Approach To A Patient With Gallbladder Disease[1]

Approach to a Patient with Gallbladder Disease

Anatomy of Gallbladder

Anatomy of the Gallbladder  Pear-shaped hollow sac-like organ;  lies in a shallow depression on the inferior surface of the liver  Normal capacity is 30-50ml

Bile Flow

In the fasting state, the Sphincter of Oddi offers a high pressure zone: - to prevent reflux of duodenal contents into the bile ducts - to promote bile filling of the gallbladder

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Cholecystokinin - is released in the duodenal mucosa in response to the ingestion of fats and amino acids.  

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Contraction of gallbladder Decreased resistance of the Sphincter of Oddi Increased hepatic secretion of bile Enhanced flow of biliary contents into the duodenum

Enterohepatic Circulation

Diseases of the Gallbladder

Acute Cholecystitis 

Types: calculous (90%) stone obstructs bile outflow acalculous absence of obstruction by stones

Cholelithiasis (Gallstones) Formation of stones in the cystic duct  Types of Stones: - cholesterol - pigment - stones 

Risk Factors:  

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Obesity Women,especially those who had multiple pregnancies Frequent changes in weight Rapid weight loss Treatment with high dose estrogen Ileal resection/ disease Diabetes Mellitus

Pathophysiology

Clinical Manifestations    

Pain and Biliary Colic Jaundice Changes in urine and stool color Vitamin Deficiency

Diagnostic Procedures

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Plain Abdominal X-ray - to rule out other possible diseases US – detects gallstones with 95% accuracy Cholescintigraphy – biliary tract is scanned after administration of a radioactive agent Cholecystography – to visualize biliary tract; x-ray is obtained after an oral contrast is administered

Surgical Management  

Laparoscopic Cholecystectomy Open Cholecystectomy

Nutritional and Supportive Therapy 

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80% of patients with acute cholecystitis achieve remission with rest, IV fluids, analgesia and antibiotics Low-fat liquid diet; should avoid hihg fat diet

Pharmacologic Management 

Dissolving agents Ursodeoxycholic acid  Chenodeoxycholic acid *** desaturates bile by inhibiting the synthesis and secretion of cholesterol *** taken for 6-12months 

Nonsurgical Management 

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Dissolving gallstones – infusion of a solvent in the gallstone (MTBE) Stone removal by instrumentation Extracorporeal Shock-wave Lithotripsy Intracorporeal Lithotripsy

Nursing Management 

Assessment    

History taking Preadmission testing Client teaching on procedures Patient’s capability to undergo procedure

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Diagnosis  

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Acute pain and discomfort Impaired gas exchange r/t high abdominal surgical incision Impaired skin integrity r/t altered biliary drainage (T-tube) Imbalance nutrition Deficient knowledge about self-care activities r/t incision care, dietary modifications, medications and followup

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Planning and Goals   

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Relief of pain Adequate ventilation Intact skin and improved biliary secretion Optimal nutrition intake Absence of complications Understanding of self-care routines

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Nursing Interventions 

Monitoring and Managing Complications 

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Improving Nutritional Status 

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T-tube care

Improving Respiratory Status 

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Low fat high carbohydrate and protein

Promoting Skin Care and Biliary Drainage 

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Bleeding, infection, leakage

Turning, early ambulation, deep breathing exercises

Relieving Pain Administer analgesics as ordered  Pillow or binder on the side of incision site 

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Evaluation  

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Reports decrease in pain Demonstrates appropriate respiratory function Exhibits normal skin integrity Obtains relief of dietary intolerance Absence of complications