biliary tract disease

1. BILIARY TRACT DISORDER
Ms. Anshu
M.Sc Nursing
KGMU Institute of
Nursing

2. INTRODUCTION-
Disorders of gallbladder and ducts are
extremely common.
Its more commonly affect people of
sedentary life style and obesity.

3. EPIDEMIOLOGY
In the united states alone, it is estimated
that 20 million people have gall stones
with approximately 1 million new cases
developing each year.
The most common conditions are gall
stones and associated cholecystitis.

4. About 98% of clients who present with
symptomatic gall bladder disease have
gall stones.
Malignancies and congenital anomalies
are very rare.

5. ANATOMY OF GALL BLADDER
Pear shape sac
7-10 cm long
Average capacity 30-
50 ml
When obstructed 300
ml

6. PHYSIOLOGY OF GALL BLADDER
The smooth muscles in the gallbladder
wall contract, leading to the bile
being secreted into the duodenum to
rid the body of waste stored in the bile as
well as aid in the absorption of
dietary fat by solubilising them using bile
acids.

7. BILE COMPOSITION
 Bile consists of water, electrolytes, bile
acids, cholesterol, phospholipids and
conjugated bilirubin
Bile is secreted by the liver into small
ducts that join to form the common hepatic
duct and get stored in gall bladder.

8. BILIARY TRACT DISORDERS INCLUDES-
Cholelithiasis
Acute cholecystitis
Chronic cholecystitis

9. CHOLELITHIASIS/ GALLSTONES
Gallstones are collections of cholesterol,
bile pigment or a combination of the two,
which can form in the gallbladder or within
the bile ducts of the liver.

10. Gallstones . .
The presence of
gallstones in the
gallbladder is called
cholelithiasis.

11. INCIDENCE
Common duct stones are found in about
10% tom15% of client with cholelithiasis.
The incidence increases with age, and the
frequency of gallstones it the common
duct in the older population may be as
high as 25%.

12. ETIOLOGY
Change in bile composition-
Gallbladder stasis
supersaturation of bile with cholesterol
Infection and tissue injury
Genetics

13. Those who are most at risk.
These are all adjectives to describe the person most at
risk of developing symptomatic gallstones.
FAIR FAT FORTY FEMALE

14. PATHOPHYSIOLOGY

16. TYPES OF GALLSTONES
Cholesterol
Pigmented
mixed

17. Cholesterol stones
Most common type
Incidence increases
with age
Female>male
Smooth & whitish
yellow to tan colour

18. Pigment stones
Excess of
unconjugated bilirubin
May be black
colour(associated
with hemolysis and
cirrhosis) or earthy
calcium bilirubinate
(associated with
infection)

19. Mixed stones
Combination of
cholesterol and
pigment stones or
other substance
Calcium
carbonate,phosphate,
bile salts, and
palmitate

20. SIGNS AND SYMPTOMS.
Complaints of
indigestion after
eating high fat foods.
Localized pain in the
right-upper quadrant
epigastric region.
Anorexia, nausea,
vomiting and
flatulence.

21. Increased heart
and respiratory
rate – causing
patient to become
diaphoretic which
in turn makes them
think they are
having a heart
attack.

22. SIGNS AND SYMPTOMS.
 Low grade fever.
 Elevated leukocyte count.
 Mild jaundice.
 Stools that contain fat – steatorrhea.
 Clay colored stools caused by a lack of
bile in the intestinal tract.
 Urine may be dark amber- to tea-colored.

23. DIAGNOSTICS TEST
History of patient
Physical examination
Laboratory test for-
Elevated conjugated bilirubin.
Elevated alkaline phosphate
Serum amylase and lipase
Elevated WBC count
Fecal studies.

24. Ultrasound of
the gallbladder

25. CT Scan
MRI
HIDA (hepato- iminodiacetic acid)
Cholangiography
ERCP (endoscopic retrograde
cholangiopancreatography)

26. Diagnostics.
 HIDA
(hydroxyiminod
iacetic acid
scan) - imaging
test used to examine
the gallbladder and
the ducts leading into
and out of the
gallbladder - also
referred to as
cholescintigraphy.

27. MEDICAL MANAGEMENT
GOALS-
To resolve symptoms
To remove stones
To prevent complications

28. 1. PAIN MANAGEMENT
Give analgesics
Antacids, H2 blockers or proton pump
inhibitors- to neutralize gastric acid
2.For nausea and vomiting
Antiemetics given
3. antibiotics

29. Endoscopy

30. Gall stone dissolution
Oral administration of agents-
chenodeoxycholic acid (CDCA) or
chenodal
ursodeoxycholic acid (UDCA) or ursodiol
Action- reduces the amount of cholesterol
in bile

31. Medical Management.
Lithotripsy Extracorporeal shock
wave lithotripsy
(ESWL)-
1500 shock waves
directed at stones
Used for fewer than 4
stones, each smaller
than 3cm.

32. Medical Management.
 If stones are present in the
common bile duct, an
endoscopic sphincterotomy
must be performed to remove
them BEFORE a
cholecystectomy is done.
A number of various
instruments are inserted
through the endoscope in
order to "cut" or stretch the
sphincter.
Once this is done, additional
instruments are passed that
enable the removal of stones
and the stretching of
narrowed regions of the
ducts.
Drains (stents) can also be
used to prevent a narrowed
area from rapidly returning to
its previously narrowed state.

33. Surgical Management.
Cholecystectomy
or
Laparoscopic Cholecystectomy
– removal of the gallbladder.
This is the treatment of choice.
The gallbladder along with the cystic
duct, vein and artery are ligated.

34. Laproscopic cholecystectomy

35. NURSING MANAGEMENT
ASSESSMENT
Assess the general condition of patient
Assess pain of patient.
Observe for bleeding.

36. NURSING DIAGNOSIS
Acute pain related to surgical procedure.
Impaired skin integrity Invasion of body
structure
Ineffective breathing pattern Pain
Risk for deficient fluid volume related to
surgical procedure

37. NURSING INTERVENTION
1. Acute pain related to surgery
Monitor and record vital signs.
 administer medication as ordered.
assess the severity,frequency, and
characteristic of pain.
Provide divertional activities such as
reading newspapers.

38. 2. Impaired skin integrity
Observe the color and character of the
drainage.
Change dressings as often as necessary.
Place patient in low- or semi-Fowler’s
position.
Monitor puncture sites (3–5) if endoscopic
procedure is done.

39. 3. Ineffective breathing pattern
Observe respiratory rate, depth.
Auscultate breath sounds.
Assist patient to turn, cough, and deep
breathe periodically.
Show patient how to splint incision.
Instruct in effective breathing techniques.
Elevate head of bed, maintain low-
Fowler’s position.

40. 4. Risk for deficient fluid volume
Monitor vital signs. Assess mucous
membranes, skin turgor, peripheral
pulses, and capillary refill.
Monitor I&O, including drainage from NG
tube ,T-tube, and wound. Weigh patient
periodically.
Observe for signs of bleeding:
hematemesis, melena, petechiae,
ecchymosis.
Administer IV fluids, blood products, as
indicated

41. What is it cholecystitis?
 By definition,
cholecystitis is an
inflammation of the
gallbladder wall and
nearby abdominal
lining.
Abdominal wall
Gallbladder

42. TYPES OF CHOLECYSTITIS
Acute cholecystitis
Chronic cholecystitis

43. ACUTE CHOLECYSTITIS
DEFINITION-
Acute cholecystitis refers to acute
inflammation of the gallbladder wall.

44. ETIOLOGY
Gall stone in cystic duct
Obstruction in cystic duct
Bacterial infection (gram positive and
gram negative aerobes and anaerobes:-
E. Coli, klebsiella, Clostredium and
streptococcus)

45. RISK FACTORS
Sedentary lifestyle
obesity

46. PATHOPHYSIOLOGY

47. PROGRESSION OF ACUTE
CHOLECYSTITIS.
- Gallbladder has a
grayish appearance & is
edematous.
-There is an obstruction
of the cystic duct and
the gallbladder begins
to swell.
- It no longer has the
"robin egg blue"
appearance of a normal
gallbladder.

48. - As acute
cholecystitis
progresses, the
gallbladder begins
to become necrotic
and gets a speckled
appearance as the
wall begins to die.

49. - Gallbladder
undergoes
gangrenous change
and the wall
becomes very dark
green or black.
- This is the stage
when perforation
occurs.

50. SIGNS AND SYMPTOMS
Complain of pain
In right upper quadrant
In epigastric region
In right subscapular
Onset sudden
Peak in 30min

51. Nausea and vomiting
Low grade fever
Mild jaundice

53. CHRONIC CHOLECYSTITIS
DEFINITION-
Repeated inflammation and infection of
gallbladder

54. SIGNS AND SYMPTOMS
Epigastric pain
Indigestion
Fat intolerance
Heart burn
Fibrosis of gall tissues
Inability to concentrate bile

55. MEDICAL MANAGEMENT
GOAL-
 to treat symptomatic causes
 to prevent complication

56. Antibiotic therapy-
Ampicillin
Ureidopenicillins – piperacillin or
mezlocillin
Third generation cephalosporins-
Ceftriaxone, cefixime, Cefotaxime
Aminoglycosides –
Gentamicin, Amikacin, Neomycin

57. SURGICAL MANAGEMENT
cholecystectomy

58. Nursing Interventions
Post Op - Cholesystectomy
1. Administer oral analgesics to facilitate movement
and deep breathing – and to stay ahead of pts pain.
2. Observe dressings frequently for exudate and hemorrhage.
3. Vitals are routinely checked.
4. Patient teaching:
-Must understand how to splint the abd. before
coughing.
-Report any abnormalities such as,
severe pain, tenderness in RUQ, increase in
pulse, etc . .
-Instructed that they usually can return to work in 3
days & can resume full activity in 1 week.
5. Fluid balance is maintained IV –
potassium added to compensate
for loss from surgery.

59. Nursing Interventions
1. Urine and stool should be observed for alterations
in the presence of bilirubin.
2. NG tube must be monitored for amount, color & consistency
of output.
Also, tube must be on LOW suction and nasal area should
be monitored for irritation and necrosis.
3. Anti-emetics may be administered if nausea persists.
4. I & O are measured and described carefully.
5. Pt. must understand how to splint the abdomen
for post op coughing, turning and deep breathing.
Interventions center on keeping patient comfortable by
carefully administering meds and watching for reactions.

60. CONCLUSION
Biliary disorders are extremely common
but diverse in nature.
Incidence rate of the disease is increasing
day by day.
Teaching and awareness is vital in
prevention and management of the
disease.

61. EVALUATION
A 45 yr old obese lady, complaining of
epigastric pain, right sided subscapular
pain which last for 3-4 hrs associated with
nausea and vomiting. She has mild icterus
and bilirubin is 3.3mg/dl.
Guess what could be the diagnosis of
patient?