Gallbladder cancer and biliary duct cancer are relatively rare and account for fewer than 1% of all cancers. In 2005, over 3200 cases will be diagnosed and almost 2000 people will die of this cancer. Gallbladder cancer occurs five times more often in Native Americans than in whites and is more common in white females than in African American females. Most cancers of the gallbladder and biliary tract are inoperable at the time of diagnosis. If the cancer has been found incidentally at the time of a cholecystectomy, longer survival may be possible. More than 75% of gallbladder cancers are nonpapillary adenocarcinomas and approximately 6% are papillary adenocarcinomas; a small number are squamous cell, adenosquamous cell, mucinous, or small cell carcinomas. Papillary cancers have a better prognosis and grow along the connective tissue and blood vessels; they are not as likely to metastasize to the liver and lymph nodes. Adenocarcinomas occur most frequently at the bifurcation in the common bile duct.
Biliary system cancer is insidious and metastasizes via the lymphatic and blood systems and by direct extension to the liver, pancreas, stomach, and duodenum. Invasion of the gastrointestinal (GI) tract can cause complete obstruction of the extrahepatic bile ducts with intrahepatic biliary dilation and enlargement of the liver. If the tumor is restricted to one hepatic duct, biliary obstruction is incomplete and jaundice may not be present. Inflammatory disorders such as cholangitis (bile duct inflammation) and peritonitis often obscure an underlying malignancy. Infection often accompanies cancer of the gallbladder, and bile duct cancers are associated with ulcerative colitis. In most patients with gallbladder and biliary cancer, the disease progresses rapidly and patients usually survive little more than a year after diagnosis.
The cause of biliary system cancer is unknown, although a possibility is gallstones. When gallstones are present, bile is released more slowly. If the bile contains carcinogens, the gallbladder tissue is exposed to these carcinogens for a longer period of time. Approximately 1% of all cholecystectomy specimens are found to be cancerous. Because of the risk of cancer, even for asymptomatic cholelithiasis, a cholecystectomy is recommended. Primary carcinoma of the gallbladder is rare and is usually associated with cholecystitis. Most biliary cancer is from metastasis, commonly from the head of the pancreas.
Nursing care plan assessment and physical examination
Some patients who do not have symptoms that can be traced back to the gallbladder may describe symptoms similar to those of cholelithiasis or cholecystitis because these result from obstruction and inflammation of the biliary tree. The most common symptom is intermittent to steady pain in the upper right abdomen. Mild pain in the epigastric area may also be reported. GI symptoms are related to the blockage of bile. Patients may complain of anorexia, nausea, vomiting, belching, diarrhea, and weight loss. Diarrhea may be related to steatorrhea, and weight loss can be as much as 14 to 28 pounds. Because of frequent metastasis to the liver and pancreas, there may be clinical manifestations of cancer in those organs.
Patients with extensive disease may appear thin and malnourished. Determine if the patient is jaundiced from an enlarging tumor that is pressing on the extrahepatic ducts, but note that jaundice may be delayed if only one main duct is involved. Inspect for skin irritation and skin trauma because of pruritus. If the tumor is of sufficient size, an abdominal mass may be palpated; this mass in the gallbladder area feels hard and is sometimes tender. Intrahepatic metastases are not usually palpable. If the abdomen is distended, individual organs may be difficult to palpate. The liver may be very large and smooth, 5 to 12 cm below the costal margin.
Because the prognosis of biliary cancer is poor, determine how much the patient understands. Determine if the patient is moving through the stages of death and dying, and be accepting of the patient’s attitude toward the diagnosis.
Nursing care plan primary nursing diagnosis: Pain (acute) related to obstruction of biliary tree.
Nursing care plan intervention and treatment plan
Most medical treatment is aimed at supportive care, such as controlling the GI symptoms and the discomforts of jaundice. A cholecystectomy is done as soon as possible after the cancer is detected, although the cancer may have been found by doing the surgery for cholecystitis. Surgery may include removal of a section of the liver. Internal radiotherapy, using iridium-129 wire or radium needles, may be combined with biliary drainage. Chemotherapy has not been shown to be effective against this cancer. External radiation may be used palliatively for cancer of the bile duct but is not effective against gallbladder cancer. If the tumor is inoperable or increases in size after surgery and is occluding any of the bile ducts, palliative measures may be taken to allow the bile to flow into the duodenum. Drainage of the bile can be accomplished by an external system, similar to that of a T-tube, or an internal stent that drains directly into the duodenum. As an alternative to surgery, a stent made of specialized plastic or steel is placed either by endoscopy or percutaneously through the tumor to allow drainage of the trapped bile. Complications include cholangitis and obstruction and dislocation of the stent.
Dietary changes are similar to those needed by patients with cholelithiasis, except the emphasis is on gaining weight rather than on weight reduction. A diet balanced with high calories and protein and low fat helps control the GI symptoms. Each individual needs to determine what foods are best tolerated. Medications to control nausea may be needed before meals, and the patient usually needs a pain-control regimen.
The nurse has an important role in maximizing the patient’s comfort. To augment the pain control obtained from analgesia, initiate nonpharmacologic strategies. Allow the patient to participate in the activities of daily living as much as possible. Assist with personal hygiene as much as needed, and include the significant others in learning the process. The itching associated with pruritus can be controlled by maintaining skin integrity, using soft, dry linens and cloths and warm water for bathing. Keep the area around all surgical incisions and drainage devices clean and dry. A large number of support groups exist to help patients and families manage cancer. Listen to the patient’s concerns. Give the patient and family the number for the American Cancer Society and hospice care if appropriate.
Nursing care plan discharge and home health care guidelines
Whether the tube is internal or external, teach the patient the signs and symptoms of a blocked tube. If the drainage system is external, teach the patient how to care for the tube, including emptying of the bag, irrigating the tube, periodic clamping of the tube, and managing skin care around the tube. Teach the patient to report signs of infection, excessive drainage, leakage, and obstruction to the physician. Provide the patient with a contact phone number. Teach the patient methods to control itching. Teach the patient about each medication, including the purpose and correct dosages, along with any potential side effects. Explain the requirements for a low-fat, high-calorie, and high-protein diet.