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Approach to a PatientApproach to a Patientwith Gallbladderwith Gallbladder
DiseaseDisease
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Anatomy of theAnatomy of theGallbladderGallbladder
Pear-shapedPear-shapedhollow sac-likehollow sac-likeorgan;organ;lies in a shallowlies in a shallowdepression on thedepression on theinferior surface of inferior surface of the liverthe liverNormal capacity isNormal capacity is30-50ml30-50ml
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Bile FlowBile Flow
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In the fasting state, the Sphincter of In the fasting state, the Sphincter of Oddi offers a high pressure zone:Oddi offers a high pressure zone:
- to prevent reflux of duodenal- to prevent reflux of duodenalcontents into the bile ductscontents into the bile ducts
- to promote bile filling of the- to promote bile filling of thegallbladdergallbladder
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CholecystokininCholecystokinin- is released in the duodenal- is released in the duodenal
mucosa in response to the ingestionmucosa in response to the ingestionof fats and amino acids.of fats and amino acids.Contraction of gallbladder Contraction of gallbladder
Decreased resistance of the Sphincter of Decreased resistance of the Sphincter of OddiOddiIncreased hepatic secretion of bileIncreased hepatic secretion of bile
Enhanced flow of biliary contents into theEnhanced flow of biliary contents into theduodenumduodenum
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Enterohepatic CirculationEnterohepatic Circulation
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Diseases of theDiseases of the
GallbladderGallbladder
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Acute CholecystitisAcute Cholecystitis
Types: calculous (90%) stone Types: calculous (90%) stoneobstructsobstructs bilebileoutflowoutflow
acalculous absence of acalculous absence of obstructionobstruction byby
stonesstones
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Cholelithiasis (Gallstones)Cholelithiasis (Gallstones)
Formation of stones in the cystic ductFormation of stones in the cystic duct Types of Stones: Types of Stones:- cholesterol- cholesterol- pigment- pigment
- stones- stones
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Risk Factors:Risk Factors:ObesityObesityWomen,especially those who hadWomen,especially those who hadmultiple pregnanciesmultiple pregnancies
Frequent changes in weightFrequent changes in weightRapid weight lossRapid weight loss
Treatment with high dose estrogen Treatment with high dose estrogenIleal resection/ diseaseIleal resection/ diseaseDiabetes MellitusDiabetes Mellitus
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PathophysiologyPathophysiology
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Clinical ManifestationsClinical Manifestations
Pain and Biliary ColicPain and Biliary Colic Jaundice JaundiceChanges in urine and stool colorChanges in urine and stool colorVitamin DeficiencyVitamin Deficiency
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Diagnostic ProceduresDiagnostic Procedures
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A.A. Plain Abdominal X-ray - to rule outPlain Abdominal X-ray - to rule outotherother possible diseasespossible diseases
B.B. US detects gallstones with 95%US detects gallstones with 95%accuracyaccuracy
C.C. Cholescintigraphy biliary tract isCholescintigraphy biliary tract is
scanned afterscanned afteradministration of aadministration of aradioactive agentradioactive agent
D.D. Cholecystography to visualizeCholecystography to visualizebiliarybiliary tract; x-ray istract; x-ray isobtained after anobtained after an oraloralcontrast is administeredcontrast is administered
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Surgical ManagementSurgical Management
Laparoscopic CholecystectomyLaparoscopic CholecystectomyOpen CholecystectomyOpen Cholecystectomy
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Nutritional and SupportiveNutritional and Supportive
Therapy Therapy80% of patients with acute80% of patients with acutecholecystitis achieve remission withcholecystitis achieve remission with
rest, IV fluids, analgesia andrest, IV fluids, analgesia andantibioticsantibioticsLow-fat liquid diet; should avoid hihgLow-fat liquid diet; should avoid hihg
fat dietfat diet
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Pharmacologic ManagementPharmacologic Management
Dissolving agentsDissolving agentsUrsodeoxycholic acidUrsodeoxycholic acid
Chenodeoxycholic acidChenodeoxycholic acid*** desaturates bile by inhibiting the*** desaturates bile by inhibiting the
synthesis and secretion of cholesterolsynthesis and secretion of cholesterol
*** taken for 6-12months*** taken for 6-12months
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Nonsurgical ManagementNonsurgical Management
Dissolving gallstones infusion of aDissolving gallstones infusion of asolvent in the gallstone (MTBE)solvent in the gallstone (MTBE)
Stone removal by instrumentationStone removal by instrumentationExtracorporeal Shock-waveExtracorporeal Shock-waveLithotripsyLithotripsyIntracorporeal LithotripsyIntracorporeal Lithotripsy
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Nursing ManagementNursing Management
AssessmentAssessmentHistory takingHistory taking
Preadmission testingPreadmission testingClient teaching on proceduresClient teaching on proceduresPatients capability to undergoPatients capability to undergo
procedureprocedure
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DiagnosisDiagnosisAcute pain and discomfortAcute pain and discomfort
Impaired gas exchange r/t highImpaired gas exchange r/t highabdominal surgical incisionabdominal surgical incisionImpaired skin integrity r/t altered biliaryImpaired skin integrity r/t altered biliary
drainage (T-tube)drainage (T-tube)Imbalance nutritionImbalance nutritionDeficient knowledge about self-careDeficient knowledge about self-careactivities r/t incision care, dietaryactivities r/t incision care, dietarymodifications, medications and follow-modifications, medications and follow-upup
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Planning and GoalsPlanning and GoalsRelief of painRelief of painAdequate ventilationAdequate ventilation
Intact skin and improved biliaryIntact skin and improved biliarysecretionsecretionOptimal nutrition intakeOptimal nutrition intake
Absence of complicationsAbsence of complicationsUnderstanding of self-care routinesUnderstanding of self-care routines
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Nursing InterventionsNursing InterventionsMonitoring and Managing ComplicationsMonitoring and Managing Complications
Bleeding, infection, leakageBleeding, infection, leakageImproving Nutritional StatusImproving Nutritional StatusLow fat high carbohydrate and proteinLow fat high carbohydrate and protein
Promoting Skin Care and BiliaryPromoting Skin Care and Biliary
DrainageDrainage T-tube care T-tube care
Improving Respiratory StatusImproving Respiratory Status Turning, early ambulation, deep breathing Turning, early ambulation, deep breathing
exercisesexercisesRelieving PainRelieving Pain
Administer analgesics as orderedAdminister analgesics as orderedPillow or binder on the side of incision sitePillow or binder on the side of incision site
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EvaluationEvaluationReports decrease in painReports decrease in painDemonstrates appropriate respiratoryDemonstrates appropriate respiratoryfunctionfunctionExhibits normal skin integrityExhibits normal skin integrityObtains relief of dietary intoleranceObtains relief of dietary intolerance
Absence of complicationsAbsence of complications