METABOLIC DISORDERS PART 2

BILIARY DISORDERS

A. Cholecystitis

• inflammation of the gallbladder which can be acute or chronic.

• Calculous cholecystitis (gall stones) is the cause of more than 90% of cases of acute
cholecystitis.

• Acalculous cholecystitis describes acute gallbladder inflammation in the absence of obstruction

by gallstones.

• empyema of the gallbladder develops if the gallbladder becomes filled with purulent fluid.

1. CALCULOUS CHOLECYSTITIS

• a gallbladder stone obstructs bile outflow.

• Bile remaining in the gallbladder causes:

1. autolysis and edema

2. the blood vessels in the gallbladder to be compressed

3. gangrene of the gallbladder (with possible perforation).

• Secondary infection of bile occurs in approximately 50% of cases.

• The organisms involved are generally enteric and include Escherichia coli, Klebsiella species, and
Streptococcus.

2. ACALCULOUS CHOLECYSTITIS

• acute gallbladder inflammation in the absence of obstruction by gallstones.

• Caused by:

• major surgical procedures,

• orthopedic procedures,

• severe trauma, or

• burns.

• alterations in fluids and electrolytes and

• alterations in regional blood flow in the visceral circulation.

• bile stasis and

 • increased viscosity of the bile.

B. CHOLELITHIASIS

• hard deposits (gallstones, calculi) that may form in the gallbladder.

• gallstones usually form from the solid constituents of bile.

• There are two major types of gallstones:

1. Pigment stones (dark brown or black in color)

- Caused by conditions that produces to much bilirubin

- The risk is increased in patients with cirrhosis, hemolysis, and infections of the biliary tract.

- cannot be dissolved and must be removed surgically.

2. Cholesterol stones (yellow-green in color)

– caused by imbalances bile composition. (decreased bile acid synthesis and increased cholesterol
synthesis in the liver

- resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form stones.

RISK FACTORS OF CHOLELITHIASIS:

• Obesity

• Women, especially those who have had multiple pregnancies or who are of Native American or
U.S. Southwestern Hispanic ethnicity

• Frequent changes in weight

• Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic
disease)

• Treatment with high-dose estrogen (eg, in prostate cancer)

• Low-dose estrogen therapy–a small increase in the risk of gallstones

• Ileal resection or disease

• Cystic fibrosis

• Diabetes mellitus

CLINICAL MANIFESTATIONS

Clinical Manifestations

1. Pain and Biliary Colic

- excruciating RUQ pain that radiates to the back or right shoulder.

- usually associated with nausea and vomiting.

 - noticeable several hours after a heavy meal.

- In some patients, the pain is constant rather than colicky

2. Jaundice

- frequently accompanied by marked pruritus of the skin.

2. Changes in Urine and Stool Color

– dark-colored urine (bile excretion by the kidney) and

- grayish or clay-colored feces. (absence of bile)

2. Vitamin Deficiency

- vitamins A, D, E, and K deficiency. No absorption.

ASSESSMENT AND DIAGNOSTIC FINDINGS

1. Abdominal X-Ray - may be obtained to exclude other causes of symptoms.

- However, only 10% to 15% of gallstones are calcified sufficiently to be visible on such x-ray studies.

2. Ultrasonography - the diagnostic procedure of choice because it is rapid and accurate. with
90% accuracy.

- most accurate if the patient fasts overnight so that the gallbladder is distended.

3. Radionuclide Imaging or Cholescintigraphy

- used successfully in the diagnosis of acute cholecystitis or blockage of a bile duct.

- a radioactive agent is administered IV which is taken up by the hepatocytes and excreted

rapidly through the biliary tract.

- The biliary tract is then scanned, and images of the gallbladder and biliary tract are obtained.

- often used when ultrasonography is not conclusive, such as in acalculous cholecystitis.

4. Oral Cholecystography - used if ultrasound equipment is not available or if the ultrasound

results are inconclusive.

- an iodine-containing contrast agent that is excreted by the liver and concentrated in the
gallbladder is given 10 to 12 hours before the x-ray study.

- If gallstones are present, they appear as shadows on the x-ray image.

5. Endoscopic Retrograde Cholangiopancreatography – permits direct visualization of structures.

- examines the hepatobiliary system via a side-viewing flexible fiberoptic endoscope inserted
through the esophagus to the descending duodenum.
 - Fluoroscopy and multiple x-rays are used during ERCP to evaluate the presence and location of
ductal stones.

- The patient is NPO for several hours before the procedure.

- Moderate sedation is used.

- During ERCP, the nurse monitors IV fluids, administers medications, and positions the patient.

- After the procedure, the nurse monitors the patient’s condition, observing vital signs and
assessing for signs of perforation or infection.

6. Percutaneous Transhepatic Cholangiography (PTC)

- involves the injection of dye directly into the biliary tract.

- reserved for patients whom an ERCP may be unsafe due to previous surgery.

- The fluoroscopy table is tilted and the patient is repositioned to allow x-rays to be taken in
multiple projections.

- It is useful for:

1. distinguishing jaundice caused by liver disease (hepatocellular jaundice) from that caused by
biliary obstruction,

2. investigating the GI symptoms of a patient whose gallbladder has been removed,

3. locating stones within the bile ducts, and

4. diagnosing cancer involving the biliary system.

Medical Management

1. Nutritional and Supportive Therapy

- rest, IV fluids, nasogastric suction, analgesia, and antibiotic agents.

- acute symptoms subside usually within a few days.

- The diet immediately after an episode is low-fat liquids (powdered supplements high in protein
and carbohydrate stirred into skim milk).

- The patient should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming
vegetables, and alcohol.

- It is important to remind the patient that fatty foods may induce an episode of cholecystitis.

2. Pharmacologic Therapy

• Ursodeoxycholic acid (ursodiol) and chenodeoxycholic acid (chenodiol) - acts by inhibiting the
synthesis and secretion of cholesterol.

- can reduce the size of existing stones, dissolve small stones, and prevent new stones from
forming.
 - Six to 12 months of therapy is required in many patients to dissolve stones.

- Side effects include GI symptoms, pruritus, headache.

- The success rate of this therapy is low as the recurrence following it is high.

3. Nonsurgical Removal of Gallstones

a. Dissolving Gallstones

- infusion of a solvent (mono-octanoin or methyl tertiary butyl ether [MTBE]) into the gallbladder.

- used for patients who may not be candidates for laparoscopic cholecystectomy.

b. Stone Removal by Instrumentation

- a catheter and instrument with a basket attached are threaded through the T-tube tract or fistula
formed at the time of T-tube insertion.

- the basket is used to retrieve and remove the stones lodged in the common bile duct.

c. Intracorporeal Lithotripsy

- Stones are fragmented by means of laser pulse technology.

- A laser pulse is directed under fluoroscopic guidance with the use of devices that can distinguish
between stones and tissue.

- The laser pulse produces rapid expansion and disintegration of plasma on the stone surface,
resulting in a mechanical shock wave.

- used percutaneously with a basket or balloon catheter system or by direct visualization through
an endoscope.

d. Extracorporeal Shock Wave Lithotripsy (lithotripsy or ESWL) - nonsurgical fragmentation of

gallstones.

- uses repeated shock waves directed at the gallstones in the gallbladder or common bile duct to
fragment the stones.

- The waves are transmitted to the body through a fluid-filled bag or by immersing the patient in
a water bath.

4. Surgical Management

a. Preoperative Measures

- Vitamin K may be given if the prothrombin level is low.

- Provide IV glucose with protein supplements to aid wound healing.

b. Laparoscopic Cholecystectomy

- the standard of therapy for symptomatic gallstones.

- performed through a small incision or puncture made through the abdominal wall at the
umbilicus.

- The abdominal cavity is insufflated with carbon dioxide (pneumoperitoneum).

- The fiberoptic scope is inserted through the small umbilical incision.

- Several additional punctures or small incisions are made in the abdominal wall to introduce
other surgical instruments.

- Camera attached to the laparoscope permits the surgeon to view the intraabdominal field on a
television monitor.

- The cystic artery is dissected free and clipped.

- The gallbladder is separated from the hepatic bed and removed from the abdominal cavity after
bile and small stones are aspirated.

- With the laparoscopic procedure, the patient does not experience paralytic ileus.

- The patient is often discharged from the hospital on the same day of surgery or within 1 or 2
days.

- The most serious complication after laparoscopic cholecystectomy is a bile duct injury (can be
repaired immediately during the procedure).

c. Cholecystectomy

- the gallbladder is removed through an abdominal incision.

- performed for acute and chronic cholecystitis.

- In some patients, a drain is placed close to the gallbladder bed and brought out through a
puncture wound if there is a bile leak.

- only a small amount of serosanguineous fluid drains in the initial 24 hours after surgery;
afterward, the drain is removed.

- The drain is maintained if there is excess oozing or bile leakage.

d. Small-Incision Cholecystectomy

- a surgical procedure in which the gallbladder is removed through a small abdominal incision.

- Drains may or may not be used.

e. Choledochostomy

- reserved for the patient with acute cholecystitis who may be too ill to undergo a surgical
procedure.

- Involves making an incision in the common duct.

- a tube is usually inserted into the duct for drainage of bile until edema subsides.
 - A laparoscopic cholecystectomy is planned for a future date after acute inflammation has
resolved.

f. Cholecystostomy

- performed when the patient’s condition precludes more extensive surgery or when an acute
inflammatory reaction is severe.

- A drainage tube is connected to a drainage system.

Surgical - The gallbladder is surgically opened, stones and the bile or the purulent drainage are removed,
and a drainage tube is secured with a purse-string suture.

Percutaneous - Under local anesthesia, a fine needle is inserted through the abdominal wall

and liver edge into the gallbladder under the guidance of ultrasound or computed tomography (CT).

Nursing Diagnoses & Nursing Interventions

Acute pain and discomfort related to surgical incision -Relieving Pain

Impaired gas exchange related to the high abdominal

surgical incision- Improving Respiratory Status

Impaired skin integrity related to altered biliary

drainage after surgical intervention - Maintaining Skin Integrity And Promoting Biliary Drainage

Imbalanced nutrition, less than body requirements,

related to inadequate bile secretion - Improving Nutritional Status

Monitoring And Managing Potential Complications

(Bleeding, Gi Symptoms, Infection)

PANCRETIC DISORDERS

A. ACUTE PANCREATITIS

• sudden inflammation of the pancreas.

• There are two main types:

(1)mild (interstitial edematous pancreatitis and

(2)severe (acute hemorrhagic pancreatitis)

1. Interstitial pancreatitis - affects the majority of patients.

 - Characterized by a lack of pancreatic or peripancreatic parenchymal necrosis with diffuse
enlargement of the gland due to inflammatory edema.

- The edema and inflammation is confined to the pancreas itself.

- return to normal function usually occurs within 6 months.

1. Interstitial pancreatitis - affects the majority of patients.

- Characterized by a lack of pancreatic or peripancreatic parenchymal necrosis with diffuse

enlargement of the gland due to inflammatory edema.

- The edema and inflammation is confined to the pancreas itself.

- return to normal function usually occurs within 6 months.

2. acute hemorrhagic pancreatitis

- presence of tissue necrosis in either the pancreatic parenchyma or in the tissue surrounding
the gland.

- Enzymes damage the local blood vessels, and bleeding and thrombosis can occur.

- Local complications include pancreatic cysts or abscesses and acute fluid collections in or near
the pancreas.

- Also, patients who develop systemic complications with organ failure, such as pulmonary
insufficiency with hypoxia, shock, kidney disease, and GI bleeding are categorized as severe.

PATHOPHYSIOLOGY

- Self-digestion

- Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes
acute pancreatitis.

- Gallstones

- Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing
the flow of pancreatic juice.

- Reflux of bile

- Reflux of bile from the common bile duct into the pancreatic duct activates the
powerful enzymes within the pancreas

- Activation of the enzymes

- Activation of the enzymes can lead to vasodilation, increased vascular permeability,

necrosis, erosion, and hemorrhage.

OTHER CAUSES OF ACUTE PANCREATITIS

• Bacterial or viral infection

 • Spasm and edema of the ampulla of Vater, caused by duodenitis

• Blunt abdominal trauma

• Peptic ulcer disease

• Ischemic vascular disease

• Hyperlipidemia

• Hypercalcemia

• Medications (corticosteroids, thiazide diuretics, oral contraceptives)

Clinical Manifestations

• Severe abdominal pain in midepigastrium (major symptom)

• Pain is frequently acute in onset, occurring 24 to 48 hours after a very heavy meal or
alcohol ingestion (unrelieved by antacids)

• Abdominal tenderness and back pain

• Abdominal distention

• Decreased peristalsis

• Nausea and vomiting (bile stained)

• Abdominal guarding (a rigid or boardlike abdomen may indicate peritonitis)

• Ecchymosis in the flank or around the umbilicus may indicate severe pancreatitis.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• Serum amylase and lipase levels (elevated within 24 hours of the onset of the symptoms).

• Blood chemistry:

• elevated WBC count,

• hypocalcemia,

• hyperglycemia and

• hyperbilirubinemia.

• Imaging studies of the abdomen and chest (X-ray, Ultrasound, CT, MRI).

• Hematocrit and hemoglobin levels

MEDICAL MANAGEMENT
1. Pain Management

- Adequate administration of analgesia to minimize restlessness, which may stimulate pancreatic

secretion further.

- Pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or
hydromorphone.

- Antiemetic agents may be prescribed to prevent vomiting.

2. Intensive Care

- Correction of fluid and blood loss and low albumin levels.

- Hemodynamic monitoring and arterial blood gas monitoring.

- Antibiotic agents may be prescribed if infection is present.

- Insulin may be required if hyperglycemia occurs.

3. Respiratory Care

4. Biliary Drainage

- Placement of biliary drains (for external drainage) and stents (indwelling tubes) in the pancreatic
duct to reestablish drainage of the pancreas.

5. Surgical Intervention

- Diagnostic laparotomy - to establish pancreatic drainage; or to resect or débride an infected,

necrotic pancreas.

- The patient may have multiple drains in place postoperatively, as well as a surgical incision that
is left open for irrigation and repacking.

6. Postacute Management

- oral feedings that are low in fat and protein

- Caffeine and alcohol are eliminated from the diet.

- Follow-up may include ultrasound, x-ray studies, or ERCP to determine whether the pancreatitis
is resolving.

NURSING MANAGEMENT

1. Relieving Pain and Discomfort

- Pharmacologic and nonpharmacologic interventions.

- Oral feedings are withheld to decrease the secretion of secretin.

- Parenteral fluids and electrolytes are prescribed to restore and maintain fluid balance.

- Bed rest to decrease the metabolic rate.

2. Improving Breathing Pattern

- Semi-Fowler’s position to decrease pressure on the diaphragm

- Frequent changes of position.

- Coughing and deep breathing.

- Use of incentive spirometry.

3. Improving Nutritional Status

- Laboratory test results and daily weights

- Enteral or parenteral nutrition may be prescribed.

- Between acute attacks, the patient receives a diet that is high in protein and low in fat.

- The patient should avoid heavy meals and alcoholic beverages.

4. Maintaining Skin Integrity

- Assess the wound, drainage sites, and skin for signs of infection, inflammation, and breakdown.

- The patient must be turned every 2 hours.

5. Monitoring and Managing Potential Complications

- Fluid and electrolyte disturbances (assess weight, skin turgor, mucous membranes, fluid I/O,
ascites).

- Fluids are administered IV and may be accompanied by infusion of blood or blood products.

- Carefully monitor vital signs and other signs and symptoms (MODS).

B. Chronic Pancreatitis

• an inflammatory disorder characterized by progressive destruction of the pancreas.

• cells are replaced by fibrous tissue with repeated attacks of pancreatitis

• Increased pressure within the pancreas causes obstruction of the pancreatic and common bile
ducts and the duodenum.

• Also, there is atrophy of the epithelium of the ducts, inflammation, and destruction of the
secreting cells of the pancreas.

• Alcohol consumption and malnutrition are the major causes of chronic pancreatitis.

• Long-term alcohol consumption causes hypersecretion of protein in pancreatic secretions,

resulting in protein plugs and calculi within the pancreatic ducts.
Clinical Manifestations

• Recurring attacks of severe upper abdominal and back pain, accompanied by vomiting (opioids,
even in large doses, do not provide relief).

• Opioid dependence

• Weight loss secondary to anorexia or fear

• Malabsorption (steatorrhea)

• Calcification of the gland may occur, and calcium stones may form within the ducts.

ASSESSMENT AND DIAGNOSTIC FINDINGS

• ERCP (most useful study in the diagnosis of chronic pancreatitis)

• Glucose tolerance test - evaluates pancreatic islet cell function.

• Increased serum amylase levels

• Laboratory analysis of fecal fat content

C. PANCREATIC CYSTS
- collections of fluid walled off by fibrous tissue (pancreatic pseudocysts)
- result of the local necrosis that occurs because of acute pancreatitis
- Pseudocysts are amylase-rich fluid collections that occur within 4 to 6 weeks after an episode of
acute pancreatitis.
- Drainage into the GI tract or through the skin and abdominal wall may be established.

CLINICAL MANIFESTATIONS

• Same as acute pancreatitis

ASSESSMENT AND DIAGNOSTIC FINDINGS

• Diagnosis of pancreatic cysts and pseudocysts is made by ultrasound, CT scan, and ERCP

D. HYPERINSULINISm

overproduction of insulin by the pancreatic islets.

characterized by episodes of unusual hunger, nervousness, sweating, headache, and faintness.

In severe cases, seizures and episodes of unconsciousness may occur.

The findings at the time of surgery or at autopsy may indicate hyperplasia of the islets of Langerhans.

All of the symptoms that accompany spontaneous hypoglycemia are relieved by the oral or parenteral
administration of glucose.

Surgical removal of the hyperplastic or neoplastic tissue from the pancreas is the only successful method
of treatment.