Biliary System and Pancreas

CHOLECYSTITIS

- Cholecystitis is an inflammation of the gallbladder wall. The “attack” usually subsides in 2 to 3

days.
- Cholecystitis is most often caused by gallstones (cholelithiasis) obstructing the cystic and/or
common bile ducts (bile flow from gallbladder to duodenum); cholecystitis without gallstones is
rare and serious.
- Bile is used for the digestion of fats. It is produced in the liver and stored in the gall bladder.
- Cholecystitis can be acute or chronic, and it can also obstruct the pancreatic duct.

A. Acute Cholecystitis ( 2 types)

1. Calculus Cholecystits – inflammation and irritation result from gallstones (cholelithiasis) that
obstruct the cystic duct (most often), gallbladder neck, or common bile duct.

2. Acalculous Cholecystitis – inflammation occurring w/ out gallstone; biliary stasis caused by

any condition that affects the regular filling or emptying of gallbladder.
B. Chronic Cholecystitis – results when repeated episodes of cystic duct obstruction cause chronic
inflammation.
Repeated episode of obstruction → lots of fibrosis; contracted →biliary obstruction.

Biliary obstruction →dark urine (tea-colored); clay-colored stool; jaundice →icterus (yellow
sclera)/pruritus (itching)

Obstruction → stasis of bile (chemical irritant) → necrosis and gangrene → perforation →

abscess or pretonitis (infection).

Large perforation – Peritonitis .

Small and localized – Abscess.

 Gallstones are composed of substance normally found in bile such as cholesterol, bilirubin,
bile salts, calcium, and various proteins. Gallstones are classified as:

1. Cholesterol stone – most common type found in people in the US; calculi form as a
result of metabolic imbalances of cholesterol and bile salts.
2. Pigmented stone – associated with cirrhosis of the liver.

Risk Factors of Cholecystitis:

  Women  Genetic predisposition
 High-fat diet  Individuals with type 1 diabetes mellitus
 Older than 60 years of age (high triglycerides)
 American Indian, Mexican American, or  Rapid weight loss (increases cholesterol)
Caucasian or prolonged fasting.
 Obesity (impaired fat metabolism, high  Crohn’s Disease
cholesterol levels) – major risk factor for  Gastric bypass surgery
gallstone.  Sickle cell anemia
 Glucose intolerance

4 F’s most at risk for cholecystitis and gallstone:

 Female  Fat
 Forty  Fertile

Assessments:

∆ An attack of cholecystitis (also known as a “gallbladder attack”) is characterized by:

 Sharp pain in the right upper quadrant of
the abdomen, often radiating to the right
shoulder.
 Pain with deep inspiration during right
sub-costal palpation (Murphy’s sign).
 Intense pain (increased heart rate, pallor,
diaphoresis) after ingestion of a large
quantity of high-fat food.
 Rebound tenderness
 Nausea, anorexia, and vomiting
 Dyspepsia, eructation (belching), and
flatulence.
 Fever.
 Jaundice, clay-colored stools, dark urine,
steatorrhea (fatty stools), and pruritus
(accumulation of bile salts in the skin)
may be seen in clients with chronic
cholecystitis (due to biliary obstruction).

Diagnostic Procedures and Nursing Interventions:

 Right upper quadrant (RUQ) ultrasound is the most diagnostic. Visualizes gallbladder edema.
 Abdominal x-ray (may visualize calcified gallstones)
 White blood cell count (elevations with left shift indicate inflammation)
 Direct (normal is 0.1 to 0.3 mg/dL), indirect (0.2 to 0.8 mg/dL), and total (0.1 to
1.0 mg/dL) serum bilirubin levels (elevated if obstruction)
 Aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) (elevated if liver
dysfunction)
 Serum cholesterol (elevated above 200 mg/dL)
 Hepatobiliary scan (assesses patency of biliary duct system)

Therapeutic Procedures and Nursing Interventions:

 Cholecystitis should be taken cared of → can develop to peritonitis.

 Cholecystectomy – removal of the gallbladder with a laparoscopic or an open approach (when

exploration of biliary ducts is indicated).
- Postoperatively, clients may experience free air pain following laparoscopic surgery.
- Ambulation is helpful.
- Following an open approach, nursing care includes monitoring drainage from inserted Jackson-
Pratt (JP) drains and T-tube.

Postoperative Care:

1. Support pain management.

2. Encourage splinting to reduce pain.
3. Encourage measures to reduce risk of respiratory complications (turn, cough, deep breathe,
ambulate).
4. Monitor wound incision(s) and provide wound care.
a. Monitor and record T-tube drainage (initially bloody, then greenbrown bile).
b. Initially, may drain > 400 mL/day and then gradually decreases in amount.
c. Report sudden increases in drainage or amounts exceeding 1,000 mL/day.
d. Inspect surrounding skin.
e. Maintain flow by gravity.
f. Clamp 1 to 2 hr ac and pc (before and after meals).
g. monitor and document the client’s response to food.
5. Client Education
a. Activity precautions 4 to 6 weeks
b. Care of T-tube (up to 6 weeks postoperatively) – Report sudden increase in drainage or
foul odor; Clamp 1 to 2 hr before and after meals.
c. Stool color should return to brown color in about a week.
d. Encourage a low-fat diet.

 Dietary Counseling

a. Encourage a low-fat diet (reduced dairy; avoid fried foods, chocolate, nuts, and
gravies).
b. Promote weight reduction.
c. Fat-soluble vitamins and bile salts may be prescribed if obstruction is present to
enhance absorption and aid digestion.
d. Avoid gas-forming foods (beans, cabbage, cauliflower, broccoli).
e. Smaller, more frequent meals may be tolerated better.

 Administer analgesics as needed and prescribed.

a. Meperidine (Demerol) is generally preferred over morphine, because morphine may

increase biliary spasms. However, Demerol breaks down into a toxic metabolite and
can cause seizure. – Morphine or Dilaudid is used.
 b. Antispasmodics and anticholinergics (Bentyl) may be given to relax smooth muscles
and ↓ ductal tone and spasm.
c. Antiemetics

 EWSL (Extracorporeal Shock Wave Lithotripsy)

- commonly used for kidney stones; shack wave breaks larger stone into smaller stones.

 Laparoscopic Cholecystectomy (Gold Standard)

- Inflate with air (CO2)

- Post op care – pain, free the air or CO2 – relieve by early ambulation (ambulation promotes
absorption of CO2)

Nursing Diagnoses:

 Acute pain
 Impaired gas exchange
 Risk for infection
 Deficient knowledge

Complications and Nursing Implications:

 Obstruction of the bile duct can cause ischemia and a rupture of the gallbladder wall is possible.
Rupture of the gallbladder wall can cause a local abscess or peritonitis (rigid, board-like
abdomen, guarding), which requires surgical intervention and administration of broad
spectrum antibiotics.

Meeting the Needs of Older Adults:

 Older adult clients may have diabetes mellitus and have atypical presentations of cholecystitis
(for example, absence of pain or fever).
 The postoperative period is always more risky for the older adult clients.
 Older adult clients may have difficulty taking care of a T-tube at home and may have difficulty
changing lifelong dietary patterns.

Application Exercises:

 Scenario: A client is admitted with severe upper abdominal pain following a family dinner
celebration. She reports frequent belching. She is febrile.

1. What could be a possible cause for the fever and the pain?

The client’s gallbladder has likely ruptured.

2. What should the nurse suspect regarding the quantity and type of food consumed at the
dinner celebration by this client?
 Large quantity, high in fat content

3. What medication(s) should the nurse anticipate being prescribed for this client at this point?

Antispasmodics and/or meperidine (Demerol); probably not morphine because of its

possible increase of biliary spasms

4. Which of the following food choices might trigger a cholecystitis attack? (Check all that
apply.)
__x__ Ice cream __x__ Broccoli with cheese sauce
__x__ Brownie with nuts __x__ Biscuits and gravy
_____ Pasta with marinara sauce _____ Sweetened strawberries
_____ Turkey sandwich __x__ Fried eggs and bacon

5. Which of the following client findings indicates biliary obstruction? (Check all that apply.)

__x__ Conjugated (direct) serum bilirubin 0.6 mg/dL

__x__ Serum cholesterol 278 mg/dL
_____ Unconjugated (indirect) serum bilirubin 0.4 mg/dL
_____ Total serum bilirubin 1 mg/dL
__x__ Yellow sclera
__x__ Light colored bowel movements
__x__ Steatorrhea (fatty stools)
_____ Dilute yellow urine
__x__ Calcifications noted on abdominal x-ray

6. Which of the following instructions is/are appropriate for a client going home with a T-tube
drain? (Check all that apply. For instructions deemed inappropriate, identify why.)

_____ Take baths rather than showers.

__x__ Clamp T-tube for 1 to 2 hr before and after meals.
_____ Keep the drainage system above the level of the gallbladder.
__x__ Avoid heavy lifting and strenuous activity.
_x__ Empty drainage bag at the same time each day.

Soaking in bath water increases risk for introduction of organisms and consequently
infection.

The drainage system needs to be kept below the level of the abdomen in order to allow
drainage by gravity and to prevent reflux.

PANCREATITIS

- The pancreas’ islets of Langerhans secrete insulin and glucagon. The pancreatic exocrine tissues
secret digestive enzymes that break down carbohydrates, proteins, and fats.
 - Pancreatitis is an autodigestion of the pancreas from a premature activation (before reaching
the intestines) of the pancreatic digestive enzymes (exact mechanism unknown). It can result in
inflammation, necrosis, and hemorrhage.

- Classic signs and symptoms of an acute attack include severe, constant, knife-like pain (right
upper quadrant, gastric, and/or radiating to the back) that is unrelieved by nausea and vomiting.

- Acute pancreatitis is an inflammation of the pancreas resulting from activated pancreatic

enzymes autodigesting the pancreas. Severity varies, but overall mortality is 10 to 20%.

- Chronic pancreatitis is a progressive destruction of the pancreas with development of

calcification and necrosis, possibly resulting in hemorrhagic pancreatitis. Mortality can be as
high as 50%.

Key Factors:

 Two primary causes of pancreatitis are alcoholism and biliary tract disease (gallstones can cause
blockage where the common bile duct and pancreatic duct meet).
 Pancreatitis is also a possible complication of endoscopic retrograde cholangiopancreatography
(ERCP).
 Triggering factors include intake of large amounts of fat and/or alcohol.

Assessments:

 Monitor for signs and symptoms.

1. Sudden onset of severe, boring pain

◊ Epigastric, radiating to back, left flank, or left shoulder
◊ Worse when lying down or with eating
◊ Not relieved with vomiting
◊Some relief in fetal position
2. Nausea and vomiting
3. Weight loss
4. Signs and symptoms of inflammation or peritonitis
5. Seepage of blood-stained exudates into tissue
◊ Ecchymoses on the flanks (Turner’s sign)
◊ Bluish periumbilical discoloration (Cullen’s sign)
6. Generalized jaundice
7. Paralytic ileus
8. Hyperglycemia

 Assess/Monitor

1. Pain level
2. Nutritional status
 3. Bowel function
4. Blood glucose levels
5. Diet and alcohol intake history
6. Fluid and electrolyte status

Diagnostic Procedures and Nursing Interventions:

 Serum amylase (rises within 12 hr, lasts 4 days) and serum lipase (rises slower but lasts up to 2
weeks).

1. Urine amylase also remains elevated for up to 2 weeks.

2. Rises in these enzymes indicate pancreatic cell injury.
3. Memory aid: In pancreatitis, the “ases” (aces) are high.
4. To be considered positive, the enzyme rise must be significant (2 to 3 times the normal
value for amylase and 3 to 5 times the normal value for lipase). The degree of enzyme
elevation does not directly correlate with the severity of disease.

 Serum calcium and magnesium levels: Decreased due to fat necrosis with pancreatitis)
 Serum liver enzymes and bilirubin levels: Elevated with associated biliary dysfunction)
 White blood cell count: Elevated due to infection and inflammation.
 Computed tomography (CT) scan with contrast: Reliably diagnostic of acute pancreatitis.

Therapeutic Procedures and Nursing Interventions:

 Endoscopic retrograde cholangiopancreatography (ERCP) to create an opening in the sphincter

of Oddi and/or an open cholecystectomy are possibly effective treatments if the pancreatitis is
a result of gallstones.

Nursing Interventions:

 Rest the pancreas.

1. NPO – no food until pain free

2. Nasogastric tube – gastric decompression
3. Total parenteral nutrition (TPN) – watch for hyperglycemia.
4. When diet is resumed: bland, low-fat diet with no stimulants (caffeine);
5. small, frequent meals rather than large meals
6. No alcohol
7. No smoking
8. Limit stress

 Pain Management

1. Administer opioids as prescribed. Often large doses of intravenous narcotics are needed for
pain management. Traditionally, meperidine (Demerol) has been preferred, because pain is
acute and morphine sulfate can cause spasms in the sphincter of Oddi.
 2. Position for comfort (fetal, side-lying, with the head of the bed elevated or sitting
up/leaning forward).

 Administer other medications as prescribed.

1. Anticholinergics
2. Antibiotics
3. Vitamin supplements
4. Pancreatic enzymes such as pancreatin (Donnazyme), pancrelipase (Viokase); take with
meals and snacks to aid with digestion of fats and proteins.

 Monitor blood glucose levels and provide insulin as needed (potential for hyperglycemia).
 Monitor hydration levels (orthostatic blood pressure, intake and output, laboratory values).
 Monitor for hypocalcemia.
 Tetany
 Trousseau’s sign (hand spasm when blood pressure cuff is inflated on that arm)
 Chvostek’s sign (facial twitching when facial nerve is tapped)

Complications and Nursing Implications:

 Hypovolemia (up to 6 L can be third-spaced, retroperitoneal loss of protein rich fluid from
proteolytic digestion): Monitor vital signs, provide IV fluid and electrolyte replacement.
 Chronic pancreatitis: Avoid alcohol intake, participate in alcoholic support groups.
 Hypocalcemia
 Pancreatic Infection: Pseudocyst (outside pancreas); abscess (inside pancreas)
 Type 1 diabetes mellitus: Total destruction of the pancreas
 Left lung effusion and atelectasis: Monitor for hypoxia, provide ventilator support.
 Organ failure (for example, renal failure): Monitor laboratory values, provide organ support.
 Coagulation defects (for example, disseminated intravascular coagulopathy): Monitor bleeding
times.

Meeting the Needs of Older Adults:

 The primary cause of chronic pancreatitis is chronic alcoholism. The older adult client can
become dependent on alcohol to cope with life changes. Explore alcohol intake. Age-related
changes reduce the older adult’s ability to physiologically handle alcohol.

Application Exercises:

1. Which of the following nursing interventions are appropriate for a client diagnosed with acute
pancreatitis? (Check all that apply.)

_____ Drink plenty of fluids.

__x__ Avoid alcohol.
__x__ Avoid smoking.
 __x__ Encourage relaxation.
_____ Place the client in a rescuer position for maximum comfort.
_____ Practice pursed-lip breathing.

The client is initially NPO. Fluids are needed, but by IV route. Clients are more comfortable
with the head of the bed elevated or sitting, leaning forward. The rescuer position is flat,
side-lying. Pursed-lip breathing is used to extend the exhalation for air trapping with COPD
clients. Clients with pancreatitis are encouraged to deep breathe.

2. A client is admitted to the hospital with a diagnosis of an acute pancreatitis attack. Which of the
following client assessments is most important for the nurse to follow up on first?

A. History of cholelithiasis
B. Serum amylase levels are three times the normal value
C. Reports severe pain radiating to the back, rated at “8”
D. Hand spasm present when the nurse is taking the blood pressure

Trousseau’s sign indicates hypocalcemia, a systemic complication that can have cardiac
effects. This must be dealt with first. Biliary tract disease is one of the two leading causes
of acute pancreatitis and probably explains why the client has this problem. Elevated
serum amylase and lipase levels are how the diagnosis is made. Pain is not desirable and
should be treated with meperidine (Demerol), but the systemic hypocalcemia is the
priority.

3. The client has arrived from the emergency department with the diagnosis of acute pancreatitis.
Which of the following client assessment findings is most important for the nurse to deal with
first?

A. Client has bluish discoloration around the periumbilical area.

B. Lying: BP 120/80 mm Hg, HR 80 beats/min; standing: BP 94/70 mm Hg,
HR 110 beats/min.
C. Serum amylase and lipase levels are five times the normal values.
D. Client reports vomiting two times in the last hour.

The client is experiencing orthostatic changes and needs fluid replacement. Cullen’s sign
(bluish periumbilical discoloration) and vomiting are expected findings. Elevated enzyme
levels are how the diagnosis is made, but the level of rise does not necessarily correlate
with the seriousness of the disease episode.

4. Which of the following is most important for a nurse to teach a client who is hospitalized with
acute pancreatitis?

A. Technique regarding how to give home injections of insulin

B. Importance of monitoring amylase and lipase levels
C. Avoidance of alcohol use for 1 year
D. Use of aspirin instead of acetaminophen (Tylenol) as an OTC medication

Chronic alcohol consumption can cause chronic pancreatitis. Clients may need insulin
 initially for hyperglycemia, but generally not as healing occurs. Amylase and lipase levels
are used for diagnostic purposes (released from the injured cells) and are usually close to
normal around 2 weeks. Tylenol does not need to be avoided in pancreatitis; it is avoided
in hepatitis.

5. A client had a Whipple procedure 3 days ago for pancreatic cancer. Which of the following client
assessments is most important for the nurse to follow up?

A. Bowel sounds are auscultated 10/min

B. Wound edges are slightly edematous, reddish, and soft
C. Client reports abdominal pain radiating to shoulder and has a fever
D. WBC 9,000/mm3

These are classic signs and symptoms of peritonitis and require further investigation.
The bowel sounds are within normal range (5 to 35/min) and would be anticipated to be
hypoactive 3 days postoperative. Wound edges should show minor inflammation. Slight
elevation of WBC is expected after surgery due to inflammation.
Pancreatitis and Pancreatic Cancer

6. Discuss some possible complications following a Whipple procedure for a client with pancreatic
cancer. For each identify an appropriate nursing intervention.

Fistula (most serious and most common). Monitor for signs and symptoms of peritonitis such
as elevated fever, WBC, abdominal pain, abdominal tenderness/rebound tenderness,
alteration in bowel sounds, pain radiating to shoulder.

Hyperglycemia/diabetes mellitus. Monitor blood glucose.

Wound infection. Monitor temperature and wound site.

Bowel obstruction. Monitor bowel sounds, stool.

Intra-abdominal abscess. Monitor temperature, pancreatitis-like severe pain.

Pulmonary complications. Monitor breath sounds, pulse oximetry, and respirations.