Chapter 40

Assessment and Management of

Patients With Biliary Disorders

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Review of Anatomy and Physiology

• Gallbladder
• Pancreas
– Insulin
– Glucagon
– Somatostatin

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Question

Which of the following has the opposite effect of insulin?

a. Lipase
b. Glucagon
c. Somatostatin
d. Amylase

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Answer

b. Glucagon
Rationale: The effect of glucagon (opposite to that of
insulin) is chiefly to raise the blood glucose by
converting glycogen to glucose in the liver.

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Liver, Biliary System, and Pancreas

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Cholelithiasis

• Pathophysiology
– Pigment stones
– Cholesterol stones
• Risk factors
See Chart 40-2

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Medical Management of Cholelithiasis

• Cholecystectomy
• Laparoscopic cholecystectomy
• Dietary management
• Medications: ursodeoxycholic acid and chenodeoxycholic
acid
• Nonsurgical removel
– By instrumentation
– Intracorporeal or extracorporeal lithotripsy

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Nonsurgical Techniques for Removing
Gallstones

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Laparoscopic Cholecystectomy

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Cholesterol Gallstones and Pigment
Gallstones

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Cholelithiasis: Manifestations
• May have no or minimal symptoms and may be acute or
chronic
• Epigastric distress: fullness, abdominal distention, vague
RUQ pain. Distress may occur after eating a fatty meal.
• Acute symptoms occur with obstruction and inflammation
or infection: fever, palpable abdominal mass, severe right
abdominal pain that radiates to the back or right
shoulder, nausea and vomiting
• Biliary colic: episodes of severe pain usually associated
with nausea and vomiting; they usually occur several
hours after a heavy meal
• Jaundice may develop due to blockage of the common
bile duct.
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Nursing Process: Care of the Patient
Undergoing Surgery for Gallbladder
Disease: Assessment
• Patient history
• Knowledge and teaching needs
• Respiratory status and risk factors for postop respiratory
complications
• Nutritional status
• Monitor for potential bleeding.
• GI symptoms: after laparoscopic surgery, assess for loss
of appetite, vomiting, pain, distention, fever--potential
infection or disruption of GI tract.
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Nursing Process: Care of the Patient
Undergoing Surgery for Gallbladder
Disease: Diagnosis
• Acute pain
• Impaired gas exchange
• Impaired skin integrity
• Imbalanced nutrition
• Deficient knowledge

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Collaborative Problems/Potential
Complications

• Bleeding
• Gastrointestinal symptoms
• Complications as related to surgery in general:
atelectasis, thrombophlebitis

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Nursing Process: Care of the Patient
Undergoing Surgery for Gallbladder
Disease: Planning
• Goals may include relief of pain, adequate ventilation,
intact skin, improved biliary drainage, optimal nutritional
intake, absence of complications, and understanding of
self-care routines.

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Postoperative Care Interventions
• Low Fowler’s position
• May have NG tube
• NPO until bowel sounds return, then a soft, low-fat, high-
carbohydrate diet postoperatively
• Care of biliary drainage system
• Administer analgesics as ordered and medicate to
promote/permit ambulation and activities, including deep
breathing.
• Turn, and encourage coughing and deep breathing,
splinting to reduce pain.
• Ambulation
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Patient Teaching (See Chart 40-3)

• Medications
• Diet: at discharge, maintain a nutritious diet and avoid
excess fat. Fat restriction is usually lifted in 4-6 weeks.
• Instruct in wound care, dressing changes, care of T-tube.
• Activity
• Instruct patient and family to report signs of
gastrointestinal complications, changes in color of stool
or urine, fever, unrelieved or increased pain, nausea,
vomiting, and redness/edema/signs of infection at
incision site.

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Pancreatitis

• A severe disorder that can lead to death. Acute

pancreatitis does not usually lead to chronic pancreatitis.
• Acute pancreatitis: pancreatic duct becomes obstructed
and enzymes back up into the pancreatic duct, causing
autodigestion and inflammation of the pancreas
• Chronic pancreatitis: a progressive inflammatory disorder
with destruction of the pancreas. Cells are replaced by
fibrous tissue, and pressure within the pancreas
increases. Mechanical obstruction of the pancreatic and
common bile ducts and destruction of the secreting cells
of the pancreas occur.

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 Manifestations
Acute Chronic
• Severe abdominal pain • Recurrent attacks of severe
upper abdominal and back
• Patient appears acutely ill. pain accompanied by
vomiting
• Abdominal guarding
• Weight loss
• Nausea and vomiting
• Steatorrhea
• Fever, jaundice, confusion,
and agitation may occur.
• Ecchymosis in the flank or
umbilical area may occur.
• Patient may develop
respiratory distress, hypoxia,
renal failure, hypovolemia,
and shock.
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Nursing Process: Care of the Patient With
Acute Pancreatitis: Assessment

• Focus on abdominal pain and discomfort.

• Fluid and electrolyte status
• Medications
• Alcohol use
• GI assessment and nutritional status
• Respiratory status
• Emotional and psychological status of patient and family;
anxiety and coping

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Question

Which of the following diagnostics is the most useful in the

diagnosis of chronic pancreatitis?
a. ERCP
b. CT
c. MRI
d. Ultrasound

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Answer

a. ERCP
Rationale: ERCP is the most useful study in the diagnosis
of chronic pancreatitis. It provides detail about the
anatomy of the pancreas and the pancreatic and biliary
tracts.

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Nursing Process: Care of the Patient With
Acute Pancreatitis: Diagnosis

• Acute pain
• Ineffective breathing pattern
• Imbalanced nutrition
• Impaired skin integrity

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Collaborative Problems/Potential
Complications

• Fluid and electrolyte disturbances

• Necrosis of the pancreas
• Shock
• Multiple organ dysfunction syndrome
• DIC

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Nursing Process: Care of the Patient With
Acute Pancreatitis: Planning

• Major goals include relief of pain and discomfort,

improved respiratory function, improved nutritional
status, maintenance of skin integrity, and absence of
complications.

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Relieving Pain and Discomfort

• Use of analgesics
• Nasogastric suction to relieve nausea and distention
• Frequent oral care
• Bed rest
• Measures to promote comfort and relieve anxiety

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Question

Tell whether the following statement is true or false.

Meperidine (Demerol) is the medication of choice for pain
management in acute pancreatitis.

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Answer

True.
Rationale: Meperidine (Demerol) has been the medication
of choice, although all opioids stimulate the sphincter of
Oddi to some degree.

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Tumors of the Pancreas
• Pancreatic cysts
• Cancer of the pancreas
– Risk factors
– Sites of lesions
– Medical treatment
• Chemotherapy
• Radiation (limited)
• Surgery
– Treatment may be palliative.
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Question

Which of the following is not considered a classic sign of

pancreatic cancer?
a. Jaundice
b. Pain
c. Hypoglycemia
d. Weight loss

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Answer

c. Hypoglycemia
Rationale: Diabetes may be an early sign of carcinoma of
the pancreas. Hyperglycemia, glucosuria, and abnormal
glucose tolerance may be present.

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Multiple Sumps after Pancreatic Surgery

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Pancreatoduodenectomy
(Whipple’s Procedure)

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