
Disorder of the Exocrine Pancreas

Manifestations
 1. Abrupt onset of continuous severe
epigastric and abdominal pain, radiating to
back and relieved somewhat by sitting up
and leaning forward; initiated by fatty meal
or alcohol intake
 2. Nausea and vomiting
 3. Abdominal distention and rigidity
 4. Decreased bowel sounds
Disorder of the Exocrine Pancreas

 5. Hypotension
 6. Fever, cold and clammy skin
 7. 24 hours later: jaundice;
 8. 3 – to 6 days: retroperitoneal bleeding,
bruising in flanks (Turner sign) or around
umbilicus (Cullen’s sign)
Disorder of the Exocrine Pancreas

Complications: Intravascular volume

depletion leads to
 1 Acute tubular necrosis and renal
failure: 24 hours post
 2. Acute respiratory distress syndrome
(ARDS): 3 – 7 days post
 3. Local complications of pancreatic
necrosis, abscess, pseudocysts,
pancreatic ascites
Disorder of the Exocrine Pancreas

Collaborative Care
 a. Acute pancreatitis is usually a mild, self-
limiting disease with care focused on
eliminating causative factors, reducing
pancreatic secretions, supportive care
 b. Severe necrotizing pancreatitis requires
intensive care management
 c. Chronic pancreatitis focuses on pain
management and treatment of malabsorption
and malnutrition
Disorder of the Exocrine Pancreas
Diagnostic Tests
a. Laboratory tests
 1. Serum amylase: 2 -3 times normal in 2 – 12 hours
with acute; returns to normal in 3 – 4 days
 2. Serum lipase: rises and remains elevated 7 – 14 days
 3. Serum trypsinogen: elevated with acute; decreased
with chronic
 4. Urine amylase: rises with acute
 5. Serum glucose: transient elevation with acute
 6. Serum bilirubin and alkaline phosphatase: may be
increased with compression of common bile duct with
acute
 7. Serum calcium: hypocalcemia with acute
 8. CBC: elevated white blood cells count
 9. BUN, Creatinine: monitor renal function
Disorder of the Exocrine Pancreas

 b. Ultrasounds to diagnose gallstones, pancreatic

mass, pseudocyst
 c. CT scan to identify pancreatic enlargement, fluid
collections, areas of necrosis
 d. Endoscopic retrograde
cholangiopancreatography (ERCP) diagnose chronic
pancreatitis (acute pancreatitis can occur after this
procedure)
 e. Endoscopic ultrasound
 f. Percutaneous fine-needle aspiration biopsy to
differentiate between chronic pancreatitis and
malignancy
Disorder of the Exocrine Pancreas

Treatment
 a. Acute pancreatitis is supportive and includes
hydration, pain control, and antibiotics
 b. Chronic pancreatitis includes pain management
without causing drug dependence
 c. Medications may include
 1. Pancreatic enzyme supplements to reduce
steatorrhea
 2 .H2 blockers or proton pump inhibitors to
decrease gastric secretions
 3 .Octreotide (sandostatin) to suppress pancreatic
secretion
Disorder of the Exocrine Pancreas
Fluid and dietary management
 1. Initially client is NPO usually with nasogastric
suction, intravenous fluids and possibly total
parenteral nutrition
 2. Oral food and fluids begun as condition resolves
 3. Low fat diet and no alcohol
Surgeries include
 1. Blocked gallstones may be removed
endoscopically
 2. Cholecystectomy for cholelithiasis
 3. Drainage procedures or resection of pancreas
may be needed
Disorder of the Exocrine Pancreas

Nursing Diagnoses
 a. Pain
 b. Impaired Nutrition: Less than body
requirements
 c. Risk for Deficient Fluid Volume

Home Care: Client and family teaching to

include prevention of future attacks including
abstinence from alcohol and smoking; low
fat diet; monitoring for signs of infection (as
with abscess formation)
Disorder of the Exocrine Pancreas
Pancreatic Cancer
 1. Definition
 a. Accounts for 2% of cancers; most are
adenocarcinoma; most common site is head of the
pancreas
 b. Very lethal death within 1 – 3 years after diagnosis
 c. Incidence increases after age 50; slightly higher in
females; and slightly higher African Americans

Risk Factors
 a. Smoking
 b. Other factors include chemical or environmental
toxins, high fat diet, chronic pancreatitis, diabetes
mellitus
Disorder of the Exocrine Pancreas

Manifestations
 a. Usually nonspecific; up to 85% persons
seek health care with advanced case
 b. Slow onset: anorexia, nausea, weight
loss, flatulence, dull epigastic pain
 c. Cancer in head of pancreas causes bile
obstruction resulting in jaundice, clay
colored stools, dark urine, pruritus
 d. Late: palpable mass and ascites
Disorder of the Exocrine Pancreas

Treatment
 a. Surgery is indicated in early cancers
 b. Pancreatoduodenectomy (Whipple’s
procedure)
 c. Radiation and chemotherapy