L5 biliary pancreatic disorder 2025 Flashcards
composition of bile
- water
- electrolytes (Na, K, Ca, Cl, HCO3)
- bilirubin
- cholesterol
- phospholipids
bile is synthesized by
hepatocytes in liver
bile is stored in
gallbladder
how many bile is produced in adult per day
400-800mL
color of bile
greenish yellow/ dark greenish
functions of bile (5)
- Emulsification of fats
- Absorption of fat soluble vitamins (A,D,E,K)
- Absorption of certain minerals
- Activate intestinal and pancreatic enzymes
- Neutralize gastric acid in duodenum
bile flow (production)
- liver
- common hepatic duct
- cystic duct (CD)
- gallbladder (GB)
bile flow (digestion)
- gallbladder contracts
- cystic duct
- common bile duct (CBD)
- Sphincter of Oddi relax
- duodenum
formation of gallstone is also known as
cholelithiasis
gallstone obstructs biliary tract is also known as
choleocholithiasis
inflammation of gallbladder is also known as
cholecystitis
inflammation of bile duct is also known as
cholangitis
pathophysiology of cholelithiasis
- Bile secreted by the liver is supersaturated with cholesterol
- Gallstone formation when cholesterol concentration in bile becomes excessive –> causing crystallization or precipitation to occur
what condition favors cholelithiasis
when gallbladder does not empty regularly
which stone (cholesterol/ pigment) is the most common type of gallstone
cholesterol type
components of cholesterol stones (4)
- 80-90% cholesterol
- calcium carbonate
- phosphates
- bilirubin
color of cholesterol stones
soft and yellow
why pigment stones are formed
too much bilirubin in bile
components of pigment stones (2)
- unconjugated bilirubin
- inorganic calcium salts
color of pigment stones
hard, black or brown
black pigment stones are more likely to be related to
chronic hemolytic disease
brown pigment stones are more likely to be related to
biliary tract infection
risk factors of cholelithiasis (the ‘5F’)
- Family history of gallbladder stones
- Forty or above (Middle age)
- Females
- Fertile (Pregnant women –> failure
to empty bile from GB) - Fat (Obesity/ Hyperlipidemia)
cholelithiasis is more common in what race?
Caucasian
cholelithiasis is common for patients receiving
oral contraceptives/ estrogen therapy
rapid weight loss has a higher risk to have cholelithiasis
yes
types of biliary statis that increases risk of cholelithiasis
- fasting
- on long term parenteral nutrition
is DM a risk factor of cholelithiasis
yes
clinical manifestations of cholelithiasis
- Can be asymptomatic
- Biliary colic 膽絞痛(Severe upper abdominal pain going through into the back)
–> occur 30 minutes to several hours after eating a fatty meal
–> can be intermittent or steady and usually located in the RUQ and radiates to the
mid-upper back - Jaundice
–> stone located in the CBD
(Choledocholithiasis) - Nausea and vomiting
pathophysiology of choledocholithiasis
Bile cannot be passed into duodenum –> reflux to the liver –> obstructive jaundice and possible liver damage
what happens if gallstones obstructs the CBD
pancreatic enzyme cannot be passed into duodenum and start digesting pancreas itself, leading to pancreatitis
complications of ERCP
- sphincterotomy related
–> bleeding (hypotension and dizziness)
–> pancreatitis (trauma to pancreatic duct following repeated cannulation/ excess fill with contrast) - contrast related
–> allergy reaction (SOB, rash, hypotension)
full name of PTBD
Percutaneous Transhepatic Biliary Drain
what is PTBD
- Non surgical, invasive and effective therapeutic intervention for relieve biliary obstruction
- Image guided (X ray or USG)
indications of PTBD
- Failure to perform endoscopic procedure (i.e. ERCP)
- Biliary strictures
- Biliary obstruction (by stones or tumor)
- Relieve jaundice- related symptoms
what catheter is used in PTBD
pigtail catheter
physical preparation of PTBD (8)
- Check latest blood result (i.e. CBC, LRFT, Clotting profile)
- Informed consent
- Allergy history (especially with contrast media)
- Keep NPO at least 4-6 hours before procedure
- IV access
- Premedication: Prophylactic antibiotic, Steroid with allergy history
- Gown up and empty bladder
- LMP for reproductive female patient
psychological preparation of PTBD
- Patient education (explain procedure, purpose, duration, potential discomfort, etc.)
- Reassurance
post-procedure nursing care of PTBD (10)
- Closely monitor vital signs
- Level of consciousness
- Pain management
- Observe any s/s of complications ( eg : abdominal pain,
- Check blood results ( eg : CBC, LRFT, Clotting
- Encourage bed rest
- Drainage system monitoring
- Resume diet if patient fully awake and no contraindications (Dr’s order)
- Continue prophylactic antibiotics as prescribed
- Educate patient to report discomfort and abnormality
drain care of PTBD (6)
- Assess catheter exit site for any oozing and discharge
- Observe the color , nature and amount of output regularly and document in I&O chart
- Maintain the drain patency , avoid kinking and traction of the tube
- Keep drainage bag below waist level
- Patient education
- Perform PTBD dressing
dressing of PTBD (6)
- Change dressing according to hospital guideline (once per week/ 2
times per week, etc.) - Change dressing once massive oozing observed
- Check the security of anchoring stitch
- Observe any s/s of infection
- Observe surrounding skin conditions
- Ensure the drain is well secured by outer dressing (i.e. Omnifix )
complications of PTBD (10)
- Infection of bile ducts (Cholangitis膽管炎)
- Wound infection
- Bile leakage into peritoneal cavity
- Catheter dislodgement脫落
- Haemobilia血膽症
- Sepsis
- Injury to other organ
- Obstruction of bile drainage
- Pneumothorax
- Perforation of duodenal diverticulum十二指腸憩室出血
cause of cholecystitis
lodging of a gallstone in the cystic duct–> obstruction–> GB become distended and inflamed (bacterial infection)
what happens after having cholecystitis
pressure against the distended wall of GB decrease blood flow and result in ischemia, necrosis and perforation of GB
clinical manifestations of acute cholecystitis
- Fever
- Chills
- Anorexia, nausea and vomiting
- Severe pain in RUQ and radiate to right scapula and shoulder–>
Aggravated by movement and breathing - Positive Murphy’s sign
- Abdominal muscle guarding and tenderness
- Jaundice (if obstruction in CBD)
–> Pruritus
–> Tea color urine
–> Yellowish skin discoloration
complications of acute cholecystitis
- Gangrenous 壞疽性的 cholecystitis
- Abscess (Pus/empyema) formation in gallbladder
- Rupture of the gallbladder –> bile peritonitis
- Body trying to get rid of pus can form fistula into adjacent organs (i.e. small intestine) –> Gallstone ileus (bowel
diagnosis method to detect acute cholecystitis
- ultrasound
- ct scan
- blood test (increased in WBC, deranged LFT)
what do we do for patients with acute cholecystitis
supportive management
nursing interventions to acute cholecystitis (2)
- Keep NPO NG tube insertion for decompression –> avoid further
gallbladder stimulation - Hydration with IVF
medication
- antibiotics (for inflammation)
- anticholinergics
- analgesic
- ursodeoxycholic acid/ chenodeoxycholic acid (to dsisolve small stones)
surgical procedures for acute cholecystitis
- ERCP with papillotomy to extract gallstones
- transhepatic biliary catheter, such as PTBD
- (open/ laparoscopic) cholecystectomy
pre-op nursing interventions (10)
- Informed consent ( with anesthetist )
- Check allergy history
- Check latest blood result (CBC, LRFT, Clotting profile)
- Ensure valid Type & Screen (T&S)
- Ensure latest diagnostic reports is ready (CXR, USG, CT, ECG, ERCP if any)
- Keep NPO at least 8 hours with IVF
- IV access
- Insert NG tube for decompression as prescribed
- Withhold anticoagulant (eg : Warfarin) and antiplatelet drug eg : Aspirin)
- Psychological preparation and reassurance
post-op nursing care (vital sign, 2)
- LOC
- temperature
post-op nursing care (wound care, 2)
- Assess wound for any oozing, mapping if oozing noted
- Keep wound dressing intact and change dressing as prescribed
post-op nursing care (drain, 4)
- Assess drain site for any oozing
- Ensure patency, no kinking, no traction
- Ensure well secured
- Monitor output characteristics and document in I&O chart
post-op nursing care (pain, 3)
- Assess pain level
- Administer analgesic as ordered or request +/ PCA
- Advice patient to splint the abdomen during cough and movement to
reduce pain
post-op nursing care (Hydration and nutritional status, 5)
- Maintain IVF if diet not yet resumed
- Monitor NG tube (if any) output and I&O balance
- Evaluate any post op nausea and vomiting
- Administer anti emetics as ordered or request
- Low fat and high carbohydrates and proteins if resume oral intake
Prevent post-op complications (6)
- SemiSemi-fowler’s position if no contraindication
- Education deep breathing and coughing
exercise - Encourage incentive spirometry exercise
- Encourage early ambulation
- Monitor blood result (WBC, bilirubin level, LFT)
- Administer prophylactic antibiotics as prescribed
what will be done if obstructions found during open cholecystectomy
- choledochotomy
- T-tube will be inserted to maintain CBD patent and promote bile drainage
amount of T tube in first 24 hours post-op
300-500mL
amount of T tube in 2-3 days post-op
less than 200mL
when can T-tube be clamped?
1 hour before and after each meal to aid digestion when diet resumed as prescribed
Nursing care of T-tube in hospital (8)
- Assess drain dressing for any oozing and discharge
- Maintain the drain patency, avoid kinking and traction of the tube
- Ensure T tube is well connected to bedside bag (BSB)
- Keep drainage bag below waist level
- Monitor signs of bile obstruction (decrease drainage output, jaundice, deranged LFT etc.)
- Patient education
- Perform T tube dressing (Same as PTBD)
- Observe skin condition (bile irritates the skin if bile leak occur) and any s/s of infection during dressing
Nursing care of T-tube discharge from hospital (5)
- Educate patient on T tube care ( eg : how to clamp and release, empty
drainage bag) - Educate patient to report early signs of infection
- Fats can be taken as tolerated
How long can T-tube be kept
up to 2 weeks
cautions of drain care (7)
- Keep drainage bag below waist level
- Ensure anchoring stitch is in in-situ, inform
doctor for re re-suturing if stitch is loosened - Ensure the drain is patent
- Observe drain output , inform doctor if
abnormal drain output - Avoid traction/dislodgement of drain during
turning and movement - NEVER clamp the drain without doctor’s order!
- NEVER use scissors to remove old dressing!
obstruction to the outflow of the pancreatic digestive enzymes are caused by
bile and pancreatic duct obstruction (eg gallstone)
acute pancreatitis can be caused by
- direct cellular injury from alcohol, drugs or viral infection
development of acute pancreatitis caused bu obstruction
- pancreatic duct obstruction
- pressure increase
- ductal rupture
- production and release of pancreatic enzyme (Trypsin)
- activate other enzymes cause autodigestion of pancreatic cells and tissues
- inflammation
- leads to vascular damage, coagulation necrosis, fat necrosis, formation of pseudocysts
what does edema within the pancreatic capsule leads to
ischemia and then necrosis
how alcohol hurts our pancreas
- pancreatic acinar cell metabolizes ethanol
- toxic metabolites are generated and injure pancreatic acinar cells
- activated enzymes are released
how does chronic alcohol causes pancreatitis
- chronic alcohol causes formation of protein plugs in pancreatic ducts and spasm of the sphincter of Oddi
- obstruction and autodigestion occurs
- inflammation occurs and develops into pancreatitis
clinical manifestations of acute pancreatitis (9)
- Severe LUQ abdominal pain +/ radiate to back
- Fever and leukocytosis
- Nausea and vomiting
- Jaundice
- Abdominal distension
- Hypotension and Tachycardia
- Tachypnea and hypoxia
- Transient hyperglycemia
- Severe –> multiorgan failure
complications of acute pancreatitis (10)
- Septic shock (Pancreatic infection)
- Hypovolemic shock
- Necrotizing pancreatitis
- Acute renal failure
- Pleural effusion
- Acute respiratory distress syndrome (ARDS)
- Atelectasis
- Pneumonia
- Multiorgan system failure
- Type 2 diabetes mellitus
imaging test and endoscopy of acute pancreatitis
- CT Scan
- USG
- MRI
- MRCP – Magnetic Resonance
Cholangioholangiopancreatography - ERCP- endoscopic retrograde cholangio pancreatography
what results of blood test may indicate acute pancreatitis
- ↑ WBC
- ↑ Amylase/ Lipase
- ↑ Bilirubin
- ↑ LDH (Lactate dehydrogenase, enzyme used in anabolism)
- ↑ Glucose
management of mild pancreatitis
conservative treatment
* pain relief
* NPO for few days
* maintain hydration through IVF therapy
* NG tube insertion for decompression
* nutritional support (enteral feeding)
* O2 therapy if necessary
what to do when septic shock occurs incacute pacnreatitis
fluid resuscitation
what to do necrotizing pancreatitis occurs inc acute pancreatitis
antibiotics +/- surgery
what to do when gallstones induced in acute pancreatitis
endoscopic retrograde choleangiopancreatgraphy for gallstones removal
types of nutritional support provided to patients with moderate to severe pancreatitis
mat start parenteral nutrition such as TPN
nursing care for acute pancreatitis (6)
- Monitor BP/P, body temp
- Monitor Respiratory status–> Administer O2 if needed
- Monitor I&O balance
–> Monitor NG tube output and aspirate regularly (i.e. Q4H)
–> Monitor urine output (Insert urinary catheter if indicated)
–> Nutritional support (Parenteral or enteral) - Monitor latest blood result (CBC, LRFT, Amylase etc.)
- Encourage bed rest
- Emotional support
- Pain assessment
–> COLDSPA
–> Administer analgesics as prescribed and request
–> Non -pharmacological method (e.g.: Fetal position when lying in bed) - Administer other medications
–> Antibiotics
–> PPI/ Somatostatin as ordered
–> Anti -emetic if nausea and vomiting
