ANATOMY AND PHYSIOLOGY OF THE GALLBLADDER

The gallbladder is a pear shaped organ located on the liver that stores bile. It is connected to the intestinal system by the cystic duct which in turn empties into the common bile duct. The gallbladder is about 1012 cm long in humans and appears dark green because of its contents (bile), rather than its tissue. When we eat a large of fatty meal, nerve and chemical signals cause our gallbladder to contract thereby adding bile into our digestive system.

The cystic duct is the short duct that joins the gallbladder to the common bile duct. It usually lies next to the cystic artery. It is of variable length. It contains a spiral valve , which does not provide much resistance to the flow of bile. Bile can flow both directions between the gallbladder and the common hepatic duct and the bile duct. In this way, bile is stored in the gallbladder in between meal time and released after a fatty meal. During a cholecystectomy, the cystic duct is clipped two or three times and a cut is made between the clips, freeing the gallbladder to be taken out.

The common hepatic duct is the duct formed by the convergence of the right hepatic duct (which drains bile from the right functional lobe of the liver) and the left hepatic duct (which drains bile from the left functional

lobe of the liver). The common bile duct then joins the cystic duct coming from the gallbladder to form the common bile duct. The hepatic duct transports more volume in people who have had their gallbladder removed. The common hepatic duct has an important relationship with the right hepatic artery and the cystic artery. All of these must be identified during a cholecystectomy avoid cutting or clipping the wrong structure.

The common bile duct that carries bile from the gallbladder and liver into the duodenum (the upper part of the small intestine). The common bile duct is formed by the junction of the cystic duct that comes from the gallbladder and the common hepatic duct that comes from the liver. The pancreatic duct, or duct of Wirsung, is a duct joining the pancreas to the common bile duct to supply pancreatic juices which aid in digestion provided by the exocrine pancreas . The pancreatic duct joins the

common bile duct just prior to the ampulla of Vater, after which both ducts perforate the medial side of the second portion of the duodenum at the major duodenal papilla. The duct of Wirsung is named after its discoverer, German anatomist Johann georg Wirsung. Most people have just one pancreatic duct. However, some have an additional accessory pancreatic duct called the Duct of Santorini. Compression, obstruction or inflammation of the pancreatic duct may lead to acute pancreatitis. The most common cause for obstruction is choledocholithiasis, or gallstones in the common bile duct. The ampulla of Vater (latin: papilla vateri, papilla duodeni major), also known as the hepatopancreatic ampulla, is formed by the union of the pancreatic duct and the common bile duct. The ampulla is specifically located at the major duodenal papilla. Various smooth muscle sphincters regulate the flow of bile and pancreatic juice through the ampulla: the sphincter of the pancreatic duct, the sphincter of the bile duct, and the hepatopancreatic sphincter (sphincter of Oddi). The sphincter of Oddi controls the introduction of bile and pancreatic secretions into the duodenum, as well as preventing the entry of duodenal contents into the Ampulla. The common bile duct and the pancreatic duct together perforate the medial side of the second portion of the duodenum obliquely, some 7 to 10 cm below the pylorus, forming a structure called the major duodenal papilla. The accessory pancreatic duct sometimes pierces it about 2 cm above and slightly in front of these. The Sphincter of Oddi, also called the hepatopancreatic sphincter or Glisson s sphincter, controls secretion from the liver, pancreas, and gallbladder into the duodenum of the small intestine. It is a sphincter muscle located at the surface of the duodenum. It appears slightly distal to the joining of the common bile duct and pancreatic duct as they enter the descending duodenum and forms from the ampulla of Vater. Bile and pancreatic secretions enter the digestive system through this point. The opening on the inside of the descending duodenum after the sphincter of Oddi is called the major duodenal pailla.

The different layers of the gallbladder are as follows: y y y y The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoofr s recesses, which are pouches the lining. Under the epithelium there is a layer of connective tissue (lamina propia). Neneath the connective tissue is a wall of smooth muscle (muscularis externa) duodenum. There is essentially no submucosa separating the connective tissue from serosa and adventitia.

Doctors Orders 8-15-11 1:15pm - admit under GSZ @ surgery west - DAT VS q shift and record: attached lab result and CP/anesthesia clearance to chart For repeat S.K KBS and Creat Determination For Or scheduling Will inform GS2 of this admission 08-16-11 6:00 am for OR scheduling Cont. meds Follow up potassium, RBS and Creatinin results 8-17-11 schedule for open cholecysteclectomy tomorrow 1st tube 8:50 am please inform OR/anesth To secure consent NPO post midnight Start D5LR 1L @ 120cc/0 suce on NPO Give ampicillin sulvactant 1.5g IVTT prior to Or Start ranitidine 50mg IVTT q8 once NPO 8:45 pm anesthesia pre-op Pt seen and examined NPO post midnight IVF D5LR @ 120cc/o Meds: ranitidine 50mg q 8 Metoclopramide 10mg PRn Check ptency of line I&o q shift For general and oral hygiene

refer Laboratory results IPD (hematology) Test RBC Result 5.16 x 10 ^ 6/ul Normal Values 4.20-6.30 x 10/L Clinical Significance -a low count of RBC indicates anemia -an increase number of RBC indicates polycythemia -if low WBC there is a risk for infection -an increase WBC indicates infection -a low hemoglobin can cause fluid overload, anemia, recent hemorrhage -low Hct indicates anemia -high Hct indicate DHN Remarks Normal

WBC

9.17 x 10 ^ 3/ ul

5.0-10.0x10/L

Normal

HgB

158

135-175g/L

Normal

Hct

0.46

0.40-0.52

Normal

The CBC is used as a broad screening test to check any abnormalities, such as anemia, infection and many other disease. Electrolytes Test Potassium Result 3.9mmol/L Normal Range 3.5-5.5 Clinical Significance -high K+ level indicates hyperkalemia -low level of sodium indicates hyponatremia -elevated creatininie level generally indicates renal disease that has seriously damaged 50% or more of the nephrons. Remarks Normal

Sodium

145.00mmol/L

136.00-155.00

Normal

Creatinine

145.50 ummol/L

53.0-115.0

Differential Count

Test Neutrophil 65

Result

Normal Range 55-75

Clinical Significance -increase neutrophil indicates bactyerial infection -decrease may indicate viral infection -lymphocytes are increase by some viral infection, diseases that affected the immune system. -decrease is caused by malnutrition and long term illness. -increase monocytes caused by infection with a virus -this can be increased by allergies and reaction to sum mediacation. -this can be decreased by severe stress. -can be increased by poorly functioning thyroid gland -decreased by severe

Remarks Normal

Lymphocytes

28

20-35

Normal

Monocytes

2-10

Normal

Eosinophil

1-6

Normal

Basophil

0-1

Normal

Nursing assessment a. head to toe assessment I. general survey We received our patient Mr. RF a 55 years old male and a Filipino citizen in East Surgery ward, last August 15, 2011. Seen seated on bed, wearing plain white t-shirt and a brown short. During our interaction he maintained eye contact with comprehensive speech and he can identify the object. He was admitted because of complaint severe pain. II. neurological Head and face is symmetrically in shape and no discharge, hair is fine and evenly distributed. The patient is conscious, coherent and responsive. He can able to move his upper and lower extremities without any assistance. His pupils are reactive to light and can see things clearly.

iii. eye/vision Patient s eyes are equal, pupils are reacted to light. He is farsighted, and can read without eye glasses. His lids are symmetrical no swelling noted. His conjunctiva is pale but no discharges noted. iv. ears/hearing patient s auricles are symmetrically aligned, no discharges noted. He can able to hear normally. V. nose Symmetrically in shape and no discharges noted. Both are patent and septum is in midline. Vi. Mouth/tounge/teeth/speech Patient can talk normally, lips are pale, tounge is in midline, speech is intact, and teeth are complete but have dental caries. Vii. Throat/neck Symmetrically in shape and no discharges, there is no tenderness noted. Respiratory system Respiratory rate is 18bpm in normal rhythms and with normal chest expansion, no complaints of pain. Circulatory.cardiovascular Circulatory function was regular, symmetrical ling expansion and has a pulse rate 72bpm. Gastrointestinal Have a good peristaltic movement, and has a good appetite. He had a normal bowel movement. The pain is usually felt in the RUQ. Genitourinary No difficulty in urinating, yellow in color and can able to urinate without complaints of pain. Musculoskeletal Symmetrically in shape, and no discharges, have normal range of motion, no tenderness. Integumentary He had a good skin turgor, rough texture, and warm to touch. No lesions noted. Obstetrical N/A Activities of daily living

The patient can able to walk, take a bath and moave without any assistance. He can able to eat own his own. Present behavior The patient is alert, cooperative, and able to anwer questions. Family concerns The patient s family is very supportive in his present situation, they pay and buy medicines prescribed.

GENERIC NAME: Ranitidine BRAND NAME: Zantac

CLASSIFICATION Therapeutic: Anti-ulcer agents Pharmacologic: Histamine H2 antagonists

DOSAGE 20 mg IV q8h MECHANISM OF ACTION Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. In addition, ranitidine bismuth citrate has some antibacterial action against H. pylori. INDICATION Treatment and prevention of heartburn, acid indigestion, and sour stomach.

CONTRA INDICATIONS Contraindicated in: Hypersensitivity, Cross-sensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in:

 Renal impair- ment Geriatric patients (more susceptible to adverse CNS reactions) Pregnancy or Lactation

SIDE EFFECTS/ ADVERSE EFFECTS CNS: Confusion, dizziness, drowsiness, hallucinations, headache CV: Arrhythmias GI: Altered taste, black tongue, constipation, dark stools, diarrhea, drug-induced hepatitis, nausea GU: Decreased sperm count, impotence ENDO: Gynecomastia HEMAT: Agranulocytosis, Aplastic Anemia, neutropenia, thrombocytopenia LOCAL: Pain at IM site Hypersensitivity reactions, vasculitis MISC: NURSING IMPLICATIONS/RESPONSIBILITIES Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Nurse should know that it may cause false-positive results for urine protein; test with sulfo salicylic acid. Inform patient that it may cause drowsiness or dizziness. Inform patient that increased fluid and fiber intake may minimize constipation. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly. Inform patient that medication may temporarily cause stools and tongue to appear gray black.

DRUG Generic Name:Metoclopramide INDICATIONS Short-term treatment of active duodenal ulcer Short-term treatment of active, benign gastric ulcer Maintenance therapy for duodenal ulcer at reduce dosage .Short-term treatment for GERD.Pathologichypersecretoryconditions(Zollinger-Ellisonsyndrome)Treatment of erosiveesophagitis Treatment of heartburn, acid indigestion ,sour stomach

DOSE 1 ampq 8 hrs ROUTE IV INDICATIONS Disturbances of GI motilityRelief of symptoms of acute andrecurrentdiabeticgastroparesis Nausea andvomitingMetabolicdiseasesShort-termtherapy for adults withsymptomaticgastroesophageal reflux whofail to respondto conventionaltherapy.Prophylaxis of postoperativenausea andvomiting whennasogastric suction isundesirable. CONTRAINDICATIONS Contraindicated withallergy to metoclopramideGI hemorrhageMechanical obstruction or perforationEpilepsyUse cautiously with previously detected breastcancer, lactation, pregnancy, fluid overload,renal impairment ACTIONStimulatesmotility of upper GItract withoutstimulatinggastric, biliary, or pancreaticsecretions;appears tosensitizetissues toaction of acetylcholine; relaxes pyloricsphincter,which,whencombinedwith effectson motility,acceleratesgastricemptyingandintestinaltransit; littleeffect ongallbladder or colon motility;increases lower cesophageal sphincter pressure; has sedative properties ;inducesrelease of prolactin

SIDEEFFECT CNS:restlessness,drowsiness,fatigue,insomnia,dizziness,anxietyCV:transienthypertensionGI: nauseaand diarrhea NURSING CONSIDERATIONS Assessment:1. History: allergy tometoclopramide, GIhemorrhage,mechanicalobstruction or perforation,depression, epilepsy,lactation, previouslydetected breast cancer 2. Physical:orientation, reflexes,affect, bowel sounds,normal output, EEGInterventions:1. Monitor BPcarefully during IVadministration.2. Monitor diabetic patients, arrange for alterations in insulindose or timing if diabetic control iscompromised byalterations in timingof food absorption. DRUG Generic Name:RanitidineHydrochlorideBrand Name:ZantacClass:Histamine2 antagonists DOSE 50 mgq 8hrs ROUTE IV INDICATIONS Short-term treatment of active duodenal ulcer Short-term treatment of active, benign gastric ulcer Maintenance therapy for duodenal ulcer at reduce dosage .Short-term treatment for GERD.Pathologichypersecretoryconditions(Zollinger-Ellisonsyndrome)Treatment of erosiveesophagitis Treatment of heartburn, acid indigestion ,sour stomach CONTRAINDICATION Contraindicated withallergy to ranitidine,lactationUse cautiously withimpaired renal or hepaticfunction, pregnancy ACTIONS Competitivelyinhibits theaction of histamine atthe H2 receptors of the parietalcells of thestomach,inhibiting basal gastricacid secretionand gastricacid secretionthat isstimulated byfood, insulin,histamine,cholinergicagonists,gastrin and pentagastrin.

SIDEEFFECT CNS:headache,malaise,dizziness,somnolence,insomnia,vertigoCV:tachycardia, bradycardiaDermatologic:rash, alopeciaGI:constipation,diarrhea,nausea andvomiting,abdominal pain, hepatitisGU:impotence or decreasedlibidoHematologic:leucopenia, granulocytopenia,thrombocytopenia , pancytopenia NURSING CONSIDERATIONS Assessment:1. History: allergy toranitidine, impairedrenal or hepaticfunction, lactation, pregnancy.2. Physical: skinlesions, orientation,affect, liver evaluation,abdominalexamination, normaloutput, renalfunction tests, CBCInterventions:1. Administer oraldrug with meals andat bedtime.2. Decrease doses inrenal and liver failure.3. Provideconcurrent antacidtherapy to relieve pain.4. Administer IMdose undiluted, deepinto large musclegroup. 5. Arrange for regular follow-upincluding blood test,to evaluate effects.