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8/6/2019 Biliary Disorders
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BILIARYDISORDER
SErick Sioco Inserto, RNNCM 103
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The gallbladder is a small pear-shapedorgan that stores and concentrates bile.
The gallbladder is connected to the liver
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 bileand concentrate
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Pancreas
Has two functions
Exocrine– secretion of pancreatic enzymes into theGIT through the pancreaticduct.
Endocrine – secretion of insulin, glucagon, andsomatostatin into the bloodstream
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Exocrine Pancreas
Secretions are high in protein content andelectrolyte rich fluid
Alkaline
Secretions includeAmylase – aids in the digestion of
carbohydrates
Trypsin – digestion of proteins
Lipase – digestion of fats
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Endocrine Pancreas
Islet of langerhansCollection of cells embedded in the
pancreatic tissue
Composed of alpha, beta, delta cells Alpha cells
Secrete glucagon – raises glucose
Beta cellsSecrete insulin – lowers blood glucose
Delta cellsSecrete Somatostatin- exerts a
hypoglycemic effect
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Disorders of the GallBladder
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Terminology
Cholecystitis – inflammation of thegallbladder
Cholelithiasis – the presence of calculi in
the gallbladder Cholecytectomy- removal of the
gallbladder
Cholecytostomy – opening and drainageof the gall bladder
Choledochotomy – opening of thecommon duct
Choledocholithiasis – stones in the
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defined as inflammation of thegallbladder that occurs mostcommonly because of an obstructionof the cystic duct from cholelithiasis
Cholecystitis
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Manifestations
Pain, Rigidity, tenderness of the upperright abdomen
Fever
Nausea Vomiting Tachycardia (+) Murphy’s Sign
described as tenderness and aninspiratory pause elicited duringpalpation of the RUQ.
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Causes
Calculous cholecystitis Female sex Obesity or rapid weight loss Drugs (especially hormonal therapy in women)
Pregnancy Increasing age
Acalculous cholecystitis Critical illnessMajor surgery or severe trauma/burns
Sepsis Long-term TPN Prolonged fasting
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Other causesCardiac events, including myocardial
infarction
Sickle cell diseaseSalmonella infections
Diabetes mellitus
Patients with AIDS with cytomegalovirus,
cryptosporidiosis, or microsporidiosis
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Diagnostics
Increased Alanine aminotransferase (ALT)and aspartate aminotransferase (AST)levels
Amylase mildly elevated Ultrasonography
Radiography
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Medical Treatment
initial treatment includes bowel rest,intravenous hydration, analgesia, andintravenous antibiotics
Emesis can be treated with antiemeticsand nasogastric suction.
Restoration of hemodynamic stability
Daily stimulation of gallbladdercontraction
Laparoscopic cholecystectomy is the standard of care for the surgical
treatment of cholecystitis
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Cholecystectomy or Cholecystotomyusually reserved for complicated cases in
which the patient has gangrene or
perforation.
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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
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is the presence of one or more calculi
(gallstones) in the gallbladder.
Cholelithiasis
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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
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Four F’sFemale
Fat
FortyFertile
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Pathophysiology
Biliary sludge is 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 whilereceiving TPN.
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Types:
Cholesterol stonesBile must be supersaturated with
cholesterol The excess cholesterol must precipitate
from solution as solid microcrystalsmicrocrystals 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
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Brown pigment stonesare soft and greasy, consisting of
bilirubinate and fatty acids (Ca palmitateor stearate). They form during infection,inflammation, and parasitic infestation
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Manifestations
Asymptomatic Epigastric distress
Fullness
Abdominal distentionVague pain in the RUQMay follow ingestion of fried and fatty
foods
Fever Biliary Colic
steady or intermittent ache in the upperabdomen, usually under the right side of
the rib cage.
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Biliary colic Nausea
Vomiting
Colicky pain
JaundiceOccurs in few patients
Changes in urine and stool colorUrine is very darkStool is clay colored, grayinsh
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Diagnostics
Abdominal xrays
Ultrasound – procedure of choice
Cholescintigraphya radioactive dye is administered IV. The
Biliary tree is then scanned
Cholecystography
An iodide containing contrast agent isadministered to the patient . And a xrayis taken
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Surgical treatment
Endoscopic RetrogradeCholangiopancreatography
(ERCP)
is a test that combines the use of aflexible, lighted scope (endoscope) withX-ray pictures to examine the tubes thatdrain the liver, gallbladder,and pancreas
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Purpose:
Check persistent abdominal painor jaundice.
Find gallstones or diseases of the liver,
bile ducts, or pancreas. Remove gallstones from the common bile
duct if they are causing a problem suchas blockage (obstruction), inflammationor infection of the common bile duct(cholangitis), or pancreatitis.
Open a narrowed bile duct or insert a
drain.
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Percutaneous transhepaticCholangiographya radiologic technique used to visualize
the anatomy of the biliary tract. Acontrast medium is injected into a bileduct in the liver, after which X-rays aretaken
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Medical Management
Reduce gallbladder pain AnalgesicsSurgery
Administration of IV fluids Nasogastric suction Adequate rest Antibiotic therapy Ursodeoxycholic acid (UDCA) Chenodeoxycholic acid
Has been used to dissolve gallstone primarilycomposed of cholesterol
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Non- surgical Treatments
Mono-octanoin or methyl tertiary butylether (MTBE) infusion
Extracorporeal Shockwave Lithotripsy
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Nursing Management
Monitor pain administer analgesics asordered
Assess vital signs
Encourage hydration Administer a low fat diet
Instruct to avoid gaseous foods
Prepare the client for surgery
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Inflammation of the pancreas that can
occur in two very different forms
Pancreatitis
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is a sudden inflammation of
the pancreas
Acute Pancreatitis
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Manifestation
Edema on the pancreas
Inflammation
Severe epigastric pain radiating to the
back Nausea, vomiting, diarrhea and loss of
appetite
Fever/chills Hemodynamic instability, including shock
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Grey-Turner's sign (hemorrhagic discoloration of the flanks)
Cullen's sign (hemorrhagic discoloration of theumbilicus)
Grünwald sign (appearanceof ecchymosis around the umbilicus due tolocal toxic lesion of the vessels.)
Körte's sign (pain or resistance in the zonewhere the head of pancreas is located
(in epigastrium, 6-7 cm above the umbilicus). Kamenchik's sign (pain with pressure underthe xiphoid process)
Mayo-Robson's sign (pain while pressing at thetop of the angle lateral to the Erector spinae
muscles and below the left 12th rib (leftcostovertebral angle (CVA))
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Grey Turners sign
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Cullen’s Sign
C it i f Ad i i t th
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Criteria for Admission to thehospital
Age > 55 years
WBC >16,00 mm3
Serum Glucose >200 mg/dL
Serum LDH > .350 IU/L AST .250/mL
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Causes
I - idiopathic. Thought to be hypertensivesphincter or microlithiasis.
G - gallstone.Gallstones that travel down the common bile
duct and which subsequently get stuck inthe Ampulla of Vater can cause obstructionin the outflow of pancreatic juices from thepancreas into the duodenum. The backflowof these digestive juices
causes lysis(dissolving) of pancreatic cellsand subsequent pancreatitis.
E - ethanol (alcohol) T - trauma
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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
also snake bites
H - hypercalcemia, hyperlipidemia/hypertriglyceridemia and hypothermia
E - ERCP (Endoscopic Retrograde Cholangio-Pancreatography - a procedure that
combines endoscopy and fluoroscopy) D - drugs (SAND) - steroids & sulfonamides, azathioprine, NS
AIDS, diureticssuch as furosemide and thiazides,& didanosine) and duodenal ulcers.
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Diagnostics
Increased blood amylase level Increased serum blood lipase level
Increase urine amylase level
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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) Remove gallstones (ERCP, ESWL) Relieve blockages of the pancreatic duct
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Nursing Management
Monitor vital sign’s Administer pain medications
Implement NPO status
Complete bed rest Assess fluid and electrolyte balance
(monitor input and output)
Monitor NGT drainage Provide health teachings
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is long-standing inflammation of the
pancreas that results in irreversibledeterioration of pancreatic structureand function
Chronic Pancreatitis
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Causes
Alcoholism Idiopathic
Cystic Fibrosis
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Manifestations
Back pain Abdominal pain Weight loss
swollen and tender abdomen nausea vomiting fever rapid pulse Fatty stools (steatorrhea)
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Diagnostics
A secretin stimulation test Is considered the gold standard functional
test for diagnosis of chronic pancreatitisbut not often used clinically
ESR, IgG4, rheumatoid factorMay be elevated
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Medical Treatment
Chemical dependency treatment is the most importantstep 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 andlimiting fats help reduce the need for digestiveenzymes.
Treatment of diabetes, if that develops
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Nursing Management
Assess painAdminister 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 andfatty foods
Assess stools
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a malignant neoplasm of the pancreas
Sometimes called a "silent killer" becauseearly pancreatic cancer often does notcause symptoms
Pancreatic cancer
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Manifestations
Pain in the upper abdomen that typicallyradiates to the
Loss of appetite and/or nausea and
vomiting Significant weight loss
Painless jaundice (yellow skin/eyes, darkurine)
pale-colored stool and steatorrhea
Trousseau sign
Diabetes mellitus, or elevated blood
sugar levels.
Causes
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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
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Diabetes mellitus is both risk factor for pancreatic cancer,
and, as noted earlier, new onsetdiabetes can be an early sign of thedisease.
Chronic pancreatitis
Helicobacter pylori infection
Diagnostics
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Diagnostics
Computed tomography (CT) scans Magnetic resonance
cholangiopancreatography (MRCP)
Endoscopic ultrasound (EUS) Endoscopic retrograde
cholangiopancreatography (ERCP)
Upper GI series
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Surgical treatment
Whipple procedure the most common surgical treatment for
cancers involving the head of thepancreas
procedure involves removing thepancreatic head and the curve of theduodenum together (pancreato-duodenectomy)
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Distal Pancreatectomy
Cancers of the tail of thepancreascan beresected
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Medical Management
Intensity Modulated Radiation Therapyuses hundreds of small radiation beams of
varying intensities to precisely targetcancer cells, while sparing healthy tissue
Chemotherapy
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Nursing Management
Assess painAdminister pain medications as ordered
Encourage adequate nutritionProvide small low fat feedingsMonitor weightAssess and monitor hydration
Provide good skin careProtect bony prominences from pressure
ulcers Relieve discomforts
Relief of itching from jaundice