Biliary Disorders

8/6/2019 Biliary Disorders

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BILIARYDISORDER

SErick Sioco Inserto, RNNCM 103



Gall bladder



The gallbladder is a small pear-shapedorgan that stores and concentrates bile.

The gallbladder is connected to the liver

by the hepatic duct. It approximately 3 to 4 inches (7.6 to 10.2

cm) long and about 1 inch (2.5 cm)wide.

function of the gallbladder is to store bileand concentrate



Pancreas

Has two functions

Exocrine– secretion of pancreatic enzymes into theGIT through the pancreaticduct.

Endocrine – secretion of insulin, glucagon, andsomatostatin into the bloodstream



Exocrine Pancreas

Secretions are high in protein content andelectrolyte rich fluid

Alkaline

Secretions includeAmylase – aids in the digestion of

carbohydrates

Trypsin – digestion of proteins

Lipase – digestion of fats



Endocrine Pancreas

Islet of langerhansCollection of cells embedded in the

pancreatic tissue

Composed of alpha, beta, delta cells Alpha cells

Secrete glucagon – raises glucose

Beta cellsSecrete insulin – lowers blood glucose

Delta cellsSecrete Somatostatin- exerts a

hypoglycemic effect



Disorders of the GallBladder



Terminology

Cholecystitis – inflammation of thegallbladder

Cholelithiasis – the presence of calculi in

the gallbladder Cholecytectomy- removal of the

gallbladder

Cholecytostomy – opening and drainageof the gall bladder

Choledochotomy – opening of thecommon duct

Choledocholithiasis – stones in the



defined as inflammation of thegallbladder that occurs mostcommonly because of an obstructionof the cystic duct from cholelithiasis

Cholecystitis



Manifestations

Pain, Rigidity, tenderness of the upperright abdomen

Fever

Nausea Vomiting Tachycardia (+) Murphy’s Sign

described as tenderness and aninspiratory pause elicited duringpalpation of the RUQ.



Causes

Calculous cholecystitis Female sex Obesity or rapid weight loss Drugs (especially hormonal therapy in women)

Pregnancy Increasing age

Acalculous cholecystitis Critical illnessMajor surgery or severe trauma/burns

Sepsis Long-term TPN Prolonged fasting



Other causesCardiac events, including myocardial

infarction

Sickle cell diseaseSalmonella infections

Diabetes mellitus

Patients with AIDS with cytomegalovirus,

cryptosporidiosis, or microsporidiosis



Diagnostics

Increased Alanine aminotransferase (ALT)and aspartate aminotransferase (AST)levels

Amylase mildly elevated Ultrasonography

Radiography



Medical Treatment

initial treatment includes bowel rest,intravenous hydration, analgesia, andintravenous antibiotics

Emesis can be treated with antiemeticsand nasogastric suction.

Restoration of hemodynamic stability

Daily stimulation of gallbladdercontraction

Laparoscopic cholecystectomy is the standard of care for the surgical

treatment of cholecystitis



Cholecystectomy or Cholecystotomyusually reserved for complicated cases in

which the patient has gangrene or

perforation.



Nursing Management

Encourage fluid input and output Monitor vital signs Assess pain and administer analgesics as

ordered Provide diet a liquid or low-fat diet if

surgery is not an option Administer antibiotics as ordered Assist with ambulation Encourage adequate nutrition Assess for complications



is the presence of one or more calculi

(gallstones) in the gallbladder.

Cholelithiasis



Risk Factors

Obesity Women Multiple preganancies

Frequent changes in weight Rapid weight loss Treatment of High dose estrogen

Ileal resection or disease Cystic fibrosis Diabetes



Four F’sFemale

Fat

FortyFertile



Pathophysiology

Biliary sludge is often a precursor of gallstones. It consists of Ca bilirubinate(a polymer of bilirubin), cholesterol

microcrystals, and mucin Sludge develops during gallbladder stasis

as occurs during pregnancy or whilereceiving TPN.



Types:

Cholesterol stonesBile must be supersaturated with

cholesterol The excess cholesterol must precipitate

from solution as solid microcrystalsmicrocrystals must aggregate and grow.

Black pigment stones are small, hard gallstones composed of Ca

bilirubinate and inorganic Ca salts (eg,Ca carbonate, Ca phosphate)

alcoholic liver disease, chronic hemolysis,and older age



Brown pigment stonesare soft and greasy, consisting of

bilirubinate and fatty acids (Ca palmitateor stearate). They form during infection,inflammation, and parasitic infestation



Manifestations

Asymptomatic Epigastric distress

Fullness

Abdominal distentionVague pain in the RUQMay follow ingestion of fried and fatty

foods

Fever Biliary Colic

steady or intermittent ache in the upperabdomen, usually under the right side of

the rib cage.



Biliary colic Nausea

Vomiting

Colicky pain

JaundiceOccurs in few patients

Changes in urine and stool colorUrine is very darkStool is clay colored, grayinsh



Diagnostics

Abdominal xrays

Ultrasound – procedure of choice

Cholescintigraphya radioactive dye is administered IV. The

Biliary tree is then scanned

Cholecystography

An iodide containing contrast agent isadministered to the patient . And a xrayis taken



Surgical treatment

Endoscopic RetrogradeCholangiopancreatography

(ERCP)

is a test that combines the use of aflexible, lighted scope (endoscope) withX-ray pictures to examine the tubes thatdrain the liver, gallbladder,and pancreas



Purpose:

Check persistent abdominal painor jaundice.

Find gallstones or diseases of the liver,

bile ducts, or pancreas. Remove gallstones from the common bile

duct if they are causing a problem suchas blockage (obstruction), inflammationor infection of the common bile duct(cholangitis), or pancreatitis.

Open a narrowed bile duct or insert a

drain.



Percutaneous transhepaticCholangiographya radiologic technique used to visualize

the anatomy of the biliary tract. Acontrast medium is injected into a bileduct in the liver, after which X-rays aretaken



Medical Management

Reduce gallbladder pain AnalgesicsSurgery

Administration of IV fluids Nasogastric suction Adequate rest Antibiotic therapy Ursodeoxycholic acid (UDCA) Chenodeoxycholic acid

Has been used to dissolve gallstone primarilycomposed of cholesterol



Non- surgical Treatments

Mono-octanoin or methyl tertiary butylether (MTBE) infusion

Extracorporeal Shockwave Lithotripsy



Nursing Management

Monitor pain administer analgesics asordered

Assess vital signs

Encourage hydration Administer a low fat diet

Instruct to avoid gaseous foods

Prepare the client for surgery



Inflammation of the pancreas that can

occur in two very different forms

Pancreatitis



is a sudden inflammation of

the pancreas

Acute Pancreatitis



Manifestation

Edema on the pancreas

Inflammation

Severe epigastric pain radiating to the

back Nausea, vomiting, diarrhea and loss of

appetite

Fever/chills Hemodynamic instability, including shock



Grey-Turner's sign (hemorrhagic discoloration of the flanks)

Cullen's sign (hemorrhagic discoloration of theumbilicus)

Grünwald sign (appearanceof ecchymosis around the umbilicus due tolocal toxic lesion of the vessels.)

Körte's sign (pain or resistance in the zonewhere the head of pancreas is located

(in epigastrium, 6-7 cm above the umbilicus). Kamenchik's sign (pain with pressure underthe xiphoid process)

Mayo-Robson's sign (pain while pressing at thetop of the angle lateral to the Erector spinae

muscles and below the left 12th rib (leftcostovertebral angle (CVA))



Grey Turners sign



Cullen’s Sign

C it i f Ad i i t th



Criteria for Admission to thehospital

Age > 55 years

WBC >16,00 mm3

Serum Glucose >200 mg/dL

Serum LDH > .350 IU/L AST .250/mL



Causes

I - idiopathic. Thought to be hypertensivesphincter or microlithiasis.

G - gallstone.Gallstones that travel down the common bile

duct and which subsequently get stuck inthe Ampulla of Vater can cause obstructionin the outflow of pancreatic juices from thepancreas into the duodenum. The backflowof these digestive juices

causes lysis(dissolving) of pancreatic cellsand subsequent pancreatitis.

E - ethanol (alcohol) T - trauma



S - steroids M - mumps (paramyxovirus) and other viruses

(Epstein-Barr virus, Cytomegalovirus) A - autoimmune diseas ( Systemic lupus

erythematosus) S - scorpion sting (e.g. Tityus trinitatis), and

also snake bites

H - hypercalcemia, hyperlipidemia/hypertriglyceridemia and hypothermia

E - ERCP (Endoscopic Retrograde Cholangio-Pancreatography - a procedure that

combines endoscopy and fluoroscopy) D - drugs (SAND) - steroids & sulfonamides, azathioprine, NS

AIDS, diureticssuch as furosemide and thiazides,& didanosine) and duodenal ulcers.



Diagnostics

Increased blood amylase level Increased serum blood lipase level

Increase urine amylase level



Medical Treatment

Pain medicines Fluids given through a vein (IV) (NPO)Stopping food or fluid by mouth to

limit the activity of the pancreas NGT to drain insertion Drain fluid that has collected in or around

the pancreas (biliary drainage) Remove gallstones (ERCP, ESWL) Relieve blockages of the pancreatic duct



Nursing Management

Monitor vital sign’s Administer pain medications

Implement NPO status

Complete bed rest Assess fluid and electrolyte balance

(monitor input and output)

Monitor NGT drainage Provide health teachings



is long-standing inflammation of the

pancreas that results in irreversibledeterioration of pancreatic structureand function

Chronic Pancreatitis



Causes

Alcoholism Idiopathic

Cystic Fibrosis



Manifestations

Back pain Abdominal pain Weight loss

swollen and tender abdomen nausea vomiting fever rapid pulse Fatty stools (steatorrhea)



Diagnostics

A secretin stimulation test Is considered the gold standard functional

test for diagnosis of chronic pancreatitisbut not often used clinically

ESR, IgG4, rheumatoid factorMay be elevated



Medical Treatment

Chemical dependency treatment is the most importantstep in treating alcohol-related pancreatitis.

Pain relief drugs Endoscopic therapy by introducing stents to drain

blocked pancreatic ducts

Shock wave lithotripsy to pulverize pancreatic stones Surgery (laparoscopic and traditional) Islet cell transplantation may be offered if most or all of

the pancreas is removed. Enzyme therapy for malabsorption helps restore normal

digestion and reduces the amount of fat in the feces,leading to weight gain and improved well-being.Dietary changes such as eating smaller meals andlimiting fats help reduce the need for digestiveenzymes.

Treatment of diabetes, if that develops



Nursing Management

Assess painAdminister analgesics as ordered

Monitor Input and output

Monitor vital signs Assess hydration status (I & 0)

Administer oxygen as ordered

Insruct the patient to avoid alcohol andfatty foods

Assess stools



a malignant neoplasm of the pancreas

Sometimes called a "silent killer" becauseearly pancreatic cancer often does notcause symptoms

Pancreatic cancer



Manifestations

Pain in the upper abdomen that typicallyradiates to the

Loss of appetite and/or nausea and

vomiting Significant weight loss

Painless jaundice (yellow skin/eyes, darkurine)

pale-colored stool and steatorrhea

Trousseau sign

Diabetes mellitus, or elevated blood

sugar levels.

Causes



Causes

Age (particularly over 60) Male

Smoking

Diets low in vegetables and fruits Diets high in red meat

Diets high in sugar-sweetened drinks (soft

drinks) Obesity



Diabetes mellitus is both risk factor for pancreatic cancer,

and, as noted earlier, new onsetdiabetes can be an early sign of thedisease.

Chronic pancreatitis

Helicobacter pylori infection

Diagnostics



Diagnostics

Computed tomography (CT) scans Magnetic resonance

cholangiopancreatography (MRCP)

Endoscopic ultrasound (EUS) Endoscopic retrograde

cholangiopancreatography (ERCP)

Upper GI series



Surgical treatment

Whipple procedure the most common surgical treatment for

cancers involving the head of thepancreas

procedure involves removing thepancreatic head and the curve of theduodenum together (pancreato-duodenectomy)



Distal Pancreatectomy

Cancers of the tail of thepancreascan beresected



Medical Management

Intensity Modulated Radiation Therapyuses hundreds of small radiation beams of

varying intensities to precisely targetcancer cells, while sparing healthy tissue

Chemotherapy



Nursing Management

Assess painAdminister pain medications as ordered

Encourage adequate nutritionProvide small low fat feedingsMonitor weightAssess and monitor hydration

Provide good skin careProtect bony prominences from pressure

ulcers Relieve discomforts

Relief of itching from jaundice

Biliary Disorders

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