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.