Assessment and management of patients with Biliary Disorder

By: Zanida Zainon

Biliary disorder
Gallbladder cholelithiasis 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 fowler s 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, highcarbohydrate, 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 ( cautodigestion) 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.