Diseases of the Biliary Tract
Chapter 51
Hepatic, Biliary Tract, and Pancreatic Dysfunction:
Nursing Management
Diseases of the Biliary Tract
Cholestasis = is any condition that impedes
bile flowing freely through the bile ducts.
• Intrahepatic =failure of bile flow within the
liver
• Extrahepatic = failure of the bile flow beyond
the liver
2
Diseases of the Biliary Tract
Manifestations of Cholestasis:
• Clay-colored stools (because the bile doesn’t
reach the intestine where it is converted to
stercobilinogen, which normally gives feces
the typical brown color).
• Dark urine (because an excess of bilirubin is
in the circulation and is excreted through the
kidneys).
3
Diseases of the Biliary Tract
• Jaundice and icterus, which also result
from the increase in serum bilirubin.
4
Cholelithiasis
= Stones (calculi) formed in the gallbladder
• Epidemiology:
– Common in people of northern European
descent. 75% of elderly Pima Indians have
incidence of gallstones
Cholelithiasis
• Etiology;
– More common in women, incidence is related
to levels of estrogen
– Women on hormone replacement therapy,
and those who are pregnant
– Those who use estrogen birth control pill
– Medications that lower serum cholesterol
– Obesity
6
Cholelithiasis
• Pathophysiology:
– Gallstones are formed from cholesterol,
which is a major component of bile.
– Stones may be attributed to the
calcification of bile pigments.
– Cholangitis = inflammation of the bile duct
and is usually attributable to the presence
of gallstones.
– With inflammation, there will be increased
edema.
7
Cholelithiasis
– Increased edema can increase
permeability of the cell membranes and
predispose the tissue to infection from
bacteria from the gut.
– Ascending cholangitis = infection that
moves in the direction of the liver
– Suppurative cholangitis = pus produced in
the biliary tract due to infection
8
Cholelithiasis
• Clinical Manifestations:
– RUQ pain which can radiate to the right
scapular region
– (+) murphy’s sign
– Anorexia
– Nausea
– Vomiting
– Signs of infection (fever, tachycardia,
hypotension)
9
Cholelithiasis
• Diagnostic tests:
– UTz = the most useful diagnostic test
because the presence of stones, the motility
of the stones, and the thickness of the
gallbladder wall can all be assessed.
– LFTs are often normal
10
Cholelithiasis
• Planning and Implementation:
– The primary methods of treating cholelithiasis
are surgery and medication
– Nutritional programs with a low-fat diet, and
exercise.
11
Cholelithiasis
• Surgery:
– Laparoscopic cholecystectomy = is the
treatment of choice
• A surgical procedure using laparoscopy to
remove the gallbladder.
• A small incision is made at the umbilicus plus
three other puncture sites. Carbon dioxide
may be pumped into the abdominal cavity to
help to separate the organs.
• A laparoscope with video camera and laser
technology is introduced.
12
Cholelithiasis
– The gallbladder is dissected, drained of fluid
and stones, and removed through the
incision at the umbilicus.
– Advantage:
• The operation has a faster recovery time, fewer
complications, and fewer bile duct injuries than
the open cholecystectomy.
– Disadvantage:
• Gallstones can still form in the biliary tree.
13
Cholelithiasis
• Open cholecystectomy
– Performed when the laparoscopic
technique fails, there are stones that are
inaccessible to the laparoscope, and other
surgeries that are required at the same
time (as in treating trauma).
– The surgeon makes an incision in the RUQ
beneath the ribs. The gallbladder is
dissected and removed, cystic duct is
ligated, and a T-tube is inserted to the
common bile duct to keep it patent.
14
15
Cholelithiasis
• Jackson-Pratt (JP) tube can be left in at
the surgical site to drain fluid from around
the area of the gallbladder.
16
17
18
Cholelithiasis
• Pharmacology:
– Nonsurgical treatment is not popular
because it takes a long time to dissolve the
stones (6 – 12 months).
– Ursodeoxycholic acid (URSO, Ursodiol, or
Actigall), alone or in combination with
– Chenodeoxycholic acid (Chenodiol, Chenix,
or CDCA).
19
Cholecystitis
= Is the inflammation of the gallbladder.
• Causes:
– Stones causing irritation and obstruction.
– Bacterial infection
– Circulatory problems secondary to trauma,
tumor impingement, shock, surgery, or
dehydration
– Pancreatitis
Cholecystitis
• Clinical manifestations:
– Acute cholecystitis:
• Pain with abdominal discomfort, which may be
referred to the right shoulder.
• Jaundice is not present (because bile flow isn’t
obstructed)
– Chronic cholecystitis:
• Fibrosis obstruct the bile flow that results in
cholangitis, pancreatitis, and jaundice.
• Pruritus (itching) occurs due to increased bile salts
deposit in the skin.
21
Cholecystitis
– Physical examination reveals abdominal
tenderness on palpation with rebound
tenderness.
– Steatorrhea
22
Primary Biliary Cirrhosis
• Is characterized by inflammation and
subsequent destruction of the bile ducts.
• Incidence:
– 9 out of 10 cases are middle-aged women
– Hereditary factor:
• More likely to occur in families where one relative
has already been diagnosed.
23
Primary Biliary Cirrhosis
• Pathophysiology:
– Exact mechanism is unknown.
– Autoimmune factors can cause progressive
inflammation.
– Inflammation causes bile congestion and
creates cholestasis.
24
Primary Biliary Cirrhosis
• Clinical manifestations:
– Asymptomatic in early stages:
– Increased alkaline phosphatase levels
– Fatigue and pruritus – the most common
complaints
– Fever, abdominal pain, hepatomegaly,
splenomegaly, and hyperpigmentation.
– Jaundice, variceal bleeding, ascites, and
encephalopathy.
25
Primary Biliary Cirrhosis
• Diagnostic Tests:
– Increased LFT, especially alkaline
phosphatase, PT, antimotichondrial antibodies
(AMA)
– Liver biopsy can be done to confirm the
diagnosis.
26
Primary Biliary Cirrhosis
• Pharmacology
– Ursodeoxycholic acid (URSO, Ursodiol, or
Actigall) = a naturally occurring bile acid that
can help to decrease the amounts of other
more toxic bile acids
– Corticosteroids which can be helpful in
decreasing the autoimmune activity
– Cyclosporin = antirejection drug
• Side effects: hypertension and kidney dysfunction
27
Primary Biliary Cirrhosis
• Immunosupressants (Methotrexate,
Chloramburil
– Side effects: myelosuppression
• Colchizine = antigout agent
– Side effects: interferes with WBC
• Aggressive antibiotic therapy
• Cholestyramine (Questran) = controls
itching
28
Primary Biliary Cirrhosis
• Antiretroviral therapy (Lamivudine,
Combivir) = effective in arresting the
disease.
29
Primary Biliary Cirrhosis
• Surgery:
– Cholangiography with balloon dilation of
narrowed ducts.
– Cholecystectomy
– Removal of gallstones through sphinterotomy
– Liver transplantation = option for definitive
treatment of end-stage disease
Copyright © 2007 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 30
Primary Biliary Cirrhosis
• Alternative therapy:
– Silymarin (Liveraid, Livermarin) = is an active
ingredient in milk thisle (Silybum marianum).
– It is thought to protect the liver and
gallbladder from toxic substances.
– People with allergies to ragweed, marigolds,
daisies and other plants of Asteraceae family
should be cautioned.
31
Diseases of the Pancreas
Chapter 51
Hepatic, Biliary Tract, and Pancreatic Dysfunction:
Nursing Management
Pancreatitis
• Is the inflammation of the pancreas, a
specialized digestive gland that has both
endocrine and exocrine functions.
33
Acute Pancreatitis
• Is an acute inflammatory process of the
pancreas.
• Is a mild, reversible condition that can
resolve with resting the gut (NPO).
34
Acute Pancreatitis
• Etiology:
– Gallstone disease
– Alcoholism
– Infections (ascariasis, clonorchiasis, mumps,
toxoplasmosis, coxsakievirus,
cytomegalovirus, or tuberculosis)
– Medications (azathioprine, mercaptopurine,
sulfonamides, salicylates, furosemide, or
methyldopa)
– Trauma
35
Acute Pancreatitis
– Obstruction
– Duodenal diseases
– Toxins
– Genetic diseases that predispose the patient
to cholelithiasis
36
Acute Pancreatitis
• Pathophysiology:
– 10 – 30% of cases are idiopathic
– Inflammation causes the exocrine enzymes
can be prematurely activated, exacerbating
the process leading to autodigestion of the
surrounding tissues and more inflammation,
edema, and necrosis.
– The edema compromises the microcirculation
releasing the cytokines, such as TNF,
interleukin-1, and platelet-activating factor –
contribute to pancreatic damage. 37
Acute Pancreatitis
• Clinical manifestations:
– Grey Turner’s spots or sign = a bluish flank
discoloration due to intravascular damage
– Cullen’s sign = a bluish periumbilical
discoloration.
Abdominal pain that radiates to the back,
guarding and rebound tenderness, nausea,
and vomiting,
and abdominal distension.
38
39
Acute Pancreatitis
• Complications:
– Atelectasis
– Pleural effusion
– ARDS
– Respiratory failure
– Cardiovascular problems with hypovolemia,
hypotension and shock
– Renal failure
– Coagulation complications
40
Acute Pancreatitis
– Metabolic complications (e.g., hypocalcemia
or hyperglycemia)
– GI problems
– Encephalopathy
41
Acute Pancreatitis
• Diagnostic Tests:
– Increased serum amylase and lipase
– Increased ALT = can be indicative of
gallstones
– CT scanning is the most useful test for
determining the presence of pancreatitis.
42
Acute Pancreatitis
• Planning and implementation:
– The goals of mild acute pancreatitis are to
rest the gut, provide supportive care to treat
symptoms, identify systemic complications
early, and decrease pancreatic inflammation.
– NPO
– IVF for proper hydration and electrolyte
replacement
– Pain control
43
Acute Pancreatitis
• EBP
– Morphine SO4 potentially causes the sphincter
of Oddi to constrict and create more pain.
– Meperidine (Demerol) = converts to the
antimetabolite Normeperidine, which can
cause seizures.
• Not a good choice for an analgesic for pancreatitis
pain
– Hydromorphone (Dilaudid)
44
Acute Pancreatitis
• Gastric decompression can relieve
nausea, vomiting, and abdominal
distension.
• TPN would be required for prolonged IV
interventions
• Aggressive antibiotic therapy would be
used
• Instruct patient to refrain alcohol
• Small, frequent meals is advisable
45
Chronic Pancreatitis
• Occurs when there is irreversible damage
to the pancreatic acini, ducts, nerves, and
islet cells because of continued to irritation
and injury.
46
Chronic Pancreatitis
• Epidemiology:
– Men between the ages of 30 and 40 are more
likely affected than women.
• Cause:
– 70% of all chronic pancreatitis cases is due to
chronic alcoholism.
– Incidence is higher for people with
hyperlipidemia and hypertrigyceridemia
47
Chronic Pancreatitis
• Predisposing factors:
– Genetics
• Pancreas divisum = is the failure of the pancreatic
ducts to fuse during embryonic development,
leaving two separate (the dorsal and ventral ducts)
to drain the different parts of the pancreas.
• Cystic fibrosis = the most common cause of
pancreatitis among children.
– Protein plugs within the ducts, causing reduced flow of
pancreatic enzymes.
48
Chronic Pancreatitis
• Clinical manifestations:
– Acute or dull and constant pain referred to the
back and be exacerbated with eating
– Malabsorption, weight loss and vitamin
deficiency
– DM
– Decreased duodenal pH = due to reduced
secretion of bicarbonate from the pancreatic
ducts
– Osteopenia and osteoporosis
49
Chronic Pancreatitis
• Diagnostic tests:
– Big duct chronic pancreatitis = indicates a
dilation of the main pancreatic ducts and is
common in alcoholic pancreatitis.
– Small duct disease = is idiopathic and less
responsive to surgical treatment.
– Serum lipase and amylase = are often normal
in chronic pancreatitis.
– Decreased serum trypsin below 20 mg/dL and
presence of steatorrhea = specific for chronic
pancreatitis. 50
51
Chronic Pancreatitis
• Planning and implementation:
– Pancreatic enzyme replacement
• Pancreatin (Viokase) and Pancrealipase
(Cotazym) = contain trypsin, amylase, and lipase
– Enteric coated to prevent the breakdown or inactivation
by gastric HCl acid.
• Should be given with acid-inhibiting drugs(H2
blockers, PPI) or acid neutralizing drugs (antacids)
– To increase stomach pH to have the most efficacy.
52
Chronic Pancreatitis
• Diet should contain a moderate amount of
fat (30%), high protein (24%) and low
carbohydrates (24%)
• Diabetic diet may be helpful
• Abstaining from alcohol is important.
53
Chronic Pancreatitis
• Pharmacology:
– Pain controlling-drugs:
• Darvocet-N or Tramadol
• Selective serotonin reuptake inhibitors = helpful to
treat pain and assist with rest.
– Ex: Citalopram (Celexa)
– Flouxetine (Prozac)
– Sertraline (Zoloft)
– Antidiarrheals: Octreotide (Sandostatin)
– antioxidants
54
Chronic Pancreatitis
• Surgery:
– Ablation (surgical severing [cutting]) of celiac
plexus
– Laparoscopic stenting to keep the ducts open,
dilation of strictures, removal of calculi, and
drainage of pseudocysts.
55
Chronic Pancreatitis
• Whipple procedure
(pancreaticoduodenectomy)
= entails resection of the
proximal pancreas
(proximal pancreatectomy),
the duodenum
(duodenectomy), the distal
portion of the stomach
(partial gastrectomy), and
the distal segment of the
common bile duct. 56
Chronic Pancreatitis
• An anastomosis of the pancreatic duct , common
bile duct, and stomach to the jejunum is done.
57
