Chapt 44 Gallbladder

Focus on Disorders of the Biliary
Tract
(Relates to Chapter 44, “Nursing Management: Liver,
Pancreas, and Biliary Tract Problems” in the textbook)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Gallbladder Disease
• Cholelithiasis
 Most common disorder of biliary
system
 Stones in the gallbladder
• Cholecystitis
 Inflammation of the gallbladder
 Usually associated with cholelithiasis
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Gallbladder With Gallstones
Fig. 44-16. Cholesterol gallstones in a gallbladder that was removed.

X-ray of Gallstones
Fig. 44-17. X-ray of a gallbladder with gallstones.

Gallbladder Disease
• Common health problem in United

States
• 8% to 10% of adults have
cholelithiasis.
• Incidence of cholelithiasis
 Higher in women, multiparous
women, and persons over 40 years
 Estrogen therapy ↑ risk
Gallbladder Disease
• Other risk factors

 Sedentary lifestyle
 Familial tendency
 Obesity
• More common in whites than in
Asian and African Americans
• ↑ incidence in Navajo and Pima

Etiology and Pathophysiology
• Cholecystitis
 Most commonly associated with
obstruction
• Gallstones or biliary sludge
 In absence of obstruction
• Occurs in older adults and those who have
trauma, extensive burns, or recent
surgery

• Cholecystitis causes
 Bacteria
• Escherichia coli—Most common
 Other factors include
• Adhesions
• Neoplasms
• Anesthesia
• Opioids

• Cholecystitis (cont’d)
 Inflammation
• Major pathophysiologic condition
• Confined to mucous lining or entire wall
• Gallbladder is edematous and hyperemic.
• May be distended with bile or pus
• Cystic duct may become occluded.

• Cholelithiasis
 Cause of gallstones unknown
 Develops when balance that keeps
cholesterol, bile salts, and calcium in
solution is altered
• Causes include infection and disturbances
in metabolism of cholesterol.

• Cholelithiasis (cont’d)
 Bile in gallbladder is supersaturated
with cholesterol.
 Precipitation of cholesterol results.

 Other components of bile that
precipitate into stones include
• Bile salts
• Bilirubin
• Calcium
• Protein

 Stones that are primarily cholesterol
are the most common.
 Immobility, pregnancy, and
inflammatory or obstructive lesions of
biliary system ↓ bile flow.

 Stones may remain in gallbladder or
may migrate to cystic or common bile
duct.
 Cause pain as they pass through ducts
• May lodge in ducts and produce an
obstruction

 If blockage occurs in cystic duct
• Bile can continue to flow into the
duodenum directly from liver
• When bile in gallbladder cannot escape
stasis, may lead to cholecystitis

Clinical Manifestations
• Vary from
 Indigestion
 Moderate to severe pain
 Fever
 Jaundice

• Initial symptoms of acute

cholecystitis
 Indigestion
 Pain
 Tenderness in right upper quadrant

• Acute cholecystitis
 Pain may be acute.
• May be accompanied by nausea,
vomiting, restlessness, and diaphoresis
 Inflammation manifestations
• Leukocytosis
• Fever

• Acute cholecystitis (cont’d)

 Physical findings
• Right upper quadrant tenderness
• Abdominal rigidity

• Chronic cholecystitis
 Symptoms
• History of
• Fat intolerance
• Dyspepsia
• Heartburn
• Flatulence

• Cholelithiasis
 May produce severe symptoms or
none at all
• “Silent cholelithiasis”
 Severity depends on
• Presence of obstruction
• Whether or not stones move

 Stones lodged in ducts or moving may
cause spasm.
• Can produce severe pain
• Termed biliary colic, although more
steady than colicky
• Pain could be accompanied by
tachycardia, diaphoresis, and prostration.

 Pain may last an hour.
• When it subsides, tenderness in right
upper quadrant develops.
 Attacks of pain occur 3 to 6 hours after
a heavy meal or after lying down.

 Total obstruction symptoms
• Jaundice
• Dark amber urine
• Clay-colored stools
• Pruritus

 Total obstruction symptoms (cont’d)
• Intolerance to fatty foods
• Bleeding tendencies
• Steatorrhea
• No urobilinogen in urine

Complications
• Cholecystitis
 Gangrenous cholecysitis
 Subphrenic abscess
 Pancreatitis
 Cholangitis

Complications
 Biliary cirrhosis
 Fistulae
 Gallbladder rupture
• Bile peritonitis

Complications
 Most common complications in older
patients and those with diabetes
• Gangrenous cholecystitis
• Bile peritonitis

Complications
• Cholelithiasis
 Cholangitis
 Biliary cirrhosis
 Carcinoma
 Peritonitis
 Choledocholithiasis

Diagnostic Studies
• Ultrasound
• Laboratory tests
 Liver function studies
 WBC count
 Serum bilirubin
 Serum amylase

Diagnostic Studies
• ERCP
• Percutaneous transhepatic
cholangiography

Collaborative Care
Conservative Therapy
• Cholecystitis
 Acute episode focus on
• Pain control
• Antibiotic treatment
• Maintenance of fluid and electrolyte
balance
 Treatment supportive and
symptomatic

Collaborative Care
 Treatment
• Gastric decompression
• If nausea/vomiting is severe
• Anticholinergics
• ↓ secretion
• Counteract smooth muscle spasms

Collaborative Care
 Treatment (cont’d)
• NSAIDs
• Pain management
• Cholecystostomy

Collaborative Care
• Cholelithiasis
 Treatment
• Depends upon stage of disease
• Bile acids are used to dissolve stones.
• Gallstones may occur.

Collaborative Care
• Cholelithiasis
 Treatment
• Two nonsurgical approaches for stone
removal
• ERCP with sphincterotomy
• Extracorporeal shock-wave lithotripsy

Collaborative Care
• Cholelithiasis
• ERCP with sphincterotomy
• Effective in removing common bile duct
stones
• Endoscope passed to duodenum
• Sphincter of Oddi is widened.
• Basket is used to retrieve stone.

Endoscopic Sphincterotomy
Fig. 44-18. During endoscopic sphincterotomy, an endoscope is advanced through the mouth and stomach until
Its tip sits in the duodenum opposite the common bile duct. Inset, after widening the duct mouth by incising the
sphincter muscle, the physician advances a basket attachment into the duct and snags the stone.
Collaborative Care
• Cholelithiasis
 Extracorporeal shock-wave lithotripsy
• Used if stone is too large to pass

Collaborative Care
Surgical Therapy
 Laparoscopic cholecystectomy
• Treatment of choice
• Removal of gallbladder through one to
four puncture holes
• Minimal postoperative pain

Collaborative Care
Surgical Therapy
 Laparoscopic cholecystectomy (cont’d)
• Discharge on day or next day
• Injury to common bile duct is the main
complication.

Collaborative Care
Surgical Therapy
 Open cholecystectomy
• Removal of gallbladder through right
subcostal incision
• T-tube inserted into common bile duct
• Ensures patency of the duct
• Allows excess bile to drain

Placement of T-Tube
Fig. 44-19. Placement of T tube. Dotted lines

indicate parts removed.
Collaborative Care
Transhepatic Biliary Catheter
• Used preoperatively in
 Biliary obstruction
 Hepatic dysfunction
• Used when
 Inoperable liver, pancreatic or bile duct
carcinoma obstructs bile flow
 Endoscopic drainage is unsuccessful.

Collaborative Care
• Inserted percutanously
• Allows for decompression of
obstructed extrahepatic bile ducts
• After insertion, catheter is
connected to drainage bag.

Collaborative Care
• Skin care
 Catheter insertion site cleaned daily
with antiseptic
 Observe for bile leakage.

Collaborative Care
Drug Therapy
• Most common
 Analgesics
• Morphine
• NSAIDs
 Anticholinergics
• Atropine
 Fat-soluble vitamins (A, D, E, K)
 Bile salts

Collaborative Care
Drug Therapy
• Cholestyramine (Questran) may be
given for pruritus.
 Given in powdered form, mixed with
milk or juice

Collaborative Care
Nutritional Therapy
• Diet modifications
 Major
• Low saturated fat diet
• High in fiber and calcium
 Reduced calorie diet if obese
 Eat small, more frequent meals.

Collaborative Care
Nutritional Therapy
• Diet modifications (cont’d)
 After laparoscopic cholecystectomy
• Liquids for day
• Light meals for several days
 After incisional cholecystectomy
• Liquids to bland diet after return of bowel
sounds
• May need to restrict fats for 4 to 6 weeks

Nursing Management
• Nursing assessment
 Subjective data
• Past medical history
• Obesity, infection, cancer, pregnancy
• Medication use
• Estrogen, oral contraceptives
• Surgical history
• Previous abdominal surgery

Nursing Management
Nursing Assessment
• Subjective data
 Positive family history
 Anorexia
 Weight loss
 Indigestion
 Nausea and vomiting

Nursing Management
Nursing Assessment
• Subjective data (cont’d)
 Fat intolerance
 Clay-colored stools
 Dark urine
 Pain in right upper quadrant
 Pruritus

Nursing Management
Nursing Assessment
• Objective data
 Fever
 Restlessness
 Jaundice
 Tachypnea

Nursing Management
Nursing Assessment
• Objective data (cont’d)
 Tachycardia
 Abnormal liver enzymes
 Abnormal gallbladder ultrasound

Nursing Management
Nursing Diagnoses
• Acute pain
• Ineffective self-health management

Nursing Management
Planning
• Overall goals
 Relief of pain and discomfort
 No complications postoperatively
 No recurrent attacks of cholecystitis or
cholelithiasis

Nursing Management
Nursing Implementation
• Health promotion
 Recognize predisposing factors in
general health screening.
• Disease more common in Native
Americans

Nursing Management
• Acute intervention
 Nursing objectives
• Relieve pain
• Relieve nausea and vomiting
• Provide comfort and emotional support

Nursing Management
• Acute intervention (cont’d)
 Nursing objectives (cont’d)
• Maintaining fluid and electrolyte balance
and nutrition
• Making accurate assessments
• Observing for complications

Nursing Management
 Assess pain and administer pain
medications.
 Provide clean bed, comfortable
positioning, and oral care.

Nursing Management
 Nausea and vomiting
• May need gastric decompression
• Oral hygiene
• Care of nares
• Accurate intake and output
• Antiemetics

Nursing Management
 Pruritus
• Relief measures
• Baking soda or calamine lotion
• Soft linen
• Control of temperature
• Shortening of nails
• Teaching patients to scratch with knuckles
rather than nails

Nursing Management
 Observe for signs of obstruction.
• Jaundice
• Clay-colored stools
• Dark, foamy urine
• Fever
• ↑ WBC
• Steatorrhea

Nursing Management
 Watch for bleeding.
• Common sites—mucous membranes
• If present
• Small-gauge needles with gentle pressure
• Know patient’s prothrombin time.

Nursing Management
 Assess for infection.
• Temperature elevation with chills and
jaundice may indicate
choledocholithiasis.

Nursing Management
• Postoperative care
• Monitoring for complications
• Common problem
• Shoulder pain from irritation of phrenic nerve
and diaphragm due to retained CO2
• Place patient in Sims’ position.
• Encourage deep breathing, ambulation.
• Administer pain medications.

Nursing Management
• Postoperative care (cont’d)
 Incisional cholecystectomy
• Maintain adequate ventilation.
• Prevent respiratory complications.
• Provide general postop nursing care.
• If T-tube present,
• Maintain bile drainage.
• Observe function and drainage.

Nursing Management
• Ambulatory and home care
 Dietary teaching
 Fat-soluble vitamin supplements
 Instructions to patient regarding
observations indicating obstruction
 Stress significance of continued health
care.

Nursing Management
• Ambulatory and home care
• Home care instructions
• Teaching essential
 Open-incision cholecystectomy
• Discharged in 2 to 3 days
• No heavy lifting for 4 to 6 weeks

Nursing Management
Evaluation
• Expected outcomes
 Appear comfortable and verbalize pain
relief
 Verbalize knowledge of activity level
and dietary restrictions

Gallbladder Cancer
• Primary cancer of gallbladder is

uncommon.
• Majority are adenocarcinomas.
• Relationship exists between
gallbladder cancer and chronic
cholecystitis and cholelithiasis.

Gallbladder Cancer
• Early symptoms
 Insidious
 Similar to those of cholecystitis and
cholelithiasis
• Late symptoms
 Usually those of biliary obstruction

Gallbladder Cancer
• Diagnosis and staging

 EUS
 Transabdominal ultrasound
 CT
 MRI
 MRCP

Gallbladder Cancer
• Usually not detected until disease

advanced
• If found early, can be curative

Gallbladder Cancer
• Factors influencing successful

surgical outcomes
 Depth of cancer invasion
 Extent of liver involvement
 Presence of venous or lymphatic
invasion
 Lymph node metastasis

Gallbladder Cancer
• If surgery is not an option

 Endoscopic stenting of biliary tree to
reduce jaundice
• Adjuvant therapies
 Radiation therapy
 Chemotherapy
• Poor prognosis overall

Gallbladder Cancer
• Nursing management
 Supportive care
• Nutrition
• Hydration
• Skin care
• Pain relief

Audience Response Question
The surgical treatment of choice for the patient with

symptomatic gallbladder disease is a:
1. Cholecystotomy.
2. Choledocholithotomy.
3. Cholecystoduodenostomy.
4. Laparoscopic cholecystectomy.

Audience Response Question
Postoperatively, a patient with an incisional
cholecystectomy has a nursing diagnosis of ineffective
breathing pattern related to splinted respirations
secondary to a high abdominal incision. The nursing
intervention that should be implemented first for this
patient is to:
1. Assess lung sounds every 2 to 4 hours.

2. Provide analgesics to relieve incisional pain.
3. Assist the patient to cough and deep breathe every
hour.
4. Position the patient on the operative side to splint the
incision.
Case Study

Case Study
• 35-year-old woman presents to

emergency department complaining
of acute abdominal pain.
• She points to pain in the right upper

quadrant.

Case Study
• She describes the pain as 7 out of 10.
• Lab values show elevated WBCs and

bilirubin.
• Ultrasound confirms gallstones.

Discussion Questions
1. What is her priority of care?
2. What are her treatment options?
3. What can you teach her about

avoiding complications or
recurrences?

Chapt 44 Gallbladder

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Focus on Disorders of the Biliary

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Fig. 44-16. Cholesterol gallstones in a gallbladder that was removed.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

Fig. 44-17. X-ray of a gallbladder with gallstones.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

• Common health problem in United

• Other risk factors

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• Initial symptoms of acute

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• Acute cholecystitis (cont’d)

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Fig. 44-19. Placement of T tube. Dotted lines

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