Assessment

HISTORY. 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.

PHYSICAL EXAMINATION. Patients with extensive disease may appear thin and malnourished. Determine if the patient is jaundiced from an enlarging tumor that is pressing on the extra-hepatic 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.

PSYCHOSOCIAL. 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.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Computed tomography

Normal gallbladder and

Presence of tumor

Detects site and size of

(CT) scan

duct system

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