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Biliary Disorder (N: 1L bile a day) (Management (Percutaneous…
Biliary Disorder (N: 1L bile a day)
Common Biliary Disorder
Chole-lithiasis: Presence of gallstones
Chole-docho-lithiasis: stones in common bile duct
Chole-cystitis (lethal)
Inflammation of gall bladder
Acute cholecystitis
95% calculous 姐系cholelithiasis la cholecystitis咩姐
lethal if untreated ( common bile duct burst)
#
5% acalculous
Chronic cholecystitis
thickened and fibrotic gallbladder
Poor contractility and dysfunctio
n
Cause
Repeated cholecystitis
Calculi
chronic irritation
Clinical Manifestations
Asymptomatic ( if stones remained in bladder)
Biliary Colic
Precipitated by large or fatty meal (by 1-6 hours)
Nausea and Vomiting
Murphy' sign: positive
RUQ
pain or guarding
漲住頂住對抗
Manifest inspiratory arrest on palpation or during USG
below the hepatic margin
Jaundice
Yellow discoloration of skin and sclera
Dark Tea-colored Urine
obstructive jaundice: Clay-colored stool
Cholangitis (lethal)
gangrenous cholecystitis
Inflammation of bile ducts
Complications
Cholangitis and Gangrenous cholecystitis
Commonly at fundus because of
compromised vascular supply
底部最遠
URGENT laparoscopic cholecystectomy
Gallbladder Perforation
Delayed medical advice
conservative treatment 好unresponsive
localized bile leakage: formation of
pericholecystic abscesses
Generalized bile leakage:
Biliary Peritonitis
Cholecystoenteric Fistulas
perforation of acutely inflamed gall bladder that
adhere to the gastrointestinal tract
common sites:
duodenum and heptatic flexure of colon
Gallstone Ileus腸梗阻 not moving
gallstone passing from biliart tract into intestinal tract via FISTULA
common finding in AXR
Pneumobilia 積氣
intestinal obstructions
gall stones in unsual sites
Diagnostic Studies
Lab Tests
Serum Bilirubin
Total: Screen for Liver/ Biliary Dysfunction
0.1-1.2 mg/dL
Direct (conjugated): Obstructive Jaundice
0-0.3 mg//dL
Indirect (unconjugated)
Poor liver uptake or conjugation problem; Hemolysis
Urinalysis
urine urobilinogen
elevated if increase serum bilirubin
<1 mg/2hr . 0.5-4 mg/dL in 24 hrs
urine bilirubin
DETECTED if increase serum bilirubin
Method
Abdominal X-Ray (AXR)
show radio-opaque gall bladder
Abdominal Ultrasonography
view
mechan. obstructions/ dilation of all bladder / comon bile ducy
Computerized tomography (CT) scan abdomen
locate
biliary obs
identify obs by pancreatic lesions
Detect w/ abd cavity
Cholescintigraphy, Radionuclide imaigng
show
stone/ inflammation
determine the site of partial obs in nonicteric holestatic conditions
ERCP endoscopic Retrograde cholangiopancreaography
For diagnostic and therapeutic
diagnostic
oesophagus/stomach/proximal duodenum,common bile duct and Ampulla of Vater
Removal of fluid for cytology
Biopsy
indications
detect intrahepatic biliary obstruction
calculi/
strictures
/ tumors/
injuries
Detect extrahepatic biliary obstruction
calculi/ tumors/
pancreatitis
/
pancreatic duct abnormalitie
s
therapeutic
lithotripsy
stent placement for strictures
(ST) sphincterotomy
choledochostomy
placement of Nasoduodenal Drain ND口去到duodenum
indications
acute cholecystitis
evacuation of stones and drainage of bile till oedema subsidies
Jaundice
Prehepatic
Haemolytic Jaundce
Destruction of Large amount of RBC
congenital Disorder
Sickle cell anaemia
Thalasemia
even smaller cbc cell volume
G6PD
lack of G6PD protective enzyme
infection: Malaria
Massive Blood transfusion
Dissolution of large hematoma
Intrahepatic
Hepatocellular Jaundice
viral infection
Paracetamol Toxicity
Liver failure: neoplasm; cirrhosis
Fluimucil 抗纖維化
Extrahepatic
Obstructive Jaundice
Biliary Tract Calculi
Biliary stricture
Pancreatic tumor compressing bile duct
PATHOPHYSIOLOGY
NOTES
Management
Surgical
Acute
Cholecystitis
Laparoscopic
Cholecystectomy
Conventional
Open Cholecystectomy
Indications for cholecystectomy
symptomatic
cholelithiasis
asymptomatic cholelithiasis w/ increased risk of carcinoma or complications
acalculous
cholecytitis
Gallbladder polyps 息肉 >0.5cm
non-surgical
choledocholithiasis and cholangitis
ERCP w/ endoscopic Papillotomy and stone extraction
By laparoscopic
LCBDE : Laparoscopic Common Bile Duct Exploration
IOC: Laparoscopic cholangiogram
LUS: laparoscopic ultrasound
Exploration of CBD follow by open cholecystectomy
PTBD Palliative Percutaneous Biliary Drain
Cholelithiasis
Endoscopic Lithotripsy
Extracorporeal 體外 Shock Wave Lithotripsy (ESWL)
少用多數for renal stone
NASOBILIARY DRAIN
Post-operative care of Cholecystectomy
Watch S & S of bile duct injury
Bile Peritonitis
RUQ pain
abdominal distension
fever and chills
jaundice
nausea and vomiting
unusual characteristics of drainage
evaluate outcome of care and modify intervention
timely document of actions
Drains 同常laparoscopic and no drains needed
Round/Tubal drain
NG tube drainage
maintain NG decompression
connect to drainage bag plus hourly aspiration
T-tube
promote bilary drianage
Percutaneous Cholecystostomy PTC
minimally invasive
PTBD: Palliative treatment for symptom of relief
acalculous cholecystitis
Performed
at bedside
under
local anaesthetic indications
Drain infected bile
Advantageous for high risk clients e.g. serious comorbidity
undergo cholecystectomy or lithotripsy after PTC
Nursing
Diagnosis
Pain/ Risk for imbalanced fluid volume
Risk for injury
Actions
Independent: monitoring and nursing care
Collaborative
Medication administration
Preparation of clients and assistance in diagnostic procedures and surgery
Medical
Cholelithiasis
Gallstone Dissolution： 通常冇效
Oral Therapy
Solvent: Ursodeoxycholic acid UDCA
local infusion注入of cholelitholytic agent via PTBD
Supportive
Pain manage ment and analgesic
Decompress stomach and biliary act
NPO
NG aspiration
bed test subdue the imflam process
oxygen therapy
Monitor
fluid/electrolyte balance
coz vomit/ bile loss
IV fluid replacement to correct dehydration or electrolyte imbalance
dehydration: dry mucous membranes, poor skin turgor, low urine output
Infection
initial antibiotics treatment
Cephalosporin
Cefuroxine (Zinacef) 1.5g Q6-8H
Metronidazole (Flagyl) 500 mh Q8H
Broadening antibiotics for SEVERE CASE
Ampicillin
Gentamycin
Clindamycin
Diet
adequate clear liquilds
low to no fat
frequent small feedings (not 4 DM)
abstinence 節制 from alcohol and caffeine
antiemetic 止吐
stemetil
Maxolon
Antihistamine for pruritus癢
e.g. piriton for puritus
anti-pruritic and antidiarrhoeal agent for partial biliary obstruction : cholestyramine