the biliary system and carcinoma that obstructs the

biliary tree. Gallbladder disease with stones is the

most common disorder of the biliary system.

Not all occurrences of cholecystitis are related to

stones (calculi) in the gallbladder (cholelithiasis) or
stones in the common bile duct (choledocholithiasis).
However, most of the 15 million Americans with
gallstones have no pain and are unaware of the
presence of stones

Cholecystitis
- (inflammation of the gallbladder which can be acute
or chronic) causes pain, tenderness, and rigidity of
the upper right abdomen that may radiate to the
midsternal area or right shoulder and is associated
with nausea, vomiting, and the usual signs of an
acute inflammation.

- An empyema of the gallbladder develops if the

gallbladder becomes filled with purulent fluid (pus).

Calculous cholecystitis (Cholelithiasis) is the cause

of more than 90% of cases of acute cholecystitis

Anatomic and Physiologic

Gallbladder
The gallbladder, a pear-shaped, hollow, saclike
organ that is 7.5 to 10 cm (3 to 4 inches) long, lies in
a shallow depression on the inferior surface of the
liver, to which it is attached by loose connective
tissue. The capacity of the gallbladder is 30 to 50 mL
of bile.

Its wall is composed largely of smooth muscle. The

gallbladder is connected to the common bile duct by
the cystic duct

-Functions as a storage depot for bile

Bile is composed of water and electrolytes (sodium,

potassium, calcium, chloride, and bicarbonate) along
with significant amounts of lecithin, fatty acids,
cholesterol, bilirubin, and bile salts.

Disorders of the Gallbladder

Several disorders affect the biliary system and
interfere with normal drainage of bile into the
duodenum. These disorders include inflammation of
 ➡️
Risk Factors Cholesterol bile

➡️
production is excessive Bile
salts cannot fully dissolve

➡️
Biliary Stasis (pooling-

➡️
stagnation) Gallbladder bile

➡️
precipitation Stone formation:

➡️ 🔽
Cholelithiasis Inflammation:

➡️ 🔼
Cholecystitis Biliary
Spasm: Biliary colic Blood
flow into the colon

Stool: Gray/ Clay= Acholic

Bilirubin into Blood= Jaundice

Clinical Manifestations

- Pain: Right upper quadrant

Radiation: Right shoulder,
Scapula Midsternum
Aggravated by an increased fats
in the diet and alcohol
Cholelithiasis consumption
Calculi, or gallstones, usually form in the gallbladder - Murphy Sign: (+) Pain Right upper quadrant upon
from the solid constituents of bile; they vary greatly in palpation during deep breathing
size, shape, and composition - Fever r/t inflammation
- Nausea & Vomiting
- Jaundice (yellowish sclera or skin)
- Gray colored stool (acholic stool)
- Tea colored urine (dark)

Vitamin Deficiency

Obstruction of bile flow interferes with absorption of

the fat-soluble vitamins A, D, E, and K. Patients may
exhibit deficiencies of these vitamins if biliary
obstruction has been prolonged.

Pathophysiology For example, a patient may have bleeding caused by

vitamin K deficiency (vitamin K is necessary for
Risk Factors: normal blood clotting).
Fat: Obesity-
Female Assessment and Diagnostic Findings
Fertile or multiparous
Fifty years of age :25-30% and 50% of women by Abdominal X-ray:
age of 70
Oral Contraceptives, Estrogen, or Clorfibrate - If gallbladder disease is suspected, an abdominal
(Atromid- S): these medications are known to x-ray may be obtained to exclude other causes of
increase biliary cholesterol saturation symptoms.
- However, only 10% to 15% of gallstones are
calcified sufficiently to be visible on such x-ray
studies
Blood results
A. Bilirubin – above 0.3-1mg/dl
B. WBC- above 5000-1000 cells/mm3
c. Alkaline Phosphatase – 44-147 IU/L
Medical Management
- Nutritional Therapy and Supportive Therapy
- Relieve Pain
- Analgesic: Morphine
- Bed Rest
- Position: Knee chest
- Diet : Decrease fatty intake ( Fried foods, organ
meats, Pastries, etc.)
- Chenodeoxycholic acid (chenodiol) and
Ursodeoxycholic acid (Ursodiol)
- Extracorporeal Shock Wave Lithotripsy (ESWL)
- Intracorporal Lithotripsy
Surgical Management
A. Laparoscopic Cholecystectomy
B. Cholecystectomy
C. Choledechostomy
D. Surgical Cholecystostomy
E. Percutaneous Cholecystectomy
 The most basic classification system used to
describe or categorize the various stages and forms
of pancreatitis divides the disorder into acute and
chronic forms.

Acute Pancreatitis

Acute pancreatitis ranges from a mild, self-limited

disorder to a severe, rapidly fatal disease that does
not respond to any treatment.

These two main types of acute pancreatitis (mild and

severe) are classified as interstitial edematous
pancreatitis and necrotizing pancreatitis,
respectively.

Approximately 200,000 cases of acute pancreatitis

occur in the United States each year, of which 80%
are the result of cholelithiasis or sustained alcohol
abuse

GERONTOLOGIC CONSIDERATION
Acute pancreatitis affects people of all ages, but the
mortality rate associated with acute pancreatitis
increases with advancing age

Younger patients tend to develop local complications;

the incidence of multiple organ dysfunction
syndrome (MODS) increases with age, possibly as a
result of progressive decreases in physiologic
function of major organs with increasing age.

Close monitoring of major organ function (i.e., lungs,

kidneys) is essential, and aggressive treatment is
Disorders of the pancreas necessary to reduce mortality from acute pancreatitis
in the older adult patient.

Pathophysiology

➡️
Gallstones enter the common bile duct and lodge at

➡️
the ampulla of Vater obstructing the flow of
pancreatic juice causing a reflux of bile from the
common bile duct into the pancreatic duct, thus
activating the powerful enzymes within the pancreas
Activation of the enzymes can lead to vasodilation,

➡️
increased vascular permeability, necrosis, erosion,

Pancreatitis
(Inflammation of the pancreas) is a serious disorder.
➡️
and hemorrhage Proteases damage to cell and
vasculature through protein mediator damage
Amylase levels increase in the blood (Useful for
diagnosing pancreatitis, 3x above normal range)
➡️ Lipases also increase in the blood and can result
of a serious complication of fatty necrosis of the
pancreas.

ETIOLOGY
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion veum
Hypercalcemia, Hyperlipidemia
ERCP
DRUGS

CLINICAL MANIFESTATIONS Diagnostic Tests

- Nausea and Vomiting 1. Blood:
- Gradual/Sudden Severe epigastric pain A. Serum Amylase
Pain radiates to the back (tripoding relieves pain), N°: 25-150 IU/L
After heavy meal/ Alcohol Result: Above normal indicates injury of the
- Tachycardia pancreas
- Jaundice
- Fever B. Serum Lipase
-Bluish/ Purplish discoloration = + Hemorrhagic N°: 10-140 IU/L
pancreatitis Result: Above normal indicates Pancreas injury after
3 days above normal in the blood
If on the flank (Back): Grey Turner’s Sign
If on periumbilical area: Cullen’s Sign 2. X-ray
3. Ultrasound
4. CT scans and MRI

Medical Management Nursing Management

1. Nasogastric Tube for feeding
2. Administration of IV fluids
3. Antiemetic agents
4. Analgesia (Morphine)
5. Urinary Catheterization
6. Daily Serology (CBC, Amylase, Electrolytes, Urea,
and Creatinine)
7. Hourly Vital signs

Chronic Pancreatitis
Chronic pancreatitis is an inflammatory disorder
characterized by progressive destruction of the
pancreas. As cells are replaced by fibrous tissue with
repeated attacks of pancreatitis, pressure within the
pancreas increases.

The result is obstruction of the pancreatic and

common bile ducts and the duodenum. In addition,
there is atrophy of the epithelium of the ducts,
inflammation, and destruction of the secreting cells
of the pancreas.
Alcohol consumption in Western societies and
malnutrition worldwide are the major causes of
chronic pancreatitis.
Clinical Manifestations
- Nausea and Vomiting
- Gradual/Sudden Severe epigastric pain
Pain radiates to the back (tripoding relieves pain),
After heavy meal/ Alcohol
- Tachycardia
- Jaundice
- Fever
-Bluish/ Purplish discoloration = + Hemorrhagic
pancreatitis
If on the flank (Back): Grey Turner’s Sign
If on periumbilical area: Cullen’s Sign
- Steatorrhea (As a result, digestion, especially of
proteins and fats, is impaired)
- Pancreatic Calculi
- Weight loss
Diagnostic Tests
1. Endoscopic Retrograde
Cholangiopancreatography (ERCP) is the most
useful study in the diagnosis of chronic pancreatitis.
It provides details about the anatomy of the pancreas
and the pancreatic and biliary ducts.
It is also helpful in obtaining tissue for analysis and
differentiating pancreatitis from other conditions,
such as carcinoma
2. X-ray
3. Ultrasound
4. CT scans and MRI
5. A glucose tolerance test evaluates pancreatic islet
cell function and provides necessary information for
making decisions about surgical resection of the
pancreas.
Medical Management
-The management of chronic pancreatitis depends
on its probable cause in each patient.
Treatment is directed toward preventing and
managing acute attacks, relieving pain and
discomfort, and managing exocrine and endocrine
insufficiency of pancreatitis
Pancreatic Cysts
- As a result of the local necrosis that occurs
because of acute pancreatitis, collections of fluid
may form close to the pancreas.
These fluid collections become walled off by fibrous
tissue and are called pancreatic pseudocysts.
Pseudocysts are amylase-rich fluid collections
contained within a wall of fibrous granulation tissue
that occur within 4 to 6 weeks after an episode of
acute pancreatitis.
They are a result of pancreatic necrosis, which
produces a pancreatic ductal leak into pancreatic
tissue weakened by extravasating enzymes
Pseudocysts are the most common type of
pancreatic ”cyst.”
Less common cysts occur as a result of congenital
anomalies or secondary to chronic pancreatitis or
trauma to the pancreas.
Diagnosis of pancreatic cysts and pseudocysts is
made by ultrasound, CT scan, and ERCP. ERCP
may be used to define the anatomy of the pancreas
and evaluate the patency of pancreatic drainage
Cancer of the Pancreas
Pancreatic cancer is the fourth leading cause of
cancer death in men in the United States and the
fifth leading cause of cancer death in women.
Risk Factors obstruct the common bile duct where the duct
- African American males passes through the head of the pancreas to join the
- Cigarette smoking pancreatic duct and empty at the ampulla of Vater
- Exposure to industrial chemicals or toxins in the into the duodenum.
environment
- Diet high in fat, meat, or both are associated risk The tumors producing the obstruction may arise from
factors the pancreas, the common bile duct, or the ampulla
- The risk of pancreatic cancer is greater in those of Vater
with a history of increased pack years of cigarette
smoking. Diagnostic Tests
- Diabetes, chronic pancreatitis, and hereditary Diagnostic studies may include duodenography,
pancreatitis are also associated with pancreatic angiography by hepatic or celiac artery
cancer catheterization, pancreatic scanning, PTC, ERCP,
and percutaneous needle biopsy of the pancreas.
Clinical Manifestations Results of a biopsy of the pancreas may aid in the
● Pain diagnosis.
● Jaundice
● Weight loss Clinical Manifestations
● Vague upper or midabdominal pain or ● Pain
discomfort that is unrelated to any GI function ● Jaundice
and is often difficult to describe. ● Weight loss
● Ascites ● Steatorrhea

Diagnostic Tests Medical Management

1. Endoscopic Retrograde
Cholangiopancreatography (ERCP) -Preoperative preparation includes adequate
2. X-ray hydration, correction of prothrombin deficiency with
3. Ultrasound vitamin K, and treatment of anemia to minimize
4. CT scans and MRI postoperative complications
5. A glucose tolerance test evaluates pancreatic islet
cell function and provides necessary information for - Enteral or parenteral nutrition and blood component
making decisions about surgical resection of the therapy are frequently required.
pancreas.
- pancreaticoduodenectomy is used for potentially
Nursing Management resectable cancer of the head of the pancreas
1. Pain management
2. Attention to nutritional requirements
3. Skin care and nursing measures are
directed toward relief of pain and discomfort
associated with jaundice, anorexia, and
profound weight loss.
4. Specialty mattresses are beneficial and
protect bony prominences from pressure.

Tumors of the head of the pancreas

Tumors of the head of the pancreas
comprise 60% to 80% of all pancreatic
tumors .

Tumors in this region of the pancreas

Nursing Management
- Preoperatively and postoperatively, nursing care is
directed toward promoting patient comfort,
preventing complications, and assisting the patient to
return to and maintain as normal and comfortable a
life as possible.
- Closely monitors the patient in the ICU after
surgery
- Monitor Vital signs
- Monitor ABG
- Monitor Laboratory output
- Monitor urine output
- Monitor nutritional status and risk of bleeding
- Support the patient’s psychological and emotional
status, along with the SO
Pancreatic Islet Tumors
At least two types of tumors of the pancreatic islet
cells are known: those that secrete insulin
(insulinoma) and those in which insulin secretion is
not increased (nonfunctioning islet cell cancer).
All of these types of tumors combined are termed
neuroendocrine tumors
Insulinomas produce hypersecretion of insulin and
cause an excessive rate of glucose metabolism.
The resulting hypoglycemia may produce symptoms
of weakness, mental confusion, and seizures. The
5-hour glucose tolerance test is helpful to diagnose
insulinoma and to distinguish a diagnosis of NET
from other causes of hypoglycemia.
Surgical Management
If a tumor of the islet cells (a type of NET) has been
diagnosed, surgical treatment with removal of the
tumor is usually recommended
The tumors may be benign adenomas, or they may
be malignant.
Complete removal usually results in almost
immediate relief of symptoms. In some patients,
symptoms may be produced by simple hypertrophy
of this tissue rather than a tumor of the islet cells.
In such cases, a partial pancreatectomy (removal of
the tail and part of the body of the pancreas) is
performed.
Nursing Management
Prepare patient for surgery
Be alert for symptoms of hypoglycemia and be ready
to administer glucose as prescribed if symptoms
occur.
Postoperatively, the nursing management is the
same as after other upper abdominal surgical
procedures, with special emphasis on monitoring
serum glucose levels.
Patient education is determined by the extent of
surgery and alterations in pancreatic function.
Hyperinsulinism
Hyperinsulinism is caused by overproduction of
insulin by the pancreatic islets.
Symptoms resemble those of excessive doses of
insulin and are attributable to the same mechanism:
an abnormal reduction in blood glucose levels.
Clinically, it is characterized by episodes during
which the patient experiences 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 (overgrowth) of the islets of
Langerhans or a benign or malignant tumor involving
the islets that is capable of producing large amounts
of insulin
Clinical Manifestations
Symptoms resemble those of excessive doses of
insulin and are attributable to the same mechanism:
an abnormal reduction in blood glucose levels.
Clinically, it is characterized by episodes during
which the patient experiences unusual hunger
nervousness
Sweating
Headache
faintness in severe cases, seizures and episodes of
unconsciousness may occur.
Occasionally, tumors of nonpancreatic origin produce
an insulinlike material that can cause severe
hypoglycemia and may be responsible for seizures
coinciding with blood glucose levels that are too low
to sustain normal brain function (i.e., lower than 30
mg/dL [1.6 mmol/L])
Medical Management
These tumors, which may be benign or malignant,
are treated by excision, if possible.
Frequently, however, removal is not possible
because of extension beyond the pancreas and
because the tumors are often quite small and difficult
to locate.

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. About 15%
of patients with spontaneous or functional
hypoglycemia eventually develop diabetes.
Ulcerogenic Tumors
Some tumors of the islets of Langerhans are
associated with hypersecretion of gastric acid that
produces ulcers in the stomach, duodenum, and
jejunum.
Acid hypersecretion in patients with gastrinoma can
be managed with proton pump inhibitors and this is
often the first-line treatment intervention.
Highly selective vagotomy may make management
easier in some patients and should be considered in
those with surgically untreatable or unresectable
gastrinoma.
Total gastrectomy for Zollinger-Ellison is not
indicated
Embolization or radiofrequency ablation may also be
used to control the tumor.

This is referred to as Zollinger-Ellison syndrome.

The hypersecretion is so excessive that even after
partial gastric resection, enough acid is produced to
cause further ulceration.
If a marked tendency to develop gastric and
duodenal ulcers is noted, an ulcerogenic tumor of the
islets of Langerhans is considered

Clinical Manifestations
Nausea
Vomiting
Diarrhea
burning discomfort or pain in the upper abdomen.

Diagnostic Tests

The diagnostic test for this disorder includes

measuring a blood gastrin level. Imaging tests may
include CT scan or MRI, EUS or upper endoscopy

Scintigraphy and positron emission tomography

(PET)/CT are sensitive and specific tests for this
disease