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Title; Biliary Obstructive Disease

BY:-Degu Tegegne

Supervised by :-Mr. Teshager Worku

 Out line
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 Normal biliary physiology

 Definition of Biliary obstructive disease
 Causes
 Pathophysiology
 C/m
 Management
 Nursing diagnosis
 Reference
 Objectives
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At the end of this session you are expected to

 Describe the normal physiology of biliary system
 Define biliary obstruction
 State causes of biliary obstruction
 Describe the pathophysiology of biliary obstruction
 Mention clinical feachers of biliary obstruction
 Normal Biliary Physiology
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Liver produces 500-1500 mL of bile/day

Major physiologic role of biliary tract and GB is to

concentrate bile and conduct it in well-timed to the intestine.

In the intestine:
 bile acids participate in normal fat digestion
 Cholesterol and other endogenous/exogenous compounds
in bile excreted in feces.
 Normal Biliary Physiology….
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 Complex fluid secreted by hepatocytes

 Then Passes through hepatic bile ducts into common hepatic duct

 Tonic contraction of sphincter of Oddi during fasting diverts ~1/2 of

bile through the cystic duct into the GB – stored and concentrated.

 Ahormone cholecystokinin–pancreozymin (CCk) – released after

food ingestion 

 GB contracts, sphincter of Oddi relaxes

 Allows delivery of bile into intestine.

 Normal Biliary Physiology….
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 Bile acids – detergent molecules

 Have both fat and water soluble molecules.

 Solubilize dietary fat and promote its digestion and absorption.

 Convey phospholipids and cholesterol from liver to intestine

Cholesterol undergoes fecal excretion

 Enterohepatic circulation
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 Bile acids efficiently

reabsorbed by SI mucosa
(terminal ileum) 
recycled to liver for re-
excretion.
 Biliary obstructive disease
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 Definition:-biliary obstruction, is when one of the ducts that

carry bile from the liver to the intestine via the gallbladder
becomes blocked.

 This can occur at various levels with in the biliary system

 If left untreated, this blockage can lead to serious

complications, including severe infection.
 Pathophysiology
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 Bile passes through the bile ducts from the liver to the gallbladder,
which stores it.
 It travels to the small intestine when it is needed to help digest
food. This network of ducts is part of the biliary system.
 When one or more of the ducts that transport bile become blocked,
it is known as a bile duct obstruction. It is also commonly referred
to as biliary obstruction.
 A bile duct obstruction can lead to bile accumulating in the liver
and a build up of bilirubin in the blood.
 Causes
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I. Intra hepatic
 Occurs at level of hepatocyte or biliary canalicular membrane
Includes:-
 hepatocellular ds(viral hepatitis, drug induced hepatitis)
 Drug induced cholestasis. e.g augementin, chlorpromazine
 Biliary cirrhosis
 Alcoholic liver disease
 Diagnosis
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To confirm the diagnosis:

 Blood tests
 abdominal ultrasound
o Increased bilirubin  abdominal computed tomography (CT)
o Increased alkaline phosphatase scan
 magnetic resonance
o Increased liver enzymes
cholangiopancreatography (MRCP)
 Suggests biliary obstruction:  percutaneous transhepatic cholangiogram
(PTCA)
 endoscopic retrograde
cholangiopancreatography (ERCP)
 Causes…
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II. Extra hepatic

 Occur with in the ducts or secondary to external compression

 Gall stones-most common

 Malignancy(Bile duct or pancreatic cancer)

 metastatic tumor-Cancers that have started elsewhere in the body may also spread

to the biliary system where they can cause an obstruction.e.g breast ca,git ca

 Neoplasm e.g cholangiocarcinomas

 choledochal cysts

 infection
 diagnosis
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 Risk factors
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o A history of any of the following can increase the risk of bile duct

obstruction:

 gallstones

 pancreatic cancer

 chronic pancreatitis

 recent biliary surgery

 recent biliary cancer

 abdominal trauma or injury

 C/M
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 Symptoms of a blocked bile duct may come on suddenly, or a person

may start to notice them slowly over many years.
 Some of the symptoms are related to the obstruction, causing liver
products to back up and leak into the bloodstream.
 Others are caused by the bile duct not being able to deliver the
digestive juices that the gut needs.
 This can stop the body from absorbing some fats and vitamins
properly.
 C/M….
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Progressive jaundice
 The obstruction and subsequent cholestasis tends to occur early if
the tumor is located in the common bile duct or common hepatic
duct.
 The excess of conjugated bilirubin is associated with bilirubinuria
and clay colored stools.

Pruritus
 C/M…
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Weight loss

Abdominal pain
 common in advanced disease and often is described as a dull ache in the RUQ

 fever or night sweats

 nausea and vomiting

 tiredness or lack of energy

 unintentional weight loss

loss of appetite
 Treatment
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 Treatment aims to relieve the blockage and depends on the underlying cause.
 remove gallstones using an endoscope during an ERCP.

 if severe or frequent symptoms may need to have their gallbladder removed.

 This will stop the problem of gallstones reoccurring as People can lead healthy
lives without a gallbladder.

 If the cause is found to be cancer, the ducts may need to be stretched and
drained.

 If someone has choledochal cysts, a surgical procedure to correct the enlarged

areas of bile ducts will be done.
 Obstructive jaundice
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 Jaundice is a yellowish discoloration of the sclera, mucous

membrane and skin.

 Occurs when bile flow obstructs on bile duct

 It becomes clinically evident when the level of serum bilirubin

reaches 2.0 to 3.0 mg/dl.

 Classification

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I Medical: This type of jaundice could be subdivided into

Pre hepatic: - when the cause is excessive destruction of

RBC (hemolytic)

Hepatic: - when the cause is due to the liver problems.

II Surgical: when the cause is obstruction of biliary trees

(obstructive jaundice)
 Causes of extra hepatic biliary
obstruction
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Obstruction in the lumen

• Gall stone(the most common)

• Parasitic occlusion e.g. Ascaris, liver flukes

• Blood clot

Obstruction in the wall:

• Atresia (congenital)

• Stricture (post traumatic)

• Tumor of the bile duct

 Cause Cont,d
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Extrinsic compression

• Carcinoma of head of pancreas(the second most common)

• Pancreatitis

• Lymph node around portal hepatics

• Choledochal cyst
 Clinical manifestation
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 History: To differentiate surgical from medical jaundice for

management decision

- Intermittent jaundice, if it is due to stone

- Progress of jaundice (progressively deepening or intermittent)

- +/- Pruritis

-Urine and stool (clay color) color change is indicative of obstruction

- RUQ abdominal pain

- Loss of appetite, weight loss

- History of abdominal trauma, surgery

 Cont,d
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Surgical jaundice is characterized by

 Yellow green icterus
 Pruritus of the skin more during night time
 Clay colored stool due to absent bile
 Dark brown urine due to conjugated bilirubin in the urine
Benign tumors of the bile duct

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Benign neoplasms causing biliary obstruction may be classified as

follows:

 papilloma and adenoma;

 multiple biliary papillomatosis

 granular cell myoblastoma

 neural tumors

 leiomyoma

 endocrine tumors.
 Malignant tumors of the bile duct

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 Carcinoma may arise at any point in the biliary tree, from

the common bile duct to the small intrahepatic ducts
 Bile duct cancer
 Rare, but incidence increasing
 Malignant tumors of the bile duct
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 Presents with jaundice and weight loss

 Diagnosis by ultrasound and CT scanning
 Jaundice relieved by stenting
 Surgical excision possible in 5%
 Prognosis poor – 90% mortality in 1 year
 Carcino ma of the gall bladder

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Gall bladder cancer

 The majority of cases are adenocarcinoma (90%).
 Grossly, carcinomas are difficult to differentiate from chronic cholecystitis
 Presents as for benign biliary disease (gallstones)
 Diagnosis by ultrasound and CT scanning
 Excision in less than 10% – remainder palliative treatment
 Prognosis poor – 95% mortality in 1 year
 Risk factors for carcinoma of gallbladder
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 Calcified gallbladder
 Cooking oil
 Calculi in the GB
-stones  Central American race
 Cyst  Prophylactic cholecystectomy
–choledochal cyst
 typhoid fever in asymptomatic gall stone
 Congenital anomalies disease
abnormal pancreatico- biliary
duct junction(APBDJ).
 Congenital lesion
 polyp
C/M of carcinoma of gallbladder
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 asymptomatic.
 If symptoms are present, they are usually
indistinguishable from benign gall bladder disease such
as biliary colic or cholecystitis, particularly in the older
patient.
 Jaundice and anorexia are late features.
 A palpable mass is a late sign.
 Nursing diagnosis
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1. Breathing Pattern, ineffective May be related to pain

AEB tachycardia, deep breathing.

2. Impaired skin integrity related to altered biliary drainage

after surgical incision

3. Deficient knowledge about self-care activities related to

incisional care, dietary modifications, medications,
reportable signs or symptoms (fever, bleeding, vomiting
 NOC/NIC
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1. Breathing Pattern, ineffective May be related to pain AEB

tachycardia,difficulty breathing
 DESIRED OUTCOMES/EVALUATION CRITERIA—
PATIENT WILL:

Respiratory Status: Ventilation (NOC)

 Establish effective breathing pattern.
 Experience no signs of respiratory compromise/complications.
 Cont….
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 ACTIONS/INTERVENTIONS
Respiratory Monitoring (NIC)
Independent
 Observe respiratory rate/depth.
 Auscultate breath sounds.
 Elevate head of bed, maintain low-Fowler’s position
 Support abdomen when coughing, ambulating.
Collaboration
 Assist with respiratory treatments, e.g., incentive spirometer.
 Administer analgesics before breathing treatments/ therapeutic
activities.
 Cont….
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2. Deficient knowledge about self-care activities related medications,

reportable signs or symptoms (fever, bleeding, vomiting
 DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Knowledge: Illness Care (NOC)

 Verbalize understanding of disease process, prognosis, potential
complications.
 Verbalize understanding of therapeutic needs.
 Initiate necessary lifestyle changes and participate in treatment
regimen.
 Cont…
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 ACTIONS/INTERVENTIONS

Teaching: Disease Process (NIC)

 Independent
 Provide explanations of/reasons for test procedures and preparation
needed.
 Discuss hospitalization and prospective treatment as indicated.
 Encourage questions, expression of concern.
 Review drug regimen, possible side effects.
 Cont.….
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3. impaired skin integrity related to altered biliary drainage

after surgical incision

 Desired Outcomes/Evaluation Criteria—patient Will:

Wound Healing: Primary/Secondary Intention (NOC)

 Achieve timely wound healing without complications.

 Demonstrate behaviors to promote healing/prevent skin

breakdown.
 Cont…
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Actions/interventions
 Wound care (NIC)
 Independent
 Observe the color and character of the drainage. 
 Change dressings as often as necessary.
 Use sterile petroleum jelly gauze, zinc oxide, or karaya powder around
the incision. 
 Place patient in low- or semi-fowler’s position.
 Check the t-tube and incisional drains; make sure they are free flowing.
 Rehabilitation
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Pain relief
 Stepwise escalation of analgesia

Symptom relief and quality of life

 Encourage normal activities
 Enzyme replacement for steatorrhoea
 Treat diabetics
 Complications
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 If left untreated, bile duct obstructions can lead to life-threatening

infection
 chronic liver diseases such as biliary cirrhosis.
 If the "drainpipe" at the bottom of the liver, or the common bile
duct, remains blocked, a buildup of bilirubin in the bloodstream can
lead to jaundice
 This blockage can also lead to bacteria backing up into the liver,
which can cause a severe infection known as ascending cholangitis.
 If the blockage occurs between the gallbladder and the common bile
duct, a person is at risk of cholecystitis.
 Research article
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World J Gastrointest Oncol. 2016 Jun 15; 8(6): 498–508.

Title:-Malignant biliary obstruction: From palliation to treatment

 70% of patients with newly diagnosed pancreatic cancer have some

degree of biliary tract obstruction at the time of diagnosis.

 Decompression via endoscopic stent placement can palliate jaundice

and pruritus for symptomatic relief[9].

 Endoscopic stent placement into the common bile duct is a fairly

routine procedure (technically successful in over 90% of cases) and

 REFERENCES
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 Brunner and Suddarth’s text of Medical- Surgical nursing 10 th edition

 Handbook for Brunner and Suddarth's txt book of Medical -Surgical nursing
12th edition
 Surgery lecture note for health officer carter center April 2004
 Barrell, Amanda. "What causes bile duct obstruction?." Medical News
Today. MediLexicon, Intl., 11 Jun. 2018. Web.
18 Apr. 2019.
 Rubin's Pathology of Clinicopathologic Foundations of medicine 6 th edition