Assessment and

management of patients with

Biliary Disorder
Biliary disorder
cholelithiasis
Gallbladder
cholecystitis

Pancreas pancreatitis
Gallbladder
The gallbladder is a small, pear-shaped
pouch that lies beneath the liver, in the
upper abdomen. It stores bile. This
fluid, produced by the liver, helps
digest fat. The gallbladder releases bile
into the small intestine through the bile
duct. This thin tube connects the liver
and gallbladder to the small intestine.
Gallbladder, liver and pancreas
Cholelithiasis
The presence of calculi in the
gallbladder
Form in the gallbladder from the solid
constituents of bile vary in size,
shape and compositions.
Incidence US (man 10% , women 20%
by age 65 years old.
Cholelithiasis
Pathophysiology
Obesity, high-calorie, high cholesterol diet
and drug that lower serum cholesterol
level.

Bile is supersaturated with cholestrol

Precipitate out to form stones

Biliary stasis or slowed emptying of the

gallbladder

cholilithisis
Risk Factors for Gallstone
Age
Family history of gallstone
Race or ethnic
Obesity, hyperlipidemia
Rapid weight loss
Female gender, use of oral contraceptives
Biliary stasis: pregnancy, fasting, prolonged
parenteral nutrition
Disease or condition: ileal disease or
resection: sickle cell anemia; glucose
intolerance
Cholecystitis
Inflammation of the gallbladder
It can be..
Acute Cholecystitis
Chronic cholecystitis
Acute Cholecystitis
Pathophysiology
Obstruction of the cystic duct by a
stone.
The obstruction increase pressure
within the gallbladder, leading to
ischemia of gallbladder wall and
mucosa.
Acute Cholecystitis
Clinical Manifestation:
Begin with an attack of biliary colic.
Pain right upper quadran (RUQ), and may
radiate to back, right scapula, or shoulder.
Movement or deep breathing may
aggravate pain.
The pain usually last longer than biliary
colic, continuing for 12-18 hours.
Anorexia, nausea, and vomiting, fever
accompanied by chill.
Chronic Cholecystitis
Asymptomatic
May result from repeated bouts of
acute cholecystitis or from persistent
irritation of the gallbladder wall by
stones. Bacteria may be present in the
bile as well.
Complication of cholecystitis
Empyema
a collection of infected fluid within the
gallbladder.
Gangrene and perforation with resulting
peritonitis or abscess formation.
Formation of a fistula into an adjacent
organ, eg: duodenum, colon, or stomach.
Obstruction of the small intestine by a
large gallstone
Assessment and diagnostic
finding
Serum Bilirubin
Complete blood count (CBC, WBC)
Serumamylase and lipase
Abdominal x- ray
Ultrasonography
Cholecystography
Endoscopic Retrograde
Cholangiopancreatography ( ERCP)
Precutaneous Transhepatic
Cholangiography
Management
Nutritional and supportive therapy
Limit dietary fat intake
If bile flow is obstructed, fat soluble
vitamins (A,D,E and K) and bile salts may
need to be administered.

Pharmacologic therapy
Management
Nutritional and supportive therapy
Pharmacologic therapy
Nonsurgical removal of gallstones
i) dissolving gallstones
ii) Stone removal by instrumentation
iii) Extracorpeal shock-wave Lithotripsy
iv) Intracorpeal Lithotripsy
Surgical management

i) Preoperatives measures
ii) Laparoscopic cholecystectomy
iii) Cholecystectomy
iv) Choledochostomy
v) Surgical cholecystostomy
vi) Percutaneous cholecystostomy
Cholecystectomy
Nursing Process : Surgery for
gallbladder disease
Pain
Imbalance Nutrition: Less than Body
Requirements
Risk for Infection
Pain related to biliary colic or
surgery
1. Assess severity of pain. Sometimes a
combination of interventions is indicated.
2. Teach way to reduce fat intake.
Eg: high fat food-
-whole-milk products (eg, cream, ice cream)
-deep-fried
-most nuts
-Butter and cooking oil
Fat entering the duodenum initiates
gallbladder contractions, causing pain when
gallstones are present in the ducts.
Cont..
3. Insert nasogastric tube and connect to
low suction if ordered, withold oral food
and fluids during episodes of acute pain.
Emptying the stomach reduces the
amount of chyme entering the duodenum
and the stimulus for gallbladder
contraction, thus reducing pain.
4.Administer morphine, meperidine, or
other narcotic analgesia as ordered.
Recent research indicates that morphine
is no more likely to cause spasms of the
sphincter of Oddi than meriperidine.
Cont..
5. Place in fowlers position decreases
pressure on the inflamed gallbladder.
6. Monitor vital signs, including
temperature, at least every 4 hours.
Bacterial infection often is present in
acute cholecystitis, and may cause an
elevated temperature and respiratory
rate.
Imbalance Nutrition: Less
than body requirements
1. Assess nutritional status, including diet
history, height and weight, and skin fold
measurements. Even though often
obese, clients with gallbladder disease
may have an imbalanced diet or may
have specific vitamin deficiencies,
particularly of the fat-soluble vitamins.
2. Evaluate laboratory results, including
serum bilirubin, albumin, glucose, and
cholesterol levels.
Cont
3. Measure and record intake and output.
Postoperative Nursing care for
choleystectomy (removal of
gallbladder)
1. Maintain T-tube, which provides for bile
drainage from liver, allowing some of
the bile to enter into the common duct,
T-tube inserterd into duct and
connected to drainage bottle.
*Procedure*
Place patient in Fowler's position to
cacilitate drainage.
Cont...
Ensure patency and avoid stress on the
tube; carefully and avoid stress on the
tube; carefully position after dressing
and changed.
Use measures to control infection.
Note character and amount of drainage.
Clamp and release regimen as initial
step in preparation for T-tube removal
2. Prevent wound infection (patienst are
often obese and may have delayed
healing)
Cont...
3.Observe for indications of biliary
obstruction, such as clay-colored stool,
jaundiced sclera and/ or skin.
4.Advise patient to remain on low-fat,
high-carbohydrate, high-protein diet for
at least 2-3 months. Also avoid alcohol
and gas-forming foods.
Pancreatitis
Inflammation of the pancreas
i) Acute pancreatitis
ii) Chronic pancreatitis
PANCREATITIS
Pancreas
Acute pancreatitis
80% -cause by alcohol and gallstone.
Characterized by edema and
inflammation confined to the pancrease
Minimal organ dysfunction is present
Pathophysiology : self digestion
( cauto- digestion) of the pancreas by
its own enzymes trypsin.
Long term use of alcohol is commonly
associated with acute pacreatitis
Clinical manifestation

1. Severe abdomen pain ( typically at

mid epigastrium)
Onset : 24 48 hours after heavy meal
or alcohol ingestion
Unrelieved by antacids
Ecchymoses in the flank or around the
umbilicus may indicate severe
pancreatitis.
Cont..
2. Nausea and vomiting
3. Fever
4. Jaundice
5. Mental confusion
6. Agitation
Assessment and diagnostic
test
1.History abdomen pain,
2.Diagnostic finding
serum amylase and lipase levels are
use in making diagnosis of acute
pancreatitis (rise 3 times from normal
value in 24 hours).
Urinary amylase levels also become
elevated.
WBC count is usually elevated
Hypocalcaemia
Cont..
Hematocrit and hemoglobin levels are
used to monitor
Stools bulky, pale and foul smelling

3. X- ray : abdomen and chest

4. Ultrasound
Medical management
To relieve symptoms and prevent
complication
All oral intake withhold to inhibit
pancreatic stimulation and secretion of
pancreatic enzymes
Parenteral nutrition part of therapy
Nasogastric suction to relieve
nausea and vomiting, to decrease of
painful abdominal distention, to
remove HCl so that it does not enter
the duodenum and stimulate pancreas.
Cont....
Administer medications.
1. Synthetic analgesic for pain - avoid opiates -
may cause spasm.
2. Anticholinergics (Pro-Banthine) to suppress
vagal stimulation.
3. Sodiam bicarbonate to reverse metabolic
acidosis.
4. Histamin H2 antagonist ( cimetidin (tagamet),
ranitidine (zantac) may be given to neutralize
HCL secreation and decrease pancreatic
activity by inhibit HCL secretion.
Cont..

Biliary drainage placement of biliary

drain and stents in the pancreatic
duct through endoscopy .
Surgical intervention often risky.
May be diagnostic laparotomy to
establish pancreatic drainage, to
resect necrosis pancreas.
Nursing Intervention
Relieve pain and discomfort NG tube
with continuos low pressure suction,
drugs Mepiredine ( Demerol).
Improving breathing pattern - Aggressive
respiratory care to prevent acute
respiratory distress syndrom (ARDS)
Improving nutritional status
Improving skin integrity
Monitor and managing potential
complication -
 Monitor glucose levels with blood tests
- may give regular insulin to treat
hyperglycemia.
Measure and record intake and output -
maintain fluids and electrolytes.
-hypocalcaemia - treated with calcium
gluconate IV.
-hypokalemia - treated with potassium.
-Hypomagnesemia treated with
magnesium - can be life- threating.
Chronic Pancreatitis
Definition:

Gland is fibrosed and ducts are

obstructed following repeated attacks
of acute pancreatitis.
Chronic pancreatitis
Characterized by progressive
anatomic and functional destruction of
the pancreas.
Alcohol consumption and malnutrition
are major causes of chronic
pancreatitis.
Excessive and prolonged consumption
of alcohol 70 % of the cases.
Clinical manifestations
1.Pain -persistent epigastric and left upper
quadrant.
.Severe pain at upper abdominal and back.
Attacks so painful opiods in large doses
do not relief.
2. Anorexia, nausea, vomiting and
constipation.
More than 75% patients weight loss, cause
of anorexia and fear meal will precipitate
another attack.
Cont....
3 Disturbance of protein and fat
digestion, malnutrition, weight loss,
abdominal distention, foul, fatty stool
cause by decrease in pancreatic
enzyme secreation..
Malabsorbtion digestion of fat and
protein impaired.> foul smelling
stools with high fat content
(statorrhea)
Assessment and diagnostic
findings
ERCP most useful study > provide
detail about anatomy of pancreas,
pancreatic and biliary ducts.
MRI
Computed tomography
Ultrasound
A glucose tolerance test evaluates
pancreatic islet cell function ( decision
to surgical resection)
Assessment and diagnostic
findings
Laboratory values: elevated serum
amylase and lipase, increased glucose,
decreased calcium and potassium

A glucose tolerance test evaluates

pancreatic islet cell function ( decision
to surgical resection)
Medical management
Non surgical management
1. Abdominal pain and discomfort non
opiods methods. Emphasize patients
to avoid alcohol and foods tend to
produce adominal pain and discomfort.
2. Endoscopy i) to remove pancreatic
duct stones
ii) stent stricture> to relieve pain and
obstruction
Surgical management
1.Pancreaticojejunostomy ( Roux-en Y)
side to side anastomosis of the
pancreatic duct to the jejunum >
allows pancreatic secretion into
jejunum
2.Pancreaticoduodenostomy ( Whipple
resection)
Nursing Care
1.Provide low-protein, low fat, high
-carbohydrate, bland diet.
2. Monitor any diabetic symstoms; insulin
may be given; monitor blood glucose
levels.
3.Monitor for potential complications -
ascites, pleural effusion, GI
hemorrhage, biliary tract obstruction
Cont...
Administer medications.
1.Antacid (Maalox) to neutralize acid
secretions.
2.Histamine antagonist
3.Proton-pump inhibitors (Prilosec) to
neutralize gastric acid.
4.Anticholinergics (atropine, pro-Banthine)
to decrease vagal stimulation.
5.Pancratic enzyme replacements (viokase,
pancrelipase) with meals to aid digestin.
6. Narcotic analgesics used for pain.