Biliary disorders

1. SALALE UNIVERSITY COLLEGAE OF HEALTH SCIENCE
DEPARTMENT OF ADULT HEALTH NURSING
Seminar Presentation on ; Gallbladder Disorders
Presented To: Mr. Melese {BSc, MSc}
Oct. 2023
Salale , Fitche

2. GROUP MEMBERS
SN Name ID
1) Kedir Mohammed RM0 182/15
2) Mekonnen Urgessa RM0 183/15
3) Shambel Debele RM0 190/15
4) Sufa Mengiste RM0 191/15
5) Worku Daba RM0 193/15

3. Biographical data of patient
Name; Alemishet Getu
Age; 43
Sex; Female
MRN;516673
Ward; Surgical ward
Bed no; 12

4. General examination
C/C; epigastric pain/burning/ 1 weeks duration
nausea and vomiting/ 4 days duration
RUQ abdominal pain/ 7 days duration
HPI; This patient was last relatively healthy 1 weeks back at
which she started to experiences sudden onset RUQ abdominal
pain which radiation to the right upper back which was
aggravated by taking fat meal but no relieving factors noticed by
patient. Associated with this she has also nausea and non blood
, non foul smelling, non projectile vomiting about 2-3 times
per/day immediately after taking meal.

5. General examination…
Past medical and surgical history;
 she was on oral contraceptive pills for the last 3
years but she has no history of taking other
medication
 She has no similar illness in the family and she has
no chronic disease and surgical history.
Physical examination
GA; acute sick looking
Vital sign; BP; 110/68mmhg PR; 78 b/m T; 37.5 oc
RR; 20br/m oxygen saturation 96
percentage on room air

6. General examination…
HEENT;
 No sore throat
 No any discharge from ear
 Jaundiced sclera
 No sign of conjunctivitis
CVS; S1 and S2 well heard
RS; clear, resonant sound heard
GIS; abdomen is flat
Tenderness over RUQ of abdomen on palpation
No ascites and shifting fluids
Positive to murphy's sign

7. General examination…
GUS; non odor white discharge from vagina
No urgency and incontinency of urination
IGS; no discoloration of skin
MS; no deformity all over the body
no edema
NS; no confusion
No loss of balance on gait

8. PERTINENT positive FINDING ON P/E
 Jaundice
 Positive murphy's sign
 Positive kher’s sign
 White non odor discharge from vagina

9. INVESTIGATION
 CBC; raised WBC
 H.pylori; negative
 RBS; 110mg/dl
 LFT Is not done
 Bilirubin and Hormonal analysis is not done
 Lipid profile is not done
 Abdominal U/S; Acute calculus cholicystitis secondary
to cholethiasis

10. Medical Diagnosis
Acute calculus cholicystitis secondary to
cholelithiasis

11. Nursing Diagnosis
 Acute pain related to inflammation and stone of
gallbladder as manifested by positive murphy’s sign
and RUQ pain after eating.
 Knowledge deficit related to unfamiliarity with the new
diagnosis secondary to cholelithiasis as evidenced by
reports of poor understanding and confusion on the
information given
 Risk for infection related to cholecystectomy secondary
to cholelithiasis

12. Nursing intervention
 Promote adequate rest and education regarding to
cholelithiasis
 Administer IV fluids, monitor intake and output
 Administering prescribed anti pain and antibiotics
 Keep NPO 24hrs then avoid eating heavy and fat
foods.

13. Prognosis
• The pain is relieved
• The vital sign is stable
• She is starting fluid diet.

14. PRESENTATION OUTLINE
Introduction
Etiology and risk Factors for cholethiasis
Pathophysiology cholethiasis
Epidemiology
Clinical Manifestations
Diagnosis
Management
Prevention
Summary
Reference

15. OBJECTIVES OF PRESENTATION
 At the end of this presentation, students will able
to:-
 Describe the etiology and pathogenesis of
gallstones
 Explain types of gallstone
 Describe complication of cholelithiasis
 Describe the clinical manifestations of
gallbladder disorders and its management

16. ANATOMY AND PHYSIOLOGY OF GALL
BLADDER
 The gallbladder is just below the liver.
 Bile is stored in the
gallbladder and flows
through the cystic duct
and the common bile
duct into the small intestine
when food is being digested.

17. EPIDEMIOLOGY
 Disorders of the biliary tract affects significant
portion of the world’s population.
 >95% of biliary tract disease is due to
cholelithiasis (gallstone)
 Cholelithiasis affect 10-20% of adult population in
developed countries
 Prevalence of cholelithiasis : certain populations
are more prone than others (US, Western Europe)

18. INTRODUCTION TO DISORDERS OF THE
GALL BLADDER
 Disorders of the Biliary tract are common and
include gallbladder stones and interfere with the
normal drainage of bile into the duodenum
 Biliary disease is any pathology affecting the
gallbladder and its conduits; commonly
cholecystitis, cholelithiasis, choledolithiasis , etc

19. TYPES OF BILIARY DISORDERS
1) Cholicystitis
2) Cholelithiasis
3) Choledolithiasis
4) cholangitis

20. TYPES OF BILIARY DISORDERS…
Cholelithiasis
 Gallstones form when bile stored in the
gallbladder hardens into stone-like material.
 Too much cholesterol, bile salts, or bilirubin (bile
pigment) can cause gallstones. When gallstones
are present in the gallbladder itself.

21. TYPES OF BILIARY DISORDERS…
Choledocholithiasis
 When gallstones are present in the common bile ducts.
Cholangitis
 Is Infection of the obstructed biliary system
 The organisms typically ascend from the duodenum by
hematogenous spread from the portal vein.

23. TYPES OF BILIARY DISORDERS…
 The size of gallstones varies from a grain of salt
to golf-ball size.
 A person can develop a single stone or several
hundred.

24. There are two types of gallstones:
1) Cholesterol stones (80%)
2) Pigment stones (20%)

25. CHOLESTEROL STONE VS PIGMENT STONES
Cholesterol stone
 Content : Crystalline cholesterol monohydrate is
predominant
Pigment stones
 Bilirubin ,calcium, salt, is predominant

26. RISK FACTORS
 Being female
 Being over weight or obese
 Being pregnant
 Eating high fat and cholesterol diet
 Eating low fiber diet
 Having family history of gallstone

27. PATHOPHYSIOLOGY
 Altered Ratio of cholesterol, phospholipids, and
bile salts > cholesterol crystals
 Gallstone formation :
Cholesterol supersaturation
Mucin hypersecretion
Bile stasis

28. PATHOPHYSIOLOGY…

29. PATHOGENESIS OF PIGMENT STONE
 Hemolytic anemia and infections of the biliary
tract → increased unconjugated bilirubin in the
biliary tree → form precipitates : insoluble
calcium bilirubinate salts.

30. CLINICAL MANIFESTATIONS GALLSTONE
 Asymptomatic
 Biliary colic (steady, severe, aching pain or
sensation of pressure in epigastrium or right
upper quadrant, which may radiate to the right
scapular area or right shoulder)
 Gallstone continue to obstruct the duct, abscess,
necrosis and perforation with generalized
peritonitis may occur.

32. CLINICAL MANIFESTATIONS…
 Jaundice
 Changes in the urine and stool color
 Vitamin deficiency due to obstruction of the bile
flow interferes with absorption of the fat soluble
vitamin A, D, E, K.

34. COMPLICATIONS OF GALLSTONES
 In the gallbladder
Biliary colic
Acute and chronic cholecystitis
perforation

35. COMPLICATIONS OF GALLSTONES…
 In the bile ducts
Obstructive jaundice
Pancreatitis
Cholangitis
 In the Gut
Gallstone ileus

36. TYPES OF CHOLECYSTITIS
 Acute cholecystitis:- Is an acute inflammation
of the gallbladder, is most commonly caused by
gallstone obstruction.
 Acalculous cholecystitis:- is acute gallbladder
inflammation without obstruction by gallstones.

37. TYPES OF CHOLECYSTITIS…
Chronic cholecystitis:-
 occurs when the gallbladder becomes
thickened, rigid, and fibrotic and functions poorly.
 Results from repeated attacks of cholecystitis.

38. ETIOLOGICAL FACTORS OF CHOLECYSTITS
 Secondary bacterial infection
 Major surgical procedures
 Cystic duct obstruction
 Bile stasis & increased viscosity of the bile
 Gallbladder stones

39. Clinical manifestations of cholecystitis
Acute cholecystitis
 Biliary colic pain that persists more than 4 hours
and increases with movement, including
respirations.
 Nausea and vomiting
 Low grade fever, Jaundice, Right upper quadrant
guarding

40. CLINICAL MANIFESTATIONS OF CHOLECYSTITIS…
 Murphy’s sign (inability to take a deep inspiration
when examiner’s finger are pressed below the
hepatic margin)
Chronic cholecystitis
 Heartburn, flatulence and indigestion

41. COMPLICATIONS
 Cholangitis
 Necrosis
 Perforation of the gallbladder
 Gallstone ileus, Adenocarcinoma of the
gallbladder

42. DIAGNOSTIC EVALUATIONS
 CBC
 Liver Function test
 Abdominal X-ray
 Ultrasonography
 Radionuclide Imaging

43. DIAGNOSTIC EVALUATIONS…
 Oral Cholangiography
 Endoscopic Retrograde
Cholengiopancreatography (ERCP)
 Percutaneous Trans hepatic Cholangiography

44. MANAGEMENT
 Supportive management
 IV fluids
 Nasogastric suction
 Pain management
 Antibiotics
 A cholecystostomy tube may be placed
percuteniously into the gallbladder to decompress
the organ in preparation for future surgery.

45. Nonsurgical treatments for cholecystolithiasis
 Butylscopolamine , flopropione,
 Oral ursodeoxycholic acid is an option for prophylaxis
against attacks.
 Extracorporeal shock wave lithotripsy (ESWL) and oral
chemical dissolution therapy have been used for the
treatment of gallbladder stones[2]

46. Endoscopic gallbladder drainage in acute
cholecystitis
 Percutaneous transhepatic gallbladder drainage
(PTGBD) is recommended in cases of acute
cholecystitis.
 Endoscopic gallbladder drainage is proposed for patients
with coagulopathy, patients receiving antithrombotic
agents, and those with ascites by a skilled endoscopist

47. Endoscopic gallbladder drainage in acute
cholecystitis
 PTGBD is recommended for high-surgical risk patients
because of its high success rate (technical success, 97–
100%; clinical success, 89.3–97.6%) and its safety
(complication rate, 3–39.5%) in previously published
data and because of the simplicity of the technique .[3]

48. MANAGEMENT…
 Dissolving Gallstones- gallstones dissolve by a
infusion of a solvent into the gallbladder
 Stone Removal by Instrumentation
 Intracorporeal lithotriopsy

49. Management…
Surgical management
 Laproscopic Cholecystectomy
 Cholecystectomy
 Choledochotomy

50. Cholecystectomy
 Cholecystectomy should be performed if
gallbladder cancer is suspected based on the
morphology of the thickened gallbladder wall
and the course of the disease.[4]

51. Nursing Diagnosis
 Deficient knowledge related to unfamiliarity with
the new diagnosis secondary to cholelithiasis as
evidenced by reports of poor understanding and
confusion on the information given
 Risk for infection related to cholecystectomy
secondary to cholelithiasis

52. NURSING MANAGEMENT
 Intervene to relive pain; give prescribed analgesics
 Promote adequate rest and education regarding to
cholelithiasis
 Administer IV fluids, monitor intake and output
 Monitor nasogastric tube and suctioning
 Administer antibiotics if prescribed.

53. SUMMARY
Gallbladder diseases are most often caused by
gallstones, which can block the flow of bile
through the bile ducts, causing inflammation
and pain. Most gallbladder diseases are treated
with gallbladder removal surgery

54. REFERENCE
1) Sabiston text book of Surgery 21th edition, 2020: the Biological bases of modern surgical
practice
2) Tomida S, Abei M, Yamaguchi T, et al. Long-term
ursodeoxycholic acid therapy is associated with reduced risk of biliary pain and acute
cholecystitis in patients with gallbladder stones: a cohort analysis. Hepatology. 1999;30:6–
13
3) Jang JW, Lee SS, Song TJ, et al. Endoscopic ultrasound-guided transmural and
percutaneous transhepatic gallbladder drainage are comparable for acute cholecystitis.
Gastroenterology.2012;142:805–11.
4) Reuther G, Kiefer B, Tuchmann A. Cholangiography before biliary surgery: single-shot MR
cholangiography versus intravenous cholangiography. Radiology. 1996;198:561–6