Biliary disorders

INTRODUCTION OF BILIARY DISORDERS
• The gallbladder and bile ducts comprise the Biliary
system and any abnormality (stones formation,
inflammation, etc) in these organs are called biliary
disorder.
• Disorders of the Biliary tract are common and
include gallbladder stones and interfere with the
normal drainage of bile into the duodenum.

DEFINITION OF BILIARY DISORDERS
❑Biliary disease is any pathology affecting the
gallbladder and its conduits; commonly
cholecystitis, cholelithiasis, etc

❑Any abnormality (stones formation, inflammation,
etc) of or relating to bile, to the ducts that convey
bile, or to the gall bladder.

CHOLEDOCHOLITHIASIS
CHOLELITHIASIS

DEFINITION OF CHOLECYSTITIS
• Cholecystitis is an inflammation of the gallbladder
wall and nearby abdominal lining. Cholecystitis is
usually caused by a gallstone in the cystic duct, the
duct that connects the gallbladder to the hepatic
duct.

TYPES OF CHOLECYSTITIS
• Acute cholecystitis, an acute inflammation of the
gallbladder, is most commonly caused by gallstone
obstruction.

• Acalculous cholecystitis is acute gallbladder
inflammation without obstruction by gallstones.

• Chronic cholecystitis occurs when the gallbladder
becomes thickened, rigid, and fibrotic and functions
poorly. Results from repeated attacks of
cholecystitis.

ETIOLOGICAL FACTORS OF CHOLECYSTITIS
• Secondary bacterial infection

• Bacteria:

o Escherichia coli

o Klebsiella

species

o Streptococcus

• Major surgical procedures

• Severe trauma

• Burns

• Cystic duct obstruction

• Bile stasis & increased viscosity of the bile

• Gallbladder stones

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

✓Murphy’s sign (inability to take a deep inspiration
when examiner’s finger are pressed below the
hepatic margin)

CLINICAL MANIFESTATION OF
CHOLECYSTITIS
Cont..

• Chronic cholecystitis-

✓Heartburn

✓flatulence

✓Indigestion

DIAGNOSTIC EVALUATION OF
CHOLECYSTITIS
▪ Oral cholecystography

▪ Ultrasonography

▪ Cholangiogram

▪Endoscopic retrograde
cholengiopancreatography
(ERCP)
Gamma-glutamyl trans-
peptidase (GGTP) markers for
Biliary stasis.

MANAGEMENT OF CHOLECYSTITIS
• Supportive management-

✓IV fluids

✓Pain management

✓Antibiotics

• A cholecystostomy tube may be placed
percuteniously into the gallbladder to decompress
the organ in preparation for future surgery.

MANAGEMENT OF CHOLECYSTITIS
Cont..

• Surgical management-

✓Cholecystectomy

✓Intraoperative cholangiography

✓Choledochoscopy

for common bile duct exploration.

✓Direct contact therapy by which a local cholelitholytic
agent is infused by a catheter directly into the
gallbladder or through a percutaneous transhepatic
biliary catheter.

COMPLICATION OF CHOLECYSTITIS
• Cholangitis

• Necrosis

• Empyema

• Perforation of the gallbladder

DEFINITION OF 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, it is called cholelithiasis.

DEFINITION OF CHOLEDOCHOLITHIASIS
• When gallstones are present in the bile ducts, it is
called choledocholithiasis.

o There are two types of gallstones:

✓Cholesterol stones (80%)

✓Pigment stones (20%)

o The size of gallstones varies from a grain of salt to
golf-ball size.

o A person can develop a single stone or several
hundred.

ETIOLOGICAL FACTORS OF CHOLELITHIASIS
& CHOLEDOCHOLITHIASIS
• Stones occur when cholesterol supersaturates the
bile in the gallbladder and precipitates out of the
bile. The cholesterol saturated bile predisposes to
the formation of gallstones and acts as an irritant,
producing inflammatory changes in the gallbladder.

• Pigment stones occur when free bilirubin combines
with calcium.

• Use of oral contraceptives and estrogens.

ETIOLOGICAL FACTORS OF CHOLELITHIASIS
Cont..

• Stone formation increases with the age because of
increased hepatic secretion of cholesterol and
decreased bile acid synthesis.

• Some disease conditions like

Cirrhosis

Hemolysis

Pathophysiology of cholelithiasis or
choledocholithiasis
• Pathophysiology of cholelithiasis.doc

CLINICAL MANIFESTATIONS OF
CHOLELITHIASIS &CHOLEDOCHOLITHIASIS
• 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, abcess, necrosis
and perforation with generalized peritonitis may occur.

• 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.

DIAGNOSTIC EVALUATION OF
CHOLELITHIASIS & CHOLDOCHOLITHISIS
• Abdominal X-Ray

• Ultrasonography

• Radionuclide imaging or cholescintigraphy

• Oral Cholangiography

• Endoscopic Retrograde Cholengiopancreatography
(ERCP)

• Percutaneous Transhepatic cholangiography

MANAGEMENT OF CHOLELITHIASIS &
CHOLEDOCHOLITHIASIS
• Supportive management-

✓IV fluids

✓Pain management

✓Antibiotics

✓Dietary management may be the major mode of
supportive management in patient who have had
only dietary intolerance to fatty foods and vague GI
system.

CHOLEDOCHOLITHIASIS
Cont..

• Pharmacologic therapy-

✓Ursodeoxycholic acid (UDCA) and chenodeoxycholic
acid (chenodilol) have been used to dissolve small,
radiolucent gallstones composed primarily of
cholesterol by inhibiting the synthesis and
secretions of cholesterol.

CHOLEDOCHOLITHIASIS
Cont..

• Non surgical removal of gallstones-

a.

Dissolving Gallstones- gallstones dissolve by a
infusion of a solvent (mono octanoin or methyl
tertiary butyl ether [MTBE]) into the gallbladder.

CHOLEDOCHOLITHIASIS
Cont..

b. Stone Removal by Instrumentation-

▪ A catheter and instrument with a basket attached are
threaded through the T- tube tract or fistula formed
at the time of T-tube insertion; the basket is used to
retrieve and remove the stones lodged in the
common bile duct.

▪ Secondly ERCP used to cut the submucosal fibers or
papilla of the sphincter of oddi, enlarging the
opening, which may allow the lodged stones to pass
spontaneously into the duodenum.

CHOLEDOCHOLITHIASIS
Cont..

c. Intracorporeal lithotripsy- stones in the gallbladder
or common bile duct may be fragmented by means
of laser pulse technology. The laser pulse produces
rapid expansion and disintegration of plasma on the
stone surface resulting in a mechanical shock wave.
This results in pressure waves that cause stones to
fragment.

CHOLEDOCHOLITHIASIS
Cont..

• Surgical management-

o Laparoscopic Cholecystectomy

o Cholecystectomy

o Choledochotomy

o Cholecystostomy

COMPLICATIONS OF CHOLELITHIASIS &
CHOLEDOCHOLITHIASIS
• Cholangitis

• Necrosis, empyema or perforation of gallbladder.

• Biliary fistula through the duodenum

• Adenocarcinoma of the gallbladder

• Bile peritonitis

NURSING MANAGEMENT OF
CHOLELITHIASIS & CHOLEDOCHOLITHIASIS
a)

Preoperative Nursing Management:

▪ Discuss with the patient to give full information about
the surgery

▪ Allow the patient to ask question and clear all his
doubts

▪ Explain what happens during anesthesia.

▪ Obtain the consent from the patients / guardian for
each operation after explaining the nature of the
operation and anesthesia.

▪ Assist the doctor to carry out a through physical
examination, assess the physical health of the patient.

Conti..

▪ Ask the patient appropriate questions to obtain
past and present medical history in order to exclude
anaemia, jaundice , drug reaction , previous
operation etc.

▪ Part preparation is done according to the surgery.

▪ Administer the pre – medications to the patient one
hour before surgery. These are the drugs that
reduce anxiety of patient .

Cont..

▪ Before giving the Pre – medications. Check the vital
signs of the patient such as blood pressure,
temperature, pulse, respiration etc. Record the vital
signs in the patient chart as baseline data.

▪ Provided the psychological support to the patient
and his family member.

▪ Prepare the articles before surgical procedure.

Cont..

b) Postoperative Nursing Management:

▪ Preparation of post anesthetic bed and reception
the patient.

▪ Assess any complication of surgery.

▪ Toprevent hypoxia, continue pulse oximetry after
surgery until an acceptable oxygen saturation level.

▪ Maintain intact dressing of the site of the surgical
wound.

Conti..

▪ Assess pulse for rate rhythm and amplitude, weak,
absent or irregular pulse may reflect hypovolemia,
decreased cardiac output. A bounding pulse
indicate hypertension, fluid overload or excitement.

▪ Assess level of consciousness by observing how the
person responds to verbal commands and touch,
pupil reaction to light and reflexes should be
observed.

▪ Continuously check the drain for any abnormal
secretions or bile.

NURSING DIAGNOSIS OF CHOLELITHIASIS
i. Acute pain and discomfort related to biliary colic
or stone obstruction, surgical incision.

ii. Impaired gas exchange related to the high
abdominal surgical incision.

iii. Deficient fluid volume related to nausea &
vomiting and decreased intake.

NURSING DIAGNOSIS OF CHOLELITHIASIS
iv. Impaired skin integrity related to altered Biliary
drainage after surgical intervention.

v. Imbalance nutrition, less than body requirement,
related to inadequate bile secretion.

vi. Deficit knowledge about self care activities related
to incision care dietary modification.

Biliary disorders

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