Overview of the disease:

Diseases of the gallbladder and biliary tract are common, typically painful conditions that usually
require surgery and may be life-threatening. They’re commonly associated with deposition of
calculi and inflammation. In most cases, gallbladder and bile duct diseases occur during middle
age. Between ages 20 and 50, they’re six times more common in women, but the incidence in
men and women becomes equal after age 50. After that, incidence rises with each succeeding
decade.

Anatomy and physiology of gallbladder

What is the gallbladder?

o The gallbladder is a hollow organ that sits in a concavity of the liver known as the
gallbladder fossa.
o The gallbladder is a pear shaped organ located on the liver that stores bile.
o It is connected to the intestinal system by the cystic duct which in turn empties into the
common bile duct. When we eat a large or fatty meal, nerve and chemical signals cause
our gallbladder to contract thereby adding bile into our digestive system.
o In adults, the gallbladder measures approximately 8 cm in length and 4 cm in diameter
when fully distended. It is divided into three sections: fundus, body, and neck. The neck
tapers and connects to the biliary tree via the cystic duct, which then joins the common
hepatic duct to become the common bile duct.
What is bile?
Bile is a complex fluid composed of bile salts, cholesterol and other molecules (phospholipids
and lecithin). The bile salts are the breakdown products of hemoglobin, the oxygen carrying
pigment of red blood cells. Bile salts and bile itself are formed in the liver and excreted into bile
ducts which converge in the liver to form the main bile ducts. Just as there is a left and right
liver lobe, there are left and right hepatic (liver) bile ducts which join to form a single bile duct,
the common hepatic or common bile duct. The common bile duct enters the duodenum, the
earliest part of the small intestine where digestion and absorption of food begins. You may
recognize the word duodenum since it is the most common site for ulcers. Normally we make
1000 to 1500cc of bile a day. It is constantly produced. As a result, there is always a steady
amount of bile entering our intestinal tract. Some of it goes into the gallbladder as it comes
down the duct. It is stored there until neurochemical signals cause the gallbladder to contract.
This provides additional bile to the intestinal system. These neurochemical signals usually occur
after eating.

Most common disorder of Gallbladder

o Galls eating. tones (Cholelithiasis)

 The most common disorder of the biliary tract (gallbladder and bile ducts) is
gallstones
 Gallstones occur very frequently in developed countries and may be associated
with eating a diet that is high in fat and refined carbohydrates and low in fiber.
 The problems that gallstones can give rise to are various and include cholecystitis
(inflammation of the gallbladder), choledocholithiasis (gallstones in the common
bile duct), and cholangitis (infection of the bile ducts), pancreatitis, and gallstone
ileus (obstruction of the intestines by a gallstone).

“Cholesterol is the major constituent of gallstones”.

Risk factor in Gallbladder disease:

 Advanced age
 Gender (female)
 Obesity with high fat intake
 Hormonal imbalance (estrogen, progestin, insulin)
 Certain drugs (oral contraceptives, clofibrate, cholestyramine)
 Enzyme defects
 Very low calorie diets.

Signs and symptoms

• Mild aching pain in the midepigasatrium

• Nausea and vomiting
• Tachycardia
• Diaphoresis
• Fever
• Flatulence, belching, epigastric heaviness, ingestion, heartburn
• Chronic upper abdominal pain
• Jaundice

Diagnosis

• Ultrasonography and X-rays detect gallstones. Specific procedures include the following:
o Ultrasonography reflects stones in the gallbladder with 96% accuracy.
o Percutaneous transhepatic cholangiography allows imaging under fluoroscopic
control to help distinguish between gallbladder or bile duct disease and cancer of
the pancreatic head in patients with jaundice.
o Endoscopic retrograde cholangiopancreatography visualizes the biliary tree after
insertion of an endoscope down the esophagus into the duodenum, cannulation of
the common bile and pancreatic ducts, and injection of contrast medium.
o Hepatobiliary iminodiacetic acid analogue scan of the gallbladder helps detect
obstruction of the cystic duct.
o Computed tomography scan, although not routinely used, helps distinguish
between obstructive and nonobstructive jaundice.
o Plain abdominal X-rays identify calcified but not cholesterol stones with 15%
accuracy.
o Oral cholecystography shows stones in the gallbladder and biliary duct
obstruction
 -Elevated icteric index and elevated total bilirubin, urine bilirubin, and alkaline
phosphatase levels support the diagnosis. White blood cell count is slightly elevated during a
cholecystitis attack.Differential diagnosis is essential because gallbladder disease can mimic
other diseases (myocardial infarction, angina, pancreatitis, pancreatic head cancer, pneumonia,
peptic ulcer, hiatal hernia, esophagitis, and gastritis). Serum amylases levels help distinguish
gallbladder disease from pancreatitis. With suspected heart disease, cardiac enzyme tests and an
electrocardiogram should precede gallbladder and upper GI diagnostic tests.

Treatment

Surgery
Usually elective
Is the treatment of choice for gallbladder and bile duct diseases.
Surgery may include open or laparoscopic cholecystectomy, cholecystectomy with operative
cholangiography and, possibly, exploration of the common bile duct
Other treatment includes a low-fat diet to prevent attacks and vitamin K for itching, jaundice,
and bleeding tendencies resulting from vitamin K deficiency. Treatment during an acute
attack may include insertion of a nasogastric tube and an I.V. line and, possibly,
administration of an antibiotic.
A nonsurgical treatment for choledocholithiasis involves insertion of a flexible catheter, formed
around a biliary tube (T tube), through a sinus tract into the common bile duct. Guided by
fluoroscopy, the catheter is directed toward the stone. A Dormia basket is threaded through
the catheter, opened, twirled to entrap the stone, closed, and withdrawn.

Nursing consideration and interventions:

Before surgery, teach the patient to deep breathe, cough, expectorate, and perform leg exercises
that are necessary after surgery. Also, teach splinting, repositioning, and ambulation
techniques. Explain the perioperative procedures to help ease the patient’s anxiety and
ensure his cooperation.
After surgery, monitor vital signs for indications of bleeding and infection.
If a T tube is surgically placed, maintain tube patency and secure placement. Measure and record
bile drainage daily (200 to 300 ml is normal).
If your patient will be discharged with a T tube, teach him how to perform dressing changes and
routine skin care.
Patients who have had a laparoscopic cholecystectomy may be discharged the same day or
within 48 hours after surgery. These patients should have minimal pain, be able to tolerate
a regular diet within 24 hours after surgery, and be able to return to normal activity within
a week.
Encourage the patient to perform deep-breathing and leg exercises every hour. The patient
should ambulate after surgery. Provide antiembolism stockings to support leg muscles and
promote venous blood flow to prevent stasis and clot formation.
Assess the location, duration, and character of any pain. Administer an analgesic, as needed, to
relieve pain.
At discharge (usually the day of surgery or 1 to 2 days afterward), teach the patient that food
restrictions are unnecessary unless he has intolerance to a specific food or some underlying
condition (such as diabetes, atherosclerosis, or obesity) that requires such restriction.

Sources:

• Book Title: Handbook of Diseases

• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams &
Wilkins.

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