BILIARY DISORDER S

Erick Sioco Inserto, RN

NCM 103

Gall bladder

Thegallbladderis a small pear-shaped organ that stores and concentrates bile. The gallbladder is connected to theliver by the hepatic duct. It approximately 3 to 4 inches (7.6 to 10.2 cm) long and about 1 inch (2.5 cm) wide. function of the gallbladder is to store bile and concentrate

Pancreas

Has two functions

Exocrine secretion of pancreatic enzymes into the GIT through the pancreatic duct. Endocrine secretion of insulin, glucagon, and somatostatin into the blood stream

Exocrine Pancreas

Secretions are high in protein content and electrolyte rich fluid Alkaline Secretions include
Amylase

aids in the digestion of carbohydrates Trypsin digestion of proteins Lipase digestion of fats

Endocrine Pancreas

Islet of langerhans
Collection

of cells embedded in the pancreatic tissue Composed of alpha, beta, delta cells

Alpha cells
Secrete

glucagon raises glucose insulin lowers blood glucose

Beta cells
Secrete

Delta cells
Secrete

Somatostatin- exerts a hypoglycemic effect

Disorders of the Gall Bladder

Terminology

Cholecystitis inflammation of the gallbladder Cholelithiasis the presence of calculi in the gallbladder Cholecytectomy- removal of the gallbladder Cholecytostomy opening and drainage of the gall bladder Choledochotomy opening of the common duct Choledocholithiasis stones in the

Cholecystitis

defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct fromcholelithiasis

Manifestations

Pain, Rigidity, tenderness of the upper right abdomen Fever Nausea Vomiting Tachycardia (+) Murphys Sign
described

as tenderness and an inspiratory pause elicited during palpation of the RUQ.

Causes

Calculous cholecystitis
Female sex Obesity or rapid weight loss Drugs (especially hormonal therapy in women) Pregnancy Increasing age

Acalculous cholecystitis
Critical illness Major surgery or severe trauma/burns Sepsis Long-term TPN Prolonged fasting

Other causes
Cardiac

events, including myocardial infarction Sickle cell disease Salmonellainfections Diabetes mellitus Patients with AIDS with cytomegalovirus, cryptosporidiosis, or microsporidiosis

Diagnostics

Increased Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels Amylase mildly elevated Ultrasonography Radiography

Medical Treatment

initial treatment includes bowel rest, intravenous hydration, analgesia, and intravenous antibiotics Emesis can be treated with antiemetics and nasogastric suction. Restoration of hemodynamic stability Daily stimulation of gallbladder contraction Laparoscopic cholecystectomy
is

the standard of care for the surgical treatment of cholecystitis

Cholecystectomy or Cholecystotomy
usually

reserved for complicated cases in which the patient has gangrene or perforation.

Nursing Management

Encourage fluid input and output Monitor vital signs Assess pain and administer analgesics as ordered Provide diet a liquid or low-fat diet if surgery is not an option Administer antibiotics as ordered Assist with ambulation Encourage adequate nutrition Assess for complications

Cholelithiasis

is the presence of one or more calculi (gallstones) in the gallbladder.

Risk Factors

Obesity Women Multiple preganancies Frequent changes in weight Rapid weight loss Treatment of High dose estrogen Ileal resection or disease Cystic fibrosis Diabetes

Four Fs
Female Fat Forty Fertile

Pathophysiology

Biliary sludgeis often a precursor of gallstones. It consists of Ca bilirubinate (a polymer of bilirubin), cholesterol microcrystals, and mucin Sludge develops during gallbladder stasis as occurs during pregnancy or while receiving TPN.

Types:

Cholesterol stones
Bile

must be supersaturated with cholesterol The excess cholesterol must precipitate from solution as solid microcrystals microcrystals must aggregate and grow.

Black pigment stones

are

small, hard gallstones composed of Ca bilirubinate and inorganic Ca salts (eg, Ca carbonate, Ca phosphate) alcoholic liver disease, chronic hemolysis, and older age

Brown pigment stones

are

soft and greasy, consisting of bilirubinate and fatty acids (Ca palmitate or stearate). They form during infection, inflammation, and parasitic infestation

Manifestations

Asymptomatic Epigastric distress

Fullness Abdominal

distention Vague pain in the RUQ May follow ingestion of fried and fatty foods

Fever Biliary Colic

steady

or intermittent ache in the upper abdomen, usually under the right side of the rib cage.

 Biliary

colic

Nausea Vomiting Colicky

pain

Jaundice
Occurs

in few patients

Changes in urine and stool color

Urine

is very dark Stool is clay colored, grayinsh

Diagnostics

Abdominal xrays Ultrasound procedure of choice Cholescintigraphy

a

radioactive dye is administered IV. The Biliary tree is then scanned iodide containing contrast agent is administered to the patient . And a xray is taken

Cholecystography
An

Surgical treatment

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a test that combines the use of a flexible, lighted scope (endoscope) with X-ray pictures to examine the tubes that drain theliver,gallbladder, andpancreas

Purpose:

Check persistent abdominal pain orjaundice. Findgallstones or diseases of the liver, bile ducts, or pancreas. Remove gallstones from the common bile duct if they are causing a problem such as blockage (obstruction), inflammation or infection of the common bile duct (cholangitis), orpancreatitis. Open a narrowed bile duct or insert a drain.

Percutaneous transhepatic Cholangiography

a

radiologic technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken

Medical Management

Reduce gallbladder pain

Analgesics Surgery

Administration of IV fluids Nasogastric suction Adequate rest Antibiotic therapy Ursodeoxycholic acid (UDCA) Chenodeoxycholic acid
Has

been used to dissolve gallstone primarily composed of cholesterol

Non- surgical Treatments

Mono-octanoin or methyl tertiary butyl ether (MTBE) infusion Extracorporeal Shockwave Lithotripsy

Nursing Management

Monitor pain administer analgesics as ordered Assess vital signs Encourage hydration Administer a low fat diet Instruct to avoid gaseous foods Prepare the client for surgery

Pancreatitis

Inflammation of thepancreas that can occur in two very different forms

Acute Pancreatitis

is a suddeninflammationof thepancreas

Manifestation

Edema on the pancreas Inflammation Severe epigastric pain radiating to the back Nausea,vomiting,diarrheaandloss of appetite Fever/chills Hemodynamicinstability, includingshock

Grey-Turner's sign(hemorrhagic discoloration of the flanks) Cullen's sign(hemorrhagic discoloration of the umbilicus) Grnwald sign (appearance ofecchymosisaround the umbilicus due to local toxic lesion of the vessels.) Krte's sign (pain or resistance in the zone where the head of pancreas is located (inepigastrium, 6-7 cm above the umbilicus). Kamenchik's sign (pain with pressure under thexiphoid process) Mayo-Robson's sign (pain while pressing at the top of the angle lateral to theErector spinae musclesand below the left 12th rib (left costovertebral angle (CVA))

Grey Turners sign

Cullens Sign

Criteria for Admission to the hospital

Age > 55 years WBC >16,00 mm3 Serum Glucose >200 mg/dL Serum LDH > .350 IU/L AST .250/mL

Causes

I -idiopathic. Thought to be hypertensive sphincter or microlithiasis. G -gallstone.

Gallstones

that travel down the commonbile ductand which subsequently get stuck in theAmpulla of Vatercan cause obstruction in the outflow of pancreatic juices from the pancreas into theduodenum. The backflow of these digestive juices causeslysis(dissolving) of pancreatic cells and subsequent pancreatitis.

E -ethanol(alcohol) T -trauma

S -steroids M -mumps(paramyxovirus) and other viruses

(Epstein-Barr virus,Cytomegalovirus)

A -autoimmune diseas(Systemic lupus erythematosus) S -scorpion sting (e.g.Tityus trinitatis), and alsosnake bites H -hypercalcemia,hyperlipidemia/hypertriglyceri demiaandhypothermia E -ERCP(EndoscopicRetrogradeCholangioPancreatography - a procedure that combinesendoscopyandfluoroscopy) D -drugs

(SAND)-steroids&sulfonamides,azathioprine,NS AIDS,diureticssuch asfurosemide andthiazides, &didanosine) and duodenal ulcers.

Diagnostics

Increased blood amylase level Increasedserum blood lipase level Increaseurine amylase level

Medical Treatment

Pain medicines Fluids given through a vein (IV) (NPO)Stopping food or fluid by mouth to limit the activity of the pancreas NGT to drain insertion Drain fluid that has collected in or around the pancreas (biliary drainage) Removegallstones (ERCP, ESWL) Relieve blockages of the pancreatic duct

Nursing Management

Monitor vital signs Administer pain medications Implement NPO status Complete bed rest Assess fluid and electrolyte balance (monitor input and output) Monitor NGT drainage Provide health teachings

Chronic Pancreatitis

is long-standing inflammation of the pancreas that results in irreversible deterioration of pancreatic structure and function

Causes

Alcoholism Idiopathic Cystic Fibrosis

Manifestations

Back pain Abdominal pain Weight loss swollen and tender abdomen nausea vomiting fever rapid pulse Fatty stools (steatorrhea)

Diagnostics

Asecretinstimulation test
Is

considered thegold standard functional test for diagnosis of chronic pancreatitis but not often used clinically be elevated

ESR,IgG4,rheumatoid factor
May

Medical Treatment

Chemical dependency treatment is the most important step in treating alcohol-related pancreatitis. Pain relief drugs Endoscopic therapy by introducing stents to drain blocked pancreatic ducts Shock wave lithotripsy to pulverize pancreatic stones Surgery (laparoscopic and traditional) Islet cell transplantation may be offered if most or all of the pancreas is removed. Enzyme therapy for malabsorption helps restore normal digestion and reduces the amount of fat in the feces, leading to weight gain and improved well-being. Dietary changes such as eating smaller meals and limiting fats help reduce the need for digestive enzymes. Treatment of diabetes, if that develops

Nursing Management

Assess pain
Administer

analgesics as ordered

Monitor Input and output Monitor vital signs Assess hydration status (I & 0) Administer oxygen as ordered Insruct the patient to avoid alcohol and fatty foods Assess stools

Pancreatic cancer
amalignantneoplasmof thepancreas Sometimes called a "silent killer" because early pancreatic cancer often does not cause symptoms

Manifestations

Pain in the upper abdomen that typically radiates to the Loss of appetiteand/or nausea and vomiting Significantweight loss Painlessjaundice(yellow skin/eyes, dark urine) pale-colored stool andsteatorrhea Trousseau sign Diabetes mellitus, or elevated blood sugar levels.

Causes

Age (particularly over 60) Male Smoking Diets low in vegetables and fruits Diets high in red meat Diets high in sugar-sweetened drinks (soft drinks) Obesity

Diabetes mellitus
is

both risk factor for pancreatic cancer, and, as noted earlier, new onset diabetes can be an early sign of the disease.

Chronic pancreatitis Helicobacter pyloriinfection

Diagnostics

Computed tomography (CT) scans Magnetic resonance cholangiopancreatography (MRCP) Endoscopic ultrasound (EUS) Endoscopic retrograde cholangiopancreatography (ERCP) Upper GI series

Surgical treatment

Whipple procedure
the

most common surgical treatment for cancers involving the head of the pancreas procedure involves removing the pancreatic head and the curve of the duodenum together (pancreatoduodenectomy)

Distal Pancreatectomy

Cancers of the tail of the pancreas can be resected

Medical Management

Intensity Modulated Radiation Therapy

uses

hundreds of small radiation beams of varying intensities to precisely target cancer cells, while sparing healthy tissue

Chemotherapy

Nursing Management

Assess pain
Administer

pain medications as ordered

Encourage adequate nutrition

Provide

small low fat feedings Monitor weight Assess and monitor hydration

Provide good skin care

Protect

ulcers

bony prominences from pressure

Relieve discomforts
Relief

of itching from jaundice