Biliary System Anatomy and Gallstones

Anatomy and Function of the Biliary System

• The biliary system includes the liver, gallbladder, bile ducts (hepatic, cystic, and common bile ducts), and pancreas.
• The liver produces bile, which aids in fat digestion.
• The gallbladder stores bile and releases it into the small intestine when needed.
• Bile emulsifies fats, aiding in fat digestion and absorption.
• Bile helps excrete bilirubin and cholesterol, eliminating waste.

Cholelithiasis (Gallstones)

• Gallstones are commonly caused by excess cholesterol in bile, bile stasis, or high bilirubin levels.
• Risk factors include being female, obesity, rapid weight loss, pregnancy, and a high-fat, low-fiber diet.
• Asymptomatic if non-obstructive; symptoms include biliary colic (RUQ pain post-fatty meals), nausea, vomiting, jaundice (if bile duct obstruction), dark urine, and clay-colored stools.
• Diagnosed via ultrasound (gold standard) or HIDA scan (assesses bile flow). Elevated bilirubin and alkaline phosphatase indicate obstruction.
• Nursing management includes encouraging a low-fat diet, administering analgesics, and monitoring for obstruction. Laparoscopic cholecystectomy may be indicated.
• Post-surgery care involves early ambulation and a low-fat diet, monitoring for bile leak.

Cholecystitis (Inflammation of the Gallbladder)

• Often caused by gallstone blockage, bile duct infection, prolonged fasting/rapid weight loss, trauma, surgery, or critical illness.
• Symptoms include severe RUQ pain (positive Murphy’s sign), nausea, vomiting, fever, leukocytosis, jaundice (if obstruction occurs), and referred pain to the right shoulder or back.
• Diagnosed via ultrasound (thickened gallbladder wall, stones) or HIDA scan. Elevated WBC, bilirubin, and liver enzymes are indicative.
• Nursing care involves keeping the patient NPO, IV fluids, pain relief, and IV antibiotics if infection is present. Cholecystectomy may be indicated.
• Monitor for complications like abscess, perforation, and sepsis.

Choledocholithiasis (Gallstones in the Common Bile Duct)

• Caused by migration of gallstones into the common bile duct, stricture/narrowing of the bile duct or biliary sludge accumulation.
• Symptoms include RUQ pain worsening after meals, jaundice, clay-colored stools, dark urine, nausea, vomiting, anorexia, and fever if infection develops (cholangitis).
• Diagnosis via MRCP or ERCP with stone removal and elevated bilirubin/alkaline phosphatase.
• Monitor for signs of sepsis, prepare for ERCP, administer IV fluids and antibiotics, and educate on a low-fat diet.
• Monitor liver function tests post-treatment.

Cholangitis (Infection of the Bile Ducts)

• Caused by bacterial infection due to bile duct obstruction from gallstones, tumors, strictures, or ERCP-related infection.
• Symptoms include Charcot’s Triad (fever, jaundice, RUQ pain) and Reynold’s Pentad (hypotension, confusion) if sepsis occurs.
• Diagnose via blood cultures, ultrasound or MRCP and elevated WBC, bilirubin, alkaline phosphatase.
• Administer broad-spectrum IV antibiotics promptly and monitor for septic shock.
• Prepare for emergency ERCP for bile duct drainage and supportive care (IV fluids, pain management).
• Educate on long-term bile duct health and diet.

Acute Pancreatitis

• Gallstones and chronic alcohol use are common causes, as well as hypertriglyceridemia, trauma, surgery, and certain medications.
• Symptoms include severe epigastric pain radiating to the back, nausea, vomiting, abdominal distension, hypotension, tachycardia, Grey Turner’s sign (flank bruising), and Cullen’s sign (periumbilical bruising).
• Elevated serum amylase and lipase are diagnostic as well as CT scan. Hypocalcemia may occur due to fat necrosis.
• Keep patient NPO and provide IV fluids; monitor for shock and administer pain relief (opioids).
• Monitor blood glucose and educate on alcohol avoidance and dietary changes.

Chronic Pancreatitis

• Chronic alcohol abuse is the most prevalent cause; can also be caused by repeated episodes of acute pancreatitis, cystic fibrosis, or autoimmune conditions.
• Symptoms include chronic epigastric pain, steatorrhea, weight loss, malnutrition, and diabetes.
• Diagnosed via CT or MRI (calcifications in the pancreas), fecal elastase test (pancreatic enzyme deficiency), or glucose intolerance/diabetes.
• Provide pancreatic enzyme replacement, encourage a low-fat, high-protein diet, monitor for diabetes development and educate on alcohol cessation.
• Prescribe pain management as needed

Gallbladder Cancer

• Risk factors include chronic gallbladder inflammation, gallstones, porcelain gallbladder, primary sclerosing cholangitis, obesity, and a high-fat diet.
• Symptoms are often asymptomatic in early stages, but can include RUQ pain, jaundice, weight loss, anorexia, or a palpable gallbladder mass.
• Diagnose via abdominal ultrasound, CT scan/MRI for staging, and biopsy via endoscopic ultrasound.
• Provide emotional support and education on prognosis.
• Pain management with NSAIDs and opioids.
• Monitor for biliary obstruction and prepare for cholecystectomy if detected early; collaborate with oncology team for chemotherapy/radiation in advanced cases.

Biliary Atresia (Congenital Bile Duct Obstruction)

• Unknown causes, suspected to be prenatal bile duct inflammation, leading to bile flow obstruction in newborns.
• Symptoms include persistent jaundice beyond two weeks, pale stools, dark urine, failure to thrive, and hepatomegaly.
• Diagnose via liver function tests (elevated bilirubin and alkaline phosphatase), ultrasound (absence/blockage of bile ducts), hepatobiliary scan, and liver biopsy.
• Support breastfeeding and nutritional needs and prepare infant for Kasai procedure (surgical bile duct reconstruction).
• Monitor for progressive liver failure and educate parents on long-term care, including potential liver transplant.
• Administer fat-soluble vitamin supplements.

Hydrops of the Gallbladder

• Prolonged cystic duct obstruction leads to excessive bile accumulation, associated with cholecystitis or gallstone disease.
• Symptoms include RUQ pain, nausea, vomiting, distended gallbladder, and no jaundice (unless secondary bile duct obstruction occurs).
• Diagnose via ultrasound (enlarged, fluid-filled gallbladder), HIDA scan (bile duct blockage), and elevated WBC if infection is present.
• Keep patient NPO, administer IV fluids, and prepare for percutaneous drainage or cholecystectomy.
• Monitor for complications like perforation or infection, provide pain relief, and patient education on gallbladder health.

Sphincter of Oddi Dysfunction

• Functional or structural abnormality of the Sphincter of Oddi.
• Caused by post-cholecystectomy complications or chronic inflammation from pancreatitis or bile duct disease.
• Symptoms include intermittent RUQ pain (worsens after eating fatty meals), nausea, vomiting, jaundice (if bile flow is blocked), and episodes of acute pancreatitis.
• Diagnose via ERCP with manometry, MRCP, and elevated liver/pancreatic enzymes during attacks.
• Provide dietary counseling (low-fat diet), administer antispasmodic medications, and prepare for endoscopic sphincterotomy if needed.
• Monitor for post-ERCP complications and encourage stress management techniques.

Gallstone Ileus

• Large gallstones erode through the gallbladder wall into the intestine, causing mechanical bowel obstruction.
• Symptoms include severe abdominal pain, distension, nausea, vomiting, no passage of stool or gas, visible peristalsis waves, and absent bowel sounds.
• Diagnose via abdominal X-ray and CT scan.
• Insert NG tube for bowel decompression, administer IV fluids, and prepare for surgical removal of the obstructing stone.
• Monitor for peritonitis and encourage ambulation postoperatively.

Mirizzi Syndrome

• Gallstones compress the common hepatic duct, resulting in obstructive jaundice.
• Symptoms include RUQ pain, progressive jaundice, fever and clay-colored stools and dark urine.
• Diagnose via MRCP or ERCP, liver function tests (elevated bilirubin, alkaline phosphatase), and ultrasound (gallstones and bile duct dilation).
• Monitor for worsening jaundice and infection signs; prepare patient for cholecystectomy with bile duct repair.
• Provide postoperative care to prevent bile leaks, administer pain relief, and IV fluids and educate patient on long-term bile duct health.

Pancreatic Cancer

• Smoking is a major risk factor, as well as chronic pancreatitis, family history, obesity, and a high-fat diet.
• Symptoms include painless jaundice (due to bile duct obstruction), unexplained weight loss, steatorrhea, abdominal pain radiating to the back, and new-onset diabetes.
• Diagnose via CT scan, CA 19-9 tumor marker, and endoscopic ultrasound with biopsy.
• Provide palliative pain management, monitor for biliary obstruction and arrange for stent placement and educate on nutrition support.
• Prepare for possible Whipple procedure and offer emotional support and hospice care for advanced cases.