BILIARY DISORDERS

The gallbladder and bile ducts comprise the biliary system. The gallbladder stores and
concentrates bile produced by the liver. The hormone cholecystokinin, secreted by the small
intestine, stimulates contraction of the gallbladder and relaxation of the sphincter of Oddi for
delivery of bile into the small intestine.
Bile assists in the emulsification (breakdown) of fat; absorption of fatty acids,
cholesterol, and other lipids from the small intestine; and excretion of conjugated bilirubin from
the liver.
Common terms related to the gallbladder and bile ducts are:
Cholecyst—gallbladder.
Cholecystitis—inflammation of the gallbladder.
Cholelithiasis—presence or formation of gallstones in the gallbladder.
Cholecystectomy—removal of the gallbladder.
Cholecystostomy—drainage of the gallbladder through a tube.
Choledocho—common bile duct.
Choledochotomy—incision into the common bile duct.
Choledocholithiasis—presence of stones in the common bile duct.
Choledocholithotomy—incision of the common bile duct for the extraction of an
impacted gallstone.
Choledochoduodenostomy—surgical formation of a communication between the
common bile duct and the duodenum.
Choledochojejunostomy—surgical formation of a communication between the common
bile duct and the jejunum.
Cholelithiasis, Cholecystitis, Choledocholithiasis
These conditions refer to stones or inflammation of the biliary system. Cholecystitis may be
acute or chronic.
Pathophysiology and Etiology
Cholelithiasis
1. Stones occur when cholesterol supersaturates the bile in the gallbladder and precipitates
out of the bile. The cholesterol-saturated bile predisposes to the formation of gallstones
and acts as an irritant, producing inflammatory changes in the gallbladder.
a. Cholesterol stones are the most common type of gallstones found in the United
States.
b. Four times more women than men develop cholesterol stones.
c. Women are usually older than age 40, multiparous, and obese.
d. Stone formation increases in users of contraceptives, estrogens, and cholesterol-
lowering drugs, which are known to increase biliary cholesterol saturation.
e. Bile acid malabsorption, genetic predisposition, and rapid weight loss are also risk
factors for cholesterol gallstones.
2. Pigment stones occur when free bilirubin combines with calcium.
a. Found in patients with cirrhosis, hemolysis, and infections in the biliary tree.
b. These stones cannot be dissolved.
3. An estimated 25 million people in the United States have gallstones, with 1 million new
cases discovered each year.
a. Incidence of stone formation increases with age because of increased hepatic
secretion of cholesterol and decreased bile acid synthesis.
b. Increased risk in patients with malabsorption of bile salts with GI disease, bile
fistula, gallstone ileus, carcinoma of the gallbladder, or in those who have had
ileal resection or ileal bypass.
Cholecystitis
1. Acute cholecystitis, an acute inflammation of the gallbladder, is most commonly caused
by gallstone obstruction.
a. Secondary bacterial infection may occur and progress to empyema (purulent
effusion of the gallbladder).
2. Acalculous cholecystitis is acute gallbladder inflammation without obstruction by
gallstones.
a. Occurs after major surgical procedures, severe trauma, or severe burns.
3. Chronic cholecystitis occurs when the gallbladder becomes thickened, rigid, and fibrotic
and functions poorly. Results from repeated attacks of cholecystitis, calculi, or chronic
irritation.
Choledocholithiasis
1. Small gallstones can pass from the gallbladder into the common bile duct and travel to
the duodenum. More commonly they remain in the common bile duct and can cause
obstruction, resulting in jaundice and pruritus.
 2. Common bile duct stones are frequently associated with infected bile and can lead to
cholangitis (inflammation/infection in the biliary system).
3. A typical clinical picture includes biliary pain in the upper abdomen, jaundice, chills and
fever, mild hepatomegaly, abdominal tenderness, and, occasionally, rebound tenderness.
Clinical Manifestations
1. Gallstones that remain in the gallbladder are usually asymptomatic.
2. Biliary colic can be caused by gallstones.
a. Steady, severe, aching pain or sensation of pressure in the epigastrium or right
upper quadrant, which may radiate to the right scapular area or right shoulder.
b. Begins suddenly and persists for 1 to 3 hours until the stone falls back into the
gallbladder or passes through the cystic duct.
3. Acute cholecystitis causes biliary colic pain that persists more than 4 hours and increases
with movement, including respirations.
a. Also causes nausea and vomiting, low-grade fever, and jaundice (with stones or
inflammation in the common bile duct).
b. Right upper quadrant guarding and Murphy’s sign (inability to take a deep
inspiration when examiner’s fingers are pressed below the hepatic margin) are
present.
4. Chronic cholecystitis causes heartburn, flatulence, and indigestion. Repeated attacks of
symptoms may occur resembling acute cholecystitis.
Diagnostic Evaluation
1. Oral cholecystography, ultrasonography, and HIDA scan may show stones or
inflammation.
2. ERCP or PTC to visualize location of stones and extent of obstruction.
3. Elevated conjugated bilirubin and alkaline phosphatase because of obstruction.
Management
1. Supportive management may include IV fluids, NG suction, pain management, and
antibiotics (with a positive culture).
2. A cholecystostomy tube may be placed percutaneously into the gallbladder to
decompress the organ in preparation for future surgery. This may be placed by
interventional radiology.
3. Surgical management.
a. Cholecystectomy, open or laparoscopic (see page 731).
b. Intraoperative cholangiography and choledochoscopy for common bile duct
exploration.
c. Placement of a T-tube in the common bile duct to decompress the biliary tree and
allow access into the biliary tree postoperatively.
4. Oral therapy with chenodeoxycholic acid, ursodeoxycholic acid, or a combination of both
to decrease the size of existing cholesterol stones or to dissolve small ones.
a. Indicated for patients at high risk for surgery because of comorbid conditions.
 b. Major adverse effects include diarrhea, abnormal liver function tests, increases in
serum cholesterol.
5. Direct contact therapy by which a local cholelitholytic agent is infused by a catheter
directly into the gallbladder or through a percutaneous transhepatic biliary catheter.
a. Indicated for a symptomatic, high-risk patient whose gallbladder can be
visualized by a radiographic study.
b. Adverse effects include pain from the catheter, nausea, and transient elevations of
liver function tests and white blood cell (WBC) count.
6. After cholecystectomy, intracorporeal lithotripsy may be used to fragment retained stones
in the common bile duct by pulsed laser or hydraulic lithotripsy applied through an
endoscope directly to the stones. The stone fragments are removed by irrigation or
aspiration. Retained stones may also be removed by basket retrieval through the
endoscopic or percutaneous transhepatic biliary approach.
Complications
1. Cholangitis.
2. Necrosis, empyema, or perforation of the gallbladder.
3. Biliary fistula through the duodenum.
4. Gallstone ileus.
5. Adenocarcinoma of the gallbladder.
Nursing Assessment
1. Obtain history and demographic data that may indicate risk factors for biliary disease.
2. Assess patient’s pain for location, description, intensity, relieving and exacerbating
factors.
3. Assess for signs of dehydration: dry mucous membranes, poor skin turgor, low urine
output with elevated specific gravity.
4. Assess sclera and skin for jaundice.
5. Monitor temperature and WBC count for indications of infection.
Nursing Diagnoses
 Acute Pain related to biliary colic or stone obstruction.
 Deficient Fluid Volume related to nausea and vomiting and decreased intake.
Nursing Interventions
Relieving Pain
1. Assess pain location, severity, and characteristics.
2. Administer medications or monitor patient-controlled analgesia (PCA) to control pain.
3. Assist in attaining position of comfort.
Restoring Normal Fluid Volume
 1. Administer IV fluids and electrolytes, as prescribed.
2. Administer anti-emetics, as prescribed, to decrease nausea and vomiting.
3. Maintain NG decompression, if needed.
4. Begin food and fluids, as tolerated, after acute symptoms subside or postoperatively.
5. Observe and record amount of biliary tube drainage, if applicable.
Patient Education and Health Maintenance
1. Instruct patient in care of tubes or catheters that may be in place at discharge.
a. Observe for bleeding or drainage around insertion site.
b. Replace dressing per facility protocol.
c. Report change or decrease in drainage.
2. Review discharge instructions for activity, diet, medications, and follow-up.
3. Emphasize symptoms of complications to be reported, such as increased or persistent
pain, fever, abdominal distention, nausea, anorexia, jaundice, unusual drainage.
4. Encourage follow-up, as indicated.
Evaluation: Expected Outcomes
 Verbalizes reduced pain level.
 Tolerates oral fluids and solid food; adequate urine output.