2

Learning Objectives
Upon completion of the lecture, students will be able to:
1. recognize the human responses to altered pathophysiology related to
biliary disorders
2. adopt a clinical reasoning approach to develop nursing care to adult
clients
3. describe the investigations and treatment based on a holistic care
concept
4. identify pertinent client information relevant to the needs in managing
the client’s condition.
5. explore the advancement and application of technology in client
management and care
6. identify and prioritize appropriate nursing interventions for clients &
their families with biliary disorders from a holistic perspective 3
4
Black, J.M., Hawks, J.H. & Keene, A.M. (2005). Medical-surgical nursing: Clinical management for positive outcomes. 5
(7th Ed.). W.B. Saunders Company.
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 Common Biliary Disorders

Cholelithiasis: presence of gallstones

Choledocholithiasis: presence of stones (calculi) in common
bile duct
Cholecystitis: inflammation of the gall bladder
Cholangitis: inflammation of the bile ducts

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 Cholecystitis
Acute Cholecystitis: Inflammation of the Gall Bladder:
Calculous Cholecystitis (95%)
Acalculous Cholecystitis (5%)
Acute cholecystitis and cholangitis if left untreated are lethal.

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 Cholecystitis
Chronic Cholecystitis:
Thickened & fibrotic gallbladder
Causes:
Repeated cholecystitis
Calculi or
Chronic irritation
Poor contractility & dysfunction

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 Clinical Manifestations

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FIGURE 3 Presentation of gallstones. From: Graham (2008) Nurs Stand, 23(7). pp 41-48
Clinical Manifestations

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 Clinical Manifestations
Asymptomatic (if gallstones remained in the bladder)
Biliary Colic:
Precipitated by large or fatty meal (by 1-6 hours)
Nausea & Vomiting

Murphy's Sign: Positive

RUQ pain or guarding
Manifest Inspiratory arrest on palpation or during USG below the
hepatic margin
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 Clinical Manifestations
Jaundice:
Yellow discolouration of Skin & Sclera
Dark Tea-coloured Urine
Obstructive Jaundice: Clay-coloured Stool

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 Recall Knowledge

Fawcett, T. & Smith, G. (2004). Jaundice: its

occurrence, causes and care. 23
Gastrointestinal Nursing, 2, 1, p.23-27.
Recall Knowledge

24
McCance, K. L. & Huether, S. E. (2006). Pathophysiology: The Biologic Basis for Disease in Adults and Children. (5th Ed.). Elsevier Mosby.
 Complications
Cholangitis & Gangrenous Cholecystitis:
Commonly occur at the fundus because of compromised vascular
supply
Urgent laparoscopic cholecystectomy
Gallbladder Perforation:
Delayed medical advice
Unresponsive to conservative treatment
Localized bile leakage: Formation of pericholecystic abscesses
Generalized bile leakage: Biliary Peritonitis
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 Complications
Cholecystoenteric Fistulas/Fistulae:
Perforation of the acutely inflamed gall bladder that adhere to the
gastrointestinal tract
Common sites: duodenum & the hepatic flexure of the colon
Gallstone Ileus:
Gallstone passing from the biliary tract into the intestinal tract through
a fistula
Common findings in AXR: pneumobilia, & gall
stones in unusual sites
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Complications

Dodgion, C., de Moya, M. (2019). Gallstone Ileus. In: Brown, C.,

Inaba, K., Martin, M., Salim, A. (eds) Emergency General
Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319- 27
96286-3_13
 Nursing Problems and Actions
Nursing Diagnosis:
 Pain
 Ineffective breathing
 Risk for Imbalanced Fluid Volume
 Risk for Injury
Nursing Actions:
 Independent: Monitoring & nursing care
 Collaborative:
 Medication administration
 Preparation of clients & assistance in diagnostic procedures & surgery 29
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 Diagnostic Studies
Laboratory Test (Blood Test) Indications or Remarks
1. Liver Function Test (LFT) Elevated liver enzymes when there is liver injury
− Liver enzymes, bilirubin, − alkaline phosphatase (ALP)
Lactate dehydrogenase − alanine transaminase (ALT)
(LDH) − aspartate aminotransferase (AST)
− gamma-glutamyl transferase (GGT)
2. Serum Bilirubin (Total) Screening for Liver/Biliary Dysfunction
− Hyperbilirubinemia is usually manifest as
jaundice when blood levels are ≥ 2 to 3 mg/dL
Direct (Conjugated) Bilirubin Obstructive Jaundice - ↑
Indirect (Unconjugated) Poor liver uptake or conjugation problem;
Bilirubin Hemolysis - ↑
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Diagnostic Studies

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Diagnostic Studies

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Diagnostic Studies

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Diagnostic Studies

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Diagnostic Studies

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Diagnostic Studies

LIM, S. T. & SOHN, M. ( 2002). Rim Sign in Acute Cholecystitis: Correlative Images Between
Hepatobiliary Scintigraphy and Helical Computed Tomography. Clinical Nuclear Medicine, 27, (1), p.67-68.
Fig. 1 Highly specific sign of acute cholecystitis on radionuclide hepatobiliary scintigraphy

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Diagnostic Studies

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Diagnostic Studies

Diagnostic & Therapeutic

Direct visualization of oesophagus, stomach, proximal
duodenum, common bile duct & Ampulla of Vater
Removal of fluid for cytology
Biopsy

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Diagnostic Studies

Diagnostic
Indications:
Detect Intrahepatic Biliary Obstruction:
 Caculi Strictures
Tumours Injuries

Detect Extrahepatic Biliary Obstruction:

 Caculi Pancreatitis
Tumours Pancreatic duct abnormalities
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Diagnostic Studies

Diagnostic & Therapeutic

Fig. 2. (A) Radiological and (B) ultrasound views of

transduodenal access of the common bile duct.
The scope is positioned in the duodenal bulb.
Arrow = guidewire.
43
Weilert, F., & Binmoeller, K. F. (2012). Endoscopic ultrasound-guided access to the bile duct: A new frontier. Gastrointestinal Intervention, 1(1), 11-18.
https://doi.org/https://doi.org/10.1016/j.gii.2012.08.005
Diagnostic Studies

Diagnostic & Therapeutic

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 Diagnostic Studies

Therapeutic
Lithotripsy
Stent Placement for strictures
Sphincterotomy (ST)
Choledochostomy:
Placement of (ND)
Indications:
Acute cholecystitis (too ill for surgery)
Evacuation of stones & drainage of bile till oedema subsides 45
 Management:
Medications
Gallstone Dissolution
 Interfere with the development of the stones
Only useful for small non-calcified cholesterol stones
Oral Therapy:
Solvent: Ursodiol – stop liver from making cholestrol
Local infusion of Cholelitholytic Agent via PTBD

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 Management:
Supportive
Pain Management & Analgesic
Decompress stomach & biliary tract
NPO
Nasogastric Aspiration
Bed rest to subdue the inflammatory process
Oxygen Therapy as appropriate
Monitor:
Fluid/electrolyte balance
IV fluid replacement to correct dehydration or electrolyte imbalance
Dehydration: dry mucous membranes, poor skin turgor, low urine output47
 Management:
Supportive
Diet: Gradual progression
Adequate clear liquids
Low- to Non-Fat Diet
Frequent small feedings
Abstinence from alcohol and caffeine
Anti-emetic: e.g.______________
Stemetil, Maxolon

Anti-pruritic & Antidiarrhoeal agent for partial biliary obstruction:

Cholestyramine
Piriton
Anithistamine for pruritus: e.g. ________ 48
 Management:
Emergence of supreimposed bacterial Infection
 Initial Antibiotics Treatment:
 Cephalosporin: Cefuroxime (Zinacef) 1.5 g Q6-8H &
 Metronidazole (Flagyl) 500 mg Q8H
 Consider broadening antibiotics for severe cases:
 Gentamycin
 Clindamycin

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 Management:
Cholelithiasis:
Endoscopic Lithotripsy:
Lithotripsy Basket
Laser Lithotripsy
Electrohydraulic Lithotripsy
(EHL): Shockwave for impacted stones

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Acute Cholecystitis:
Laparoscopic Cholecystectomy (LC)
Conventional Open Cholecystectomy
Indications for Cholecystectomy:
▲Symptomatic cholelithiasis
▲Asymptomatic cholelithiasis with increased risk for carcinoma or
complications
▲Acalculous cholecytitis
▲Gallbladder polyps > 0.5cm
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 Management:
Choledocholithiasis & Cholangitis:
ERCP with Endoscopic Papillotomy & Stone Extraction followed by
Laparoscopic Cholecystectomy
LC and laparoscopic common bile duct exploration (LCBDE) with
laparoscopic cholangiogram (IOC) or laparoscopic ultrasound (LUS) with
high success rate
Exploration of Common Bile Duct (CBD) followed by Open
Cholecystectomy
Palliative Percutaneous Biliary Drain (PTBD)

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or Round drain
or Tubal drain

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 Taylor, C., Lillis, C. & LeMone, P. (2005). Fundamentals of
nursing : the art and science of nursing care. (5th ed.).
Philadelphia: Lippincott Williams & Wilkins.

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Yetisir, F., Sarer, A. E., Acare, H. Z., Polat, Y., Osmanoglu, G., Aygar, M., Ciftciler, A. E., & Parlak, O. (2016).
Case Reports in Surgery. http://dx.doi.org/10.1155/2016/1030358
Puri, R., Paleari, N., Stauffer, J., &
Asbun, H. J. (2016). The
development of minimal access
hepatopancreatobiliary surgery. In
Laparoscopic Liver, Pancreas, and
Biliary Surgery (pp. 1-16).
https://doi.org/https://doi.org/10.
1002/9781118781166.ch1

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Epigastric Pain for Investigation

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Epigastric Pain for Investigation

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Admission for Surgery: Preoperative Care

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Admission for Surgery: Preoperative Care

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Admission for Surgery: Preoperative Care

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Admission for Surgery: Preoperative Care

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Admission for Surgery: Preoperative Care

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22/11/2021 09:00 7 hours

Gall stone and ? Ca gallbladder

Ca gallbladder confined to muscularis

Radical resection with hepatectomy + cholecystectomy + LN resection + excision of CBD + Hepaticojejunostomy

Gallbladder and CBD, live segments 3, 4 & 5, hilar lymph node and coeliac lymph nodes
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2 gallstones
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Watch for signs & symptoms of Bile duct injury:
B
RUQ pain:persistent pain unrelieved by analgesics
Abdominal distension
Fever & Chills
Jaundice
Nausea & vomiting
Unusual characteristics of drainage
Evaluate the outcome of care & modify interventions if required
Timely documentation of actions

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Post-Operative Care

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Post-Operative Care

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Post-Operative Care

103
Simpson, J. C., Bao, X., & Agarwala, A. (2019). Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols. Clin Colon Rectal Surg, 104
32(2), 121-128. https://doi.org/10.1055/s-0038-1676477
Simpson, J. C., Bao, X., & Agarwala, A. (2019). Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols. Clin Colon Rectal Surg, 105
32(2), 121-128. https://doi.org/10.1055/s-0038-1676477
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Upon Discharge

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Post operative care

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Percutaneous Cholecystostomy (PTC):
A Minimally Invasive procedure
PTBD: Palliative treatment for symptom relief
Definitive treatment in patients with acalculous cholecystitis
Percutaneous cholecystostomy: to drain infected bile
Can be performed at the bedside under local anaesthetic
Indications
Advantageous for high risk clients, e.g. with serious comorbidity
or unstable clients
Undergo cholecystectomy or lithotripsy after percutaneous
cholecystostomy 111
Percutaneous Cholecystostomy

Fig. 1. 3-Steps of Percutaneous

Transhepatic Biliary Drain (PTBD)
Oran, N. T., Oran, I. & Memis, a. (2000).
Management of Patients With Malignant Obstructive
Jaundice: NURSING PERSPECTIVE FROM THE
INTERVENTIONAL RADIOLOGY ROOM. Cancer
Nursing, 23, (2), p.128-13.

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 Percutaneous Cholecystostomy
Percutaneous Transhepatic Biliary Drain (PTBD) -

113
 Percutaneous Cholecystostomy

Oran, N. T., Oran, I. & Memis, a. (2000). Management of patients with malignant obstructive jaundice:
nursing perspective from the interventional radiology room. Cancer Nursing, 23, (2), p.128-13. 114
Fig. 2. PTBD & STENT PLACEMENT.