Cs

PATHOPHYSIOLOGY Risk factors: ● Aging ● Obesity ● Dietary Factors

Causes: Estrogen and progesterone stimulation High cholesterol synthesis / secretion High-fat intake

Increased cholesterol into bile

Stasis of Bile

Bile salts precipitation

Storage of bile in gallbladder

Cholelithiasis

Distention of gallbladder with excess bile

Gallstones in common bile duct (obstruction)

If treated

Thickened and edematous gallbladder wall from exposure to concentrated bile

Inflammation of the gallbladder (Cholecystitis)

If untreated

Pharmacological Manifestations of the ff. signs and symptoms: Possible treatment: ● Biliary colic Complications may ● Indigestion ● Antimicrobials ● Jaundice occur such as: ● Vomiting ● Ischemia ● Narcotic ● Fever ● Clay-colored stool Analgesics ● Necrosis ● Fatty food intolerance ● dark urine ● Anticholinergics ● Rupture of ● Nausea ● steatorrhea gallbladder ● Antiemetics ● Pain ff. eating fatty foods ● Gallstone ● Gangrene solubilizer ● Peritonitis Surgical Management: DEATH ● Cholecystectomy ● Litotripsy ● Endoscopic Papillotomy

Good Prognosis RECOVERY

PATIENT’S PROFILE Name: Armando Solis Address: Blk 11, Lot 2 Silcas Village San Francisco Biñan, Laguna Age: 28 Gender: Male Nationality: Filipino Religion: Roman Catholic Birth Date: May 03, 1980 Birth Place: Manila Attending Physician: Dr. Anadol Gonzales Admitting Physician: Dr. Angelito Geronimo Date of Admission: January 20, 2008 Time of Admission: 05:00 pm Chief Complain: abdominal pain Admission Diagnosis: Calculous Cholecystitis

History of Past Illness: Two days prior to admission, the patient started to experience abdominal pain not associated with fever or nausea .Then after a day, the patient still complained with episodes of epigastric pain. And few hours prior to admission, epigastric pain was accompanied by vomiting. This prompted consult in Sta. Rosa Community Hospital where he was advised to be confined after undergoing a series of examinations. Results of the examinations showed that he has Calculous Cholecystitis.

SAINT MICHAEL’S COLLEGE OF LAGUNA Old National Highway, Platero, Biñan Laguna.

School of Nursing and Midwifery

In partial Fulfillment in Review of Related Learning Experience

A Case Study in Calculous Cholecystitis &

Cholecystecto my Submitted by:

Angelique A. Malabo Airish Nyn M. Manzo BSN3B / Group 8 Submitted to:

Sir Reigh Tenorio 02Feb2009 MEDICAL MANAGEMENT A cholecystectomy is the surgical removal of the gallbladder. The two basic types of this procedure are open cholecystectomy and the laparoscopic approach. The laparoscopic cholecystectomy involves the insertion of a long narrow cylindrical tube with a camera on the end, through an approximately 1 cm incision in the abdomen, which allows visualization of the internal organs and projection of this image onto a video monitor. Three smaller incisions allow for insertion of other instruments to perform the surgical procedure. A laser may be used for the incision and cautery (burning unwanted tissue to stop bleeding), in which case the procedure may be called laser laparoscopic cholecystectomy. In a conventional or open cholecystectomy, the gallbladder is removed through a surgical incision high in the right abdomen, just beneath the ribs. A drain may be inserted to prevent accumulation of fluid at the surgical site. Purpose

A cholecystectomy is performed to treat cholelithiasis and cholecystitis. In cholelithiasis, gallstones of varying shapes and sizes form from the solid components of bile. The presence of these stones, often referred to as gallbladder disease, may produce symptoms of excruciating right upper abdominal pain radiating to the right shoulder. The gallbladder may become the site of acute infection and inflammation, resulting in symptoms of upper right abdominal pain, nausea, and vomiting. This condition is referred to as cholecystitis. The surgical removal of the gallbladder can provide relief of these symptoms. Cholecystectomy is used to treat both acute and chronic cholecystitis when there are significant pain symptoms. The typical composition of gallstones is predominately cholesterol, or a compound called calcium bilirubinate.

An example of Cholecystectomy

Laparoscopic Cholecystectomy

In a laparoscopic cholecystectomy, four small incisions are made in the abdomen (A). The abdomen is filled with carbon dioxide, and the surgeon views internal structures with a video monitor (B). The gallbladder is located and cut with laparoscopic scissors (C). It is then removed through an incision (D).

Intraoperative Cholangiogram During surgery to remove the gallbladder (cholecystectomy), you may have a procedure called intraoperative cholangiogram. The doctor places a small tube called a catheter into the cystic duct, which drains bile from the gallbladder into the common bile duct. A dye that blocks X-rays is injected into the common bile duct, and then you will have X-rays taken. You may have intraoperative cholangiogram to: • Look for gallstones that may be in the common bile duct. • Allow the surgeon to see the anatomy of the bile duct system from the liver to the small intestine. Viewing the bile ducts before removal of the gallbladder may help ensure that the surgeon does not accidentally cut or damage the common bile duct. Complications of intraoperative cholangiogram can include: • Infection and bleeding. • Inflammation of the pancreas (pancreatitis). • Damage to the common bile duct.

Common Bile Duct Exploration (CBDE) The CBD is a tube connecting the liver, gallbladder, and pancreas to the small intestine that helps deliver fluid to aid in digestion.

The CBD exploration is a procedure used to see if a stone or some obstruction is blocking the flow of bile from your liver and gallbladder to your intestine. If a stone or obstruction is blocking the CBD, bile can back up into the liver causing jaundice. Jaundice is when the skin and white of the eyes become yellow. The CBD might become infected and require emergency surgery if the stone or blockage is not removed. This procedure can be done during the removal of the gall bladder. An alternative would be an ERCP (Endoscopic retrograde cholangiopancreatogram) or not having treatment. You should discuss these options with your doctor. Preparation for CBD exploration • Eat light the day before • Have nothing to eat or drink after midnight • Take only medicines as instructed the morning of surgery During the procedure •

General anesthesia relaxes your muscles and puts you into a deep sleep, so you will feel no pain.

•

• • • •

The doctor will make a small incision in the abdomen, locate the CBD, and inject a dye into the duct. Your doctor will then take an X-ray, which will show where the stone or obstruction is located. If stones are found, the doctor will make a cut into the duct and remove them. A tube might be inserted into the duct and out the skin to drain bile into a bag. The bag will remain in place anywhere from seven days to many weeks. The doctor might repeat the dye procedure before removing your tube.

Benefits of CBD exploration The surgery should alleviate your discomfort and will decrease the chance of infection and jaundice. Risks As with any surgery there are risks, although minimal: • Complications of general anesthesia • Swelling or scarring of the duct • Bile leak • Bleeding • Infection

Aftercare Postoperative care for the patient who has had an open cholecystectomy, as with those who have had any major surgery, involves monitoring of blood pressure, pulse, respiration, and temperature. Breathing tends to be shallow because of the effect of anesthesia, and the patient's reluctance to breathe deeply due to the pain caused by the proximity of the incision to the muscles used for respiration. The patient is shown how to support the operative site when breathing deeply and coughing and is given pain medication as necessary. Fluid intake and output is measured, and the operative site is observed for color and amount of wound drainage. Fluids are given intravenously for 24–48 hours, until the patient's diet is gradually advanced as bowel activity resumes. The patient is generally encouraged to walk eight hours after surgery and discharged from the hospital within three to five days, with return to work approximately four to six weeks after the procedure. Care received immediately after laparoscopic cholecystectomy is similar to that of any patient undergoing surgery with general anesthesia. A unique postoperative pain may be experienced in the right shoulder related to pressure from carbon dioxide used in the laparoscopic tubes. This pain may be relieved by lying down on the left side with right knee and thigh drawn up to the chest. Walking will also help increase the body's reabsorption of the gas. The patient is usually discharged the day after surgery and allowed to shower on the second postoperative day. The patient is advised to gradually resume normal activities over a three-day period, while avoiding heavy lifting for about 10 days. Risks Potential problems associated with open cholecystectomy include respiratory problems related to location of the incision, wound infection, or abscess formation. Possible complications of laparoscopic cholecystectomy include accidental puncture of the bowel or bladder and

uncontrolled bleeding. Incomplete reabsorption of the carbon dioxide gas could irritate the muscles used in respiration and cause respiratory distress. While most patients with acute cholecystitis respond well to the laparoscopic technique, about 5–20% of these patients require a conversion to the open technique because of complications. Normal Results The prognosis for cholecystitis and cholelithaisis patients who receive cholecystectomy is generally good. Overall, cholecystectomy relieves symptoms in about 95% of cases. Alternatives Acute cholecystitis usually improves following conservative therapy in most patients. This conservative therapy involves the withholding of oral feedings, the use of intravenous feedings, and the administration of antibiotics and analgesics. This is only a short-term alternative in hospitalized patients. Most of these patients should receive cholecystectomy within a few days to prevent recurrent attacks. In the short-term, patients often receive narcotic analgesics such as meperidine to relieve the intense pain associated with this condition. Patients who have evidence of gallbladder perforation or gangrene need to have an immediate cholecystectomy. In patients with cholelithasis who are deemed unfit for surgery, alternative treatments are sometimes effective. These individuals often have symptom improvement after lifestyle changes and medical therapy. Lifestyle changes include dietary avoidance of foods high in polyunsaturated fats and gradual weight loss in obese individuals. Medical therapy includes the administration of oral bile salts. Patients with three or fewer gallstones of cholesterol composition and with a gallstone diameter less than 0.6 in (15 mm) are more likely to receive medical therapy and have positive results. The primary requirements for receiving medical therapy include the presence of a functioning gallbladder and the absence of calcification on computed tomography (CT) scans. Other nonsurgical alternatives include using a solvent to dissolve the stones and using sound waves to breakup small stones. A major drawback to medical therapy is the high recurrence rate of stones in those treated.

INTRODUCTION Several disorders affect the biliary system and interfere with normal drainage of the bile into the duodenum. The disorders include inflammation of the biliary system and carcinoma that obstruct the biliary tree. Gallbladder disease with gallstones is the most common disorder of the biliary system. Although not all occurrences of gallbladder inflammation (cholecystitis) are related to gallstones (cholelithiasis), more than 90% of patients with acute cholecystitis have gallstones. It is an acute inflammation (cholecystitis) of the gallbladder causes pain, tenderness, and rigidity of the upper abdomen that may radiate to the midsternal area or right shoulder and is associated with nausea, vomiting, and the urinal signs of an acute inflammation. In empyema of

the gallbladder develops if the gallbladder becomes filled with purulent fluid (pus). Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis. In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis and edema occur, and the blood vessels in the gallbladder are compressed, compromising its vascular supply. Gangrene of the gallbladder with perforation may result. Bacteria play a minor role in acute cholecystitis; however, secondary infection of bile with Escherichia coli (60%), klebsiella species (22%), or streptococcus (18%) is identified with cultures obtained during surgery in a small percentage of surgical treated patients. Acalculous cholecystitis describes acute inflammation in the absence of obstructions by gallstones. Acalculous cholecystitis occurs after major surgical procedures, severe trauma or burns. Other factors associated with this type of cholecystitis include torsion, cystic duct obstruction, primary bacterial infection of the gallbladder and multiple blood transfusions. It is speculated that acalculous cholecystitis is caused by alterations in fluids and electrolytes and alterations in regional blood flow in the visceral circulation. Bile stasis (lack of gallbladder contraction) and increase viscosity of the bile are also thought to play a role. A typical attack of cholecystitis usually lasts two to three days. The following are the most common symptoms of gallstones. However, each individual may experience symptoms differently. Symptoms may include; pain in the upper right part of the abdomen, pain (often worse with deep breaths and extends to lower part of right shoulder blade) , nausea, vomiting , rigid abdominal muscles on right side , and slight fever . The symptoms of cholecystitis may resemble other conditions or medical problems. Consult a physician for diagnosis.

ANATOMY AND PHYSIOLOGY

The liver, gallbladder, and pancreas share intimate anatomical and physiological codependence and therefore, will be discussed together in this section. The liver lies just below the diaphragm occupying the entire right hypochondrium, epigastrium, and a portion of the left side of the abdomen. Although it lies below the diaphragm it is attached to it moving up and down with ventilations. Under the cover of the 5th to 10th ribs it is easily injured by rib fractures resulting from high impact trauma. The liver is the largest organ and gland in the body weighing approximately 1500-1700 grams. Its surface anatomy consists of four lobes that can be plainly seen at dissection. Only two major lobes, the right and left lobes, which are separated by the falciform ligament, are seen on the anterior surface. The falciform ligament is a remnant of the umbilical vein; it attaches the liver to the anterior abdominal wall and diaphragm. Posteriorly the liver presents the left lobe and the right lobe that is divided into three lobes: the right lobe proper, and two minor lobes, the caudate and quadrate lobes. Frequently seen in women is a normal variation of the right lobe that gives the appearance of an additional lobe that has become known as the Riedel lobe. The liver’s diaphragmatic surface is dome shaped conforming to the shape of the inferior surface of the diaphragm. The gallbladder usually lies in a shallow surface on the posterior aspect of the right lobe. Liver lobes are composed of cells called hepatocytes that are arranged into lobules. Liver cells perform over 100 known functions among which are forming blood cells, detoxifying poisons (alcohol and drugs), and metabolizes foodstuff (carbohydrates, fats, proteins). The liver also stores fat soluble vitamins A, D, E, K, and B12 but no water-soluble vitamins like vitamin C. Special cells called Kuppfler cells are found within the liver’s parenchyma. They engulf spent red blood cells (phagocytosis) and recycle hemoglobin in the form of bilirubin making it available for newly formed red blood cells. All hepatocytes make bile from substrates like bilirubin and cholesterol. The liver also makes many essential blood proteins products like albumin and fibrinogen for clotting blood. Urea excreted in urine comes from protein metabolism in the liver, and the liver can even make glucose when blood sugar becomes low. With so many functions it is easy to see why any process that diminishes the liver’s functions will be felt systemically. This remarkable organ can maintain the body’s physiological needs even when up to 70% of it is removed. It also has remarkable regenerative properties to replace hepatocytes lost due to liver resection, which is something other organs cannot do. Deep fissures on the posterior surface form an “H-shaped” groove further dividing the liver into four lobes. The crossbar of the H is called the porta hepatis; it separates the caudate and quadrate lobes. This area is important to radiologists, surgeons, and to imaging professions because it contains the portal vein, hepatic artery, and hepatic ducts. Though it is only about 5 cm in length it is very compact with anatomical structures that include nerves and lymphatics. The liver performs several important roles in the digestive system. One is the removal of toxins and bacteria that enter the blood during absorption of raw foods (lipids, carbohydrates, and proteins) through the gut mucosa. Purification of nutrients occurs before they are released into the systemic circulation and made available to the body’s cells. The liver is therefore a defense organ of the body’s immune system protecting it against microorganism invasion. The importance here is in the absorption of nutrients to supply the energy needs of the body. This function is dependent on a good blood supply, which the liver has. Moreover, the liver is special in that it receives a double blood supply. The portal vein supplies most of the blood (70%) and the hepatic artery gives the remainder (30%); this duel supply is important to the unique metabolic needs of the liver. The portal vein is formed just posterior to the neck of the pancreas by the union of the superior mesenteric and splenic veins. The portal vein carries nutrients it receives from the gut (via the superior mesenteric vein) to the liver for detoxification.

Hepatocytes require lots of energy and oxygen when detoxifying nutrients received from the portal vein. The hepatic artery brings oxygenated blood that mixes with deoxygenated blood from the portal vein to supply the additional oxygen hepatocytes need for detoxification. This happens within the sinusoids of the liver parenchyma where the hepatocytes are bathed with unidirectional blood flow. The hepatic artery is a distal branch of the hepatic artery proper that branches from the celiac trunk on the anterior surface of the aorta. Hepatocytes are stacked hexagonally to form the architecture of the sinusoids. The apposing membranes of hepatocytes form channels for bile to flow called canaliculi. The functional unit is the lobule where detoxification and bile secretion occurs in a counter current type flow, an arrangement that maximizes cellular contact with blood. These rich vascular beds perfuse the liver allowing hepatocytes to perform metabolic functions like detoxification of nutrients. Once these foods are “cleaned” they leave the liver via hepatic veins. The hepatic veins join the inferior vena cava, which carries blood to the right atrium of the heart. Blood in the sinusoids travel towards the hepatic veins, while bile moves in the opposite direction within the hepatic plates, so blood and bile never mix in the liver lobules. Bidirectional flow allows for what is called enterohepatic circulation. As blood moves along in the sinusoids hepatocytes absorb and secrete a variety of exogenous compounds. Many medications used to treat illnesses are removed from the liver by this mechanism too. The removal of drugs from the blood by the liver is called the first-pass effect, or first-pass metabolism. During first-pass metabolism an ingested drug is absorbed through the bowel mucosa into the blood. The superior mesenteric vein takes the drug to the liver via the portal vein where some, but not all of it is absorbed by hepatocytes and secreted into the bile. This accounts for the low bioavailability of many drugs. Drugs administered by intravenous, intramuscular, or sublinguinal routes can avoid the first-pass effect. What is interesting about the liver is that hepatocytes can recognize sugars, proteins, amino acids, and lipids and do not filter food vital to the body for energy production. Bile is released into the gut through the duodenum returning drugs to the gut to be reabsorbed and a portion released in stool. All hepatocytes synthesize and secrete bile into small ducts called canaliculi, which lie between the hepatic plates. These canaliculi anastomose to form networks throughout the liver parenchyma. Bile canaliculi have no structure of their own; the membranes of adjacent hepatocytes form channels that are the bile canaliculi. These many small microscopic intrahepatic bile canaliculi form a network of ducts that become progressively larger becoming the hepatic ducts that drain the liver. A normal liver will secrete between 700 and 1200 ml of bile into these ducts daily. Bile is collected from both main lobes of the liver into the large right and left hepatic ducts that come together to form the extrahepatic common hepatic duct. The biliary tree is formed by the right and left hepatic ducts, common hepatic duct, cystic duct, common bile duct, the ampula of Vater. The biliary duct system shunts bile to the gallbladder to be concentrated and stored, and ultimately to the duodenum. The gallbladder is a pear-shaped sac that lies in a shallow fossa on the posterior inferior surface of the gallbladder. Only a small portion (the fundus) can be seen from the anterior surface. The gallbladder’s surface anatomy is quite simple consisting of three parts: fundus, body, and neck. The neck of the gallbladder is continuous with the cystic duct that receives and empties bile from the common bile duct. The mucosa of the cystic duct is thrown into rugae that form spiral tracts called the spiral valve of Heister. The valve performs like a sphincter to regulate substances entering and leaving the gallbladder. Some individuals have a prominent pouch just posterior to the neck of the gallbladder called a Hartmann pouch. This is a prime site for gallstones to lodge possibly obstructing the gallbladder. A Hartmann pouch can best be seen with ultrasound when imaging the gallbladder.

The function of the gallbladder is to concentrate and store bile. The liver produces up to 20 times more bile than the capacity of the gallbladder. The cells of the gallbladder absorb water returning it to surrounding capillaries. Water, sodium, chloride and most electrolytes are absorbed from bile concentrating bile salts, cholesterol, lecithin, and bilirubin. Bile in the gallbladder is concentrated by a factor of 12 to 18 fold its liver secretion. The capacity of the gallbladder is between 30 and 60 ml. The mucosa of the gallbladder is formed into rugae that expand as it receives bile. Within its wall is a smooth muscle layer called the muscularis, which contracts when stimulated providing the force to eject bile. Contractions of the gallbladder eject concentrated bile into the biliary tree. This is coordinated with relaxation of the sphincter of Oddi to allow bile to pass into the duodenum without resistance. It is important for radiographers to understand the role of bile salts. There are two main functions of bile salts (bile acids), emulsification of fats and facilitating absorption of lipids and fat-soluble vitamins. Bile is composed of bile salts, bile pigments, cholesterol, bilirubin, inorganic ions (sodium, potassium, chloride, and calcium), and substances that give alkalinity to bile. Bile salts are made from cholesterol that is either supplied in the diet or is synthesized in the liver. Cholesterol is converted in the liver to two bile salts: cholic acid and chenodeoxycholic acid. Bacteria in the gut convert a portion of these primary bile acids to secondary bile acid: deoxycolic and lithocholic acids. Bile salts cannot perform their function of emulsifying fat in the intestine until they are conjugated to either glycine or to taurine (amino acids) to form glycolconjugated bile acids or taurine-conjugated bile acids. Conjugation of bile acids takes place in the liver. Calcium or potassium is added to conjugated bile acids to form a bile salt. Conjugated bile salts when secreted from the liver are able to emulsify lipids. The emulsification action of bile on lipids has been called the detergent function of bile. This is because bile breaks lipids apart causing them to foam when agitated by peristalsis. Emulsified lipids look a lot like soapy foam produced by dishwashing liquid. At the molecular level, we would see small structures called micelles formed in the emulsification process. Micelles are small “bubbles” of lipids that have cholesterol and fat inside and bile acids on the outside. This arrangement gives lipids solubility in water; otherwise lipids are insoluble and float on water. This arrangement also facilitates the transport of lipids to the gut mucosa and causes them to stick to it. This is an effective and efficient method of absorption of fats from the diet. As you can see bile plays an important role in providing nutrients to the body. Here are a few other important reasons bile salts must be available in the gut to aid in digesting lipids. Without bile salts about 40% of lipids are lost in the stool creating a deficit of essential lipids. Essential lipids are those needed by the body for normal bodily functions, but cannot be endogenously synthesized by the body. Linoleate and linolenate are the two essential fatty acids that must be taken in through the diet. Fat-soluble vitamins A, D, E, and K are absorbed with lipids from the gut; excess fat-soluble vitamins are also stored in the liver. Of these, only vitamin K is not stored in sufficient quantity by the liver. In just a few days vitamin K deficiency will develop if insufficient amount is not absorbed from the diet. Vitamin K is a necessary nutrient for the liver to synthesize blood clotting agents. In just a few days without vitamin K, prothrombin, and coagulation factors VII, IX, and X become deficient. Therefore, bile formation and flow are very important for homeostasis of the blood coagulation system. Bile salts are physiologically conserved; approximately 95% of bile salts are reabsorbed in the small intestine terminal ileum. Only a small amount of bile is newly synthesized daily, approximately about 0.2-0.5 grams per day. The circulating bile pool is roughly 2-3 grams, which recycles in enterohepatic circulation at a rate of twice per meal, or 6 times a day. In the liver bile is reabsorbed by hepatocytes almost 100% in the first pass and secreted into the bile canaliculi. It is estimated that bile salts circulate some 18 times in the enterohepatic cycle before being excreted in feces. The small quantity of bile

salts (less than 5 %) that is lost in feces is replaced with newly synthesized bile salts by hepatocytes. Any impairment of enterohepatic bile circulation, such as obstruction of the biliary ducts by cholelith or chronic cirrhosis of the liver is a significant medical problem. Enterohepatic circulation is defined as the recurrent cycle in which bile salts and other substances excreted by the liver pass through the intestinal mucosa and become reabsorbed by the hepatic cells and re-excreted. Any impairment of enterohepatic bile circulation, such as obstruction of the biliary ducts by cholelith or chronic cirrhosis of the liver is a significant medical problem. The pancreas is positioned horizontally along the posterior abdominal wall adjacent to lesser curvature of the stomach. It is a retroperitoneal organ located mainly in the epigastrium. It consists of a head, neck, body, and tail. The head is the expanded part found within the C-loop of the duodenum. Inferiorly the head constricts forming an uncinate process before tapering slightly forming the neck. The head and neck lie anterior to the inferior vena cava. The body is the longest part lying transversely across the posterior abdominal wall. The tail tapers along its course ending in or near the hilum of the spleen. It is a soft spongy organ about 12 cm long and 2.5 cm thick. The pancreas is both an endocrine and exocrine gland. Clusters of cells called the pancreatic islets (a.k.a. islets of Langerhans) carry out endocrine functions. The pancreatic islets produce insulin and glucagons. Both insulin and glucagon are secreted into the blood directly and are distributed systemically by the superior mesenteric vein to the portal vein. Because these hormones are secreted into the blood they are not affected by biliary duct obstruction. These hormones participate in carbohydrate metabolism and help regulate blood glucose level. Special exocrine cells called alpha 2 and beta cells comprise about 2% of the pancreas parenchyma. Alpha 2 cells secrete glucagons, and beta cells of the islets produce insulin. Endocrine cells comprise about 2% of the pancreas and exocrine cells make up about 98% of the pancreas. The biliary system consists of the liver, gallbladder and biliary ducts. The pancreas is not considered part of the biliary system based on its role of secreting inactive digestive juices into the duodenum. Inability to secrete digestive juices into the duodenum due to biliary obstruction can adversely affect the pancreas. What we are concerned with in this module is the exocrine functions of the pancreas, which produces digestive enzymes. Pancreatic juice contains enzymes to digest all three major foods: proteins, carbohydrates, and lipids. The pancreas also secretes sodium bicarbonate at a concentration of nearly 5 times that in serum. Strong digestive juices produced by the pancreas are capable of digesting it so these enzymes are secreted into ducts. Pancreatic enzymes are produced in an inactive form called a zymogen. Once they enter the protected mucosa of the duodenum they become activated and can digest proteins, lipids, and carbohydrates. Pancreatic enzymes are secreted into two main ducts of the pancreas. The main pancreatic duct called Wirsung’s duct runs transversely from the head to the tail of the pancreas. It joins the common duct that partially passes through the head of the pancreas as it transports bile to the duodenum. A minor accessory duct is seen in about 15% of the population; it drains the head of the pancreas into a minor duodenal papilla. Pancreatic enzymes are necessary to help digest food for absorption across the bowel mucosa. Pancreatic enzymes are alkaline so that when they are secreted into the duodenum acidic chyme is neutralized. Neutralization of acids from the stomach protects the rest of the gut from self-digestion. Enzymes from the pancreas include amylase to metabolize sugars, lipase to digests lipids, and trypsin, which digest proteins. These enzymes are inactive until they enter the duodenum where catalytic enterokinase activates them. This protects the pancreas and biliary ducts for self-digestion. Acute pancreatitis can be caused by reflux of active pancreatic enzymes from the duodenum back into the pancreatic duct. Enzymatic necrosis is a type of inflammation that is unique to the pancreas and is seen in acute

pancreatitis. Active pancreatic digestive enzymes’ entering the main pancreatic duct digesting the pancreas causes this condition. The biliary system consists of the organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile. The transportation of bile follows this sequence: 1. When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts. 2. These ducts ultimately drain into the common hepatic duct. 3. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine). 4. However, not all bile runs directly into the duodenum. About 50 percent of the bile produced by the liver is first stored in the gallbladder, a pearshaped organ located directly below the liver. 5. Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats. The organs and ducts by which bile is formed, concentrated, and carried from the liver to the duodenum (the first part of the small intestine). Bile removes waste products from the liver and carries bile salts, necessary for the breakdown and absorption of fat, to the intestine. Bile is secreted by the liver cells and collected by a system of tubes that mirrors the blood supply to the organ. This network of bile-drainage channels carries the bile out of the liver by way of the hepatic ducts, which join together to form a common duct that opens into the duodenum at a controlled orifice called the ampulla of Vater. Bile does not pass directly into the duodenum but is first concentrated and then stored until needed in the gall bladder, a pearshaped reservoir lying in a hollow under the liver, to which it gains access by way of the cystic duct. When food is eaten, the presence of fat in the duodenum causes the secretion of a hormone, which opens the ampulla of Vater and causes the gall bladder to contract, squeezing stored bile via the cystic and common bile ducts into the duodenum. In the duodenum, bile salts emulsify the fat, breaking it down to a kind of milk of microscopic globules. Functions of the biliary system: The biliary system's main function includes the following: • •

to drain waste products from the liver into the duodenum to help in digestion with the controlled release of bile

Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions, including the following: • •

to carry away waste to break down fats during digestion

Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of feces, is what gives feces its dark brown color. The biliary tree conducts bile and pancreatic digestive enzymes to the duodenum. The gross anatomy of the biliary tree begins with the right and left hepatic ducts that drain bile from the two halves of the liver. These become the

common hepatic duct that is joined by the cystic duct from the gallbladder. The union of the common hepatic and cystic ducts form the common bile duct. The common bile duct is about 7.5 cm long. It passes posterior and often through the pancreas to join the main pancreatic duct (duct of Wirsung). The union of the main pancreatic duct and common bile duct form a short ampula called the hepatopancreatic ampula (a.k.a. ampula of Vater). The ampula inserts on the major duodenal papilla, which is guarded by the hepatopancreatic sphincter (a.k.a. sphincter of Oddi). A minor accessory duct called Santorini’s duct, when present may drain a portion of the pancreatic head into the minor duodenal papilla. The accessory duct is not present in most individuals. The physiology of the biliary tract causes bile to be concentrated in the gallbladder in the absence of fat in the diet. Likewise, bile is released when fat and some proteins are present in the diet. The mechanism for bile concentration, storage and release is controlled primarily by the hormone cholecystokinin (CCK); other hormones gastrin and secretin along with vagal stimulation play minor roles. When the sphincter of Oddi is closed, hydrostatic pressure forces bile through the cystic duct into the gallbladder (retrograde filling). When chymecontaining fat reaches the duodenum, cells in the duodenum secrete CCK into the blood. Cholecystokinin is a hormone that when it reaches the gallbladder it causes it to contract. The action of CCK on the duodenal sphincter is to relax allowing muscular contractions of the gallbladder moves bile without resistance. The time from ingestion of lipids to stimulation of the gallbladder to contract is roughly 30 minutes. Complete emptying of the gallbladder takes about 1 hour. The hormones CCK, gastrin and secretin are cholesecretagogues. A secretagogue is a substance that stimulates secretion. Cholesecretagogues stimulate secretion of bile by the gallbladder.

LABORATORY AND DIAGNOSTIC EXAMS

NURSING CARE PLAN Assessment

Nursing Diagnosis

Scientific Explanation

Planning

Interventions

Rationale

Evaluation

S: “lagi na lang akong nakahiga” as verbalized by the patient.

Risk for Impaired Skin Integrity r/t prolonged bed rest 20 postoperative procedure

Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; environmental moisture, especially from incontinence; and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Groups of persons with the highest risk for altered skin integrity are the spinal cord injured, those who are confined to bed or wheelchair for prolonged periods of time, those with edema, and those

Patient’s skin remains intact, as evidenced by no redness over bony prominences and absence of skin breakdown

 establish rapport  place the pt in a comfortable position  take and record vital signs

 to facilitate NPI  to prevent backaches or muscle aches.  to note any significant changes that may be brought about by the disease  Healthy skin varies from individual to individual, but should have good turgor, feel warm and dry to the touch, be free of impairment, and have quick capillary refill (<6 seconds).  Areas where skin is stretched tautly over bony prominences are at higher risk for breakdown because the possibility of ischemia to skin is high as a result of compression of skin capillaries between a hard surface and the bone.

Patient’s skin remained intact, as evidenced by no redness over bony prominences and absence of skin breakdown

O:  Conscious and coherent  c body weakness  restless  c limited ROM  ambulatory c assistance  V/S taken as follows: T: 37.4 P: 86 R: 18 BP: 120/70

 Assess general condition of skin.

 Specifically assess skin over bony prominences

 Assess patient’s ability to move.  Reassess skin often and whenever the patient’s

who have altered sensation that triggers the normal protective weight shifting. Pressure relief and pressure reduction devices for the prevention of skin breakdown include a wide range of surfaces, specialty beds and mattresses, and other devices. Preventive measures are usually not reimbursable, even though costs related to treatment once breakdown occurs are greater.

condition or treatment plan results in an increased number of risk factors.  encourage change of position in a regular basis  provide adequate clothing/covers; protect from drafts  emphasize importance of adequate nutritional/ fluid intake  recommend keeping nails short  recommend elevation of lower extremities when sitting  encourage ambulation as tolerated

 Immobility is the greatest risk factor in skin breakdown.  The incidence and onset of skin breakdown is directly related to the number of risk factors present.  to prevent pressure to certain parts of the body  to prevent vasoconstriction  to maintain general good health and skin turgor  to reduce risk of dermal injury when severe itching is present  to enhance venous return and reduce edema formation  to enhance circulation

Assessment

Nursing Diagnosis

Scientific Explanation

Planning

S: “Hindi ko alam ang gagawin sa sugat ko” as verbalized by the patient.

Knowledge deficient regarding condition and self care r/t information misinterpretation.

Knowledge deficit is a nursing diagnosis that addresses a client problem or potential problem resulting from a lack of knowledge or psychomotor skill. The evolutionary view of analysis acknowledges that contextual and temporal influences affect concepts. Because the contextual attributes of a concept change over time, either by convention or purposeful redefinition, the continued

After 8 hours of nursing interventions the patient will verbalize understanding of therapeutic needs.

O:

 Statement of misinterpretation  Request for information  V/S taken as follows: T: 37.3 P: 80 R: 19 BP: 120/80

Interventions Independent:  Review disease process, surgical procedure or prognosis.  Demonstrate care of incisions or dressing or drains.  Emphasize importance of maintaining low fat diet, eating small frequent meals, gradual reintroduction of foods or fluids containing fats over 4 to 6 month period.  Discuss avoiding or limiting use of alcoholic beverages.  Inform patient that loose stools may occur for several months.  Identify signs and symptoms requiring notification of

Rationale

 Provides knowledge base on which patient can make informed choices.  Promotes Independence in care and reduces risk of complications.  During initial 6 months after surgery, low fat diet limits need for bile and reduces discomfort associated with inadequate digestion of fats.  Minimizes the risk of pancreatic involvement.  Intestines require time to adjust to stimulus of continuous output of bile.  Indicators of obstruction of bile flow or altered

Evaluation After 8hours of nursing interventions, the patient was able verbalize understanding of therapeutic needs.

development of knowledge depends on its reevaluation and refinement.

healthcare provider like dark urine, jaundiced color of eyes or skin, clay colored stools.  Review activity limitations depending on individual situation.

digestion, requiring further evaluation and intervention.  Resumption of usual activities is normally Accomplished within 4-5 weeks.

Assessment S: “Masakit yung tahi ko” as verbalized by the patient. O:  Facial mask of pain.  Guarding behavior.  Narrowed focus.  V/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 110/90

Nursing Diagnosis Acute pain r/t disruption of skin, tissue, and muscle integrity.

Scientific Explanation

Planning

Interventions

Pain has 4 stages; the first one is the transduction, it occurs when a stimulus, such as pressure, thermal energy, or chemical irritation, is converted into a nerve signal. This occurs at the ends of sensory nerve cells whose terminals are sensitive to this type of activation. These cells, known as nociceptors, are distributed throughout the body. Second is the transmission, it is the process of transferring pain information from the peripheral to the central nervous system. Signals are transmitted along the axons of nociceptors. From here, projection neurons carry information to the brainstem, thalamus, and hypothalamus as well as to reflex arcs

After 8 hours of nursing interventions, the patient’s pain will be relieved or controlled

Independent:  Evaluate pain regularly noting characteristics, location, intensity (0-10 scale).  Identify specific activity limitations.  Recommend

planned or progressive exercise.  Schedule

adequate rest periods.  Review importance of nutritious diets and adequate fluid intake.  Reposition as indicated.  Provide

additional comfort measures like back rub.  Encourage use

of relaxation

Rationale  Provides

information about need for or effectiveness of interventions.  Prevents undue strain on operative site.  Promotes return of normal function and enhances feelings of general well being.  Prevents fatigue and conserves energy for healing.  Provides elements necessary for tissue regeneration or healing.  May relieve pain and enhance circulation.  Improves circulation, reduces muscle tension and anxiety associated with pain.

Evaluation After 8 hours of Nursing interventions, patient’s pain was relieved and controlled.

technique like deep breathing exercises.

to mediate an avoidance response. The third stage is the pain modulation wherein there is transmission of pain signals through the dorsal horn. The current view is that signals originating in the brain can both inhibit and facilitate pain signal transmission. And the last stage is the perception; it is the awareness of pain associated with a specific area of the body. It depends on the transmission of pain signals through the thalamus to the cortex and limbic system.

 Relieves

Collaborative:  Administer analgesics or non steroidal antiinflammatory drugs as prescribed.

muscle and emotional tension.  To relieve mild

or moderate pain.

DRUG STUDY Narcotic analgesics GENERIC NAME Meperdine

–

relieves pain of inflammation and infection

BRAND NAME Demerol

ACTION

INDICATION

Narcotic

-

moderate

CONTRA-INDICATION Hypersensitivity.

-

ADVERSE REACTION respiratory and

NURSING CONSIDERATION - Assess level,

analgesic. They attach to specific receptor located in the CNS to produce alteration of both perception and emotional response to pain. It involves decreased permeability of the cell membrane to sodium, which result to diminished transmission of pain impulse.

An

-

to sever pain preoperative medication

-

circulatory depression Respiratory and circulatory arrest. Shock Lightheadednes s Sedation Nausea Vomiting sweating

-

duration and frequency of pain. Assess renal function before initiating therapy. Assess respiration Monitor allergic reactions. Monitor for possible drug induced adverse reaction.

ticholinergics – used to relieved spasm of the gallbladder by inhibiting the action of acetylcholine on the postganglionic parasympathetic muscarinic receptors, local anesthetic action and decreasing GI motility.

GENERIC NAME Dicyclomine

BRAND NAME Bentyl

ACTION

INDICATION

Acts on the muscle in the wall of the gut and also the urinary bladder. It relaxes the muscle and prevents spasms from occurring. It also can slightly reduce the production of stomach acid.

Treatment of functional bowel/irritable bowel syndrome.

-

-

-

CONTRAINDICATION Obstructive uropathy Obstructive disease of the gastrointestinal tract Severe ulcerative colitis Reflux esophagitis Unstable cardiovascular status in acute hemorrhage Glaucoma Myasthenia gravis

-

ADVERSE REACTION dry mouth nausea vomiting constipation bloated feeling abdominal pain taste loss anorexia

NURSING CONSIDERATION - Assess for signs of toxicity to other drugs. - Monitor I and O ratio. - Monitor for possible drug induced adverse reaction

Anti-emetics – used to reduce nausea and vomiting by depressing the chemoreceptor trigger zone or by inhibiting serotonin receptors to block nausea response.

GENERIC NAME Dimenhydrinate

BRAND NAME

ACTION

--

Inhibits vestibular stimulation which may prevent motion sickness.

INDICATION -

treatment for nausea vomiting dizziness or vertigo

CONTRAINDICATION --

ADVERSE REACTION - drowsiness - GI disturbances

NURSING CONSIDERATION - assess for signs of toxicity to other drugs. - monitor v/s; BP - monitor I and O ratio.

Gallstone solubilizer – used for dissolving gallstones that are less than 20mm diameter by suppression of liver synthesis and secretion of cholesterol and inhibition of intestinal absorption of cholesterol. GENERIC NAME Ursodeoxychlolic acid ((urosodiol)

BRAND NAME ursofalk

ACTION

INDICATION

Suppresses the synthesis and secretion of cholesterol by the liver and inhibits intestinal absorption of cholesterol.

Dissolution of cholesterol gallstones

CONTRAINDICATION - Inflammatory bile duct disease. - acute cholecystitis - obstructive hepatobiliary disease

ADVERSE REACTION Rarely, doughy stools.

NURSING CONSIDERATION - obtain patients history: lifestyle, hypersensitivity and medication. - perform Complete blood test; cholesterol level. - perform liver function test. Assess for tenderness in the RUQ. Assess for radiating pain to the right left scapula Perform ultrasound.