Exocrine Pancreatic and

Biliary Disorders
Prepared by: Jed Keoni Uy Jolo, RN
Lecturer: Anthony C. Barrera
Anatomic and
Physiologic
 Gallbladder
The gallbladder, a pear-shaped, hollow,
saclike organ that is 7.5 to 10 cm (3 to 4
inches) long, lies in a shallow depression
on the inferior surface of the liver, to
which it is attached by loose connective
tissue. The capacity of the gallbladder is
30 to 50 mL of bile.

Its wall is composed largely of smooth

muscle. The gallbladder is connected to
the common bile duct by the cystic duct

-Functions as a storage depot for bile

 Gallbladder
Bile is composed of water and electrolytes
(sodium, potassium, calcium, chloride, and
bicarbonate) along with significant amounts of
lecithin, fatty acids, cholesterol, bilirubin, and
bile salts.
 Disorders of the
Gallbladder
Several disorders affect the biliary system and
interfere with normal drainage of bile into the
duodenum. These disorders include inflammation
of the biliary system and carcinoma that obstructs
the biliary tree. Gallbladder disease with stones is
the most common disorder of the biliary system.

Not all occurrences of cholecystitis are related to

stones (calculi) in the gallbladder (cholelithiasis) or
stones in the common bile duct
(choledocholithiasis). However, most of the 15
million Americans with gallstones have no pain and
are unaware of the presence of stones
 Cholecystitis
- (inflammation of the gallbladder which
can be acute or chronic) causes pain,
tenderness, and rigidity of the upper right
abdomen that may radiate to the
midsternal area or right shoulder and is
associated with nausea, vomiting, and the
usual signs of an acute inflammation.

- An empyema of the gallbladder develops

if the gallbladder becomes filled with
purulent fluid (pus).
 Cholecystitis
Calculous cholecystitis
(Cholelithiasis) is the cause of more
than 90% of cases of acute
cholecystitis
 Cholelithiasis
Calculi, or gallstones, usually form in
the gallbladder from the solid
constituents of bile; they vary
greatly in size, shape, and
composition
 Pathophysiology
Risk Factors:
Fat: Obesity-
Female
Fertile or multiparous
Fifty years of age :25-30% and 50% of
women by age of 70
Oral Contraceptives, Estrogen, or
Clorfibrate (Atromid- S): these
medications are known to increase biliary
cholesterol saturation
 Pathophysiology
Risk Factors Cholesterol bile
production is excessive Bile salts
cannot fully dissolve Biliary Stasis
(pooling- stagnation) Gallbladder
bile precipitation Stone formation:
Cholelithiasis Inflammation:
Cholecystitis Biliary Spasm: Biliary
colic Blood flow into the colon
Stool: Gray/ Clay= Acholic
Bilirubin into Blood= Jaundice
Clinical Manifestations
- Pain: Right upper quadrant
Radiation: Right shoulder, Scapula
Midsternum
Aggravated by an increased fats in the diet
and alcohol consumption
- Murphy Sign: (+) Pain Right upper quadrant
upon palpation during deep breathing
- Fever r/t inflammation
- Nausea & Vomiting
- Jaundice (yellowish sclera or skin)
- Gray colored stool (acholic stool)
- Tea colored urine (dark)
Clinical Manifestations
Vitamin Deficiency

Obstruction of bile flow interferes with

absorption of the fat-soluble vitamins A, D, E,
and K. Patients may exhibit deficiencies of
these vitamins if biliary obstruction has been
prolonged.

For example, a patient may have bleeding

caused by vitamin K deficiency (vitamin K is
necessary for normal blood clotting).
 Assessment and
Diagnostic Findings
Abdominal X-ray:

- If gallbladder disease is suspected, an abdominal x-ray may be

obtained to exclude other causes of symptoms.

- However, only 10% to 15% of gallstones are calcified

sufficiently to be visible on such x-ray studies

Blood results
A. Bilirubin – above 0.3-1mg/dl
B. WBC- above 5000-1000 cells/mm3
c. Alkaline Phosphatase – 44-147 IU/L
 Assessment and
Diagnostic Findings
Medical Management
- Nutritional Therapy and Supportive Therapy
- Relieve Pain
- Analgesic: Morphine
- Bed Rest
- Position: Knee chest
- Diet : Decrease fatty intake ( Fried foods, organ
meats, Pastries, etc.)
- Chenodeoxycholic acid (chenodiol) and
Ursodeoxycholic acid (Ursodiol)
- Extracorporeal Shock Wave Lithotripsy (ESWL)
- Intracorporal Lithotripsy
 Surgical Management
A. Laparoscopic Cholecystectomy
B. Cholecystectomy
C. Choledechostomy
D. Surgical Cholecystostomy
E. Percutaneous Cholecystectomy
Disorders of the
pancreas
 Pancreatitis
(Inflammation of the pancreas) is a
serious disorder.

The most basic classification system

used to describe or categorize the
various stages and forms of
pancreatitis divides the disorder into
acute and chronic forms.
 Acute Pancreatitis
Acute pancreatitis ranges from a mild, self-
limited disorder to a severe, rapidly fatal
disease that does not respond to any
treatment.

These two main types of acute pancreatitis

(mild and severe) are classified as interstitial
edematous pancreatitis and necrotizing
pancreatitis, respectively.

Approximately 200,000 cases of acute

pancreatitis occur in the United States each
year, of which 80% are the result of
cholelithiasis or sustained alcohol abuse
GERONTOLOGIC CONSIDERATION
Acute pancreatitis affects people of all ages, but the
mortality rate associated with acute pancreatitis
increases with advancing age

Younger patients tend to develop local complications;

the incidence of multiple organ dysfunction syndrome
(MODS) increases with age, possibly as a result of
progressive decreases in physiologic function of major
organs with increasing age.

Close monitoring of major organ function (i.e., lungs,

kidneys) is essential, and aggressive treatment is
necessary to reduce mortality from acute pancreatitis
in the older adult patient.
 Pathophysiology
Gallstones enter the common bile duct and lodge
at the ampulla of Vater obstructing the flow of
pancreatic juice causing a reflux of bile from
the common bile duct into the pancreatic duct,
thus activating the powerful enzymes within the
pancreas Activation of the enzymes can lead to
vasodilation, increased vascular permeability,
necrosis, erosion, and hemorrhage Proteases
damage to cell and vasculature through protein
mediator damage Amylase levels increase in
the blood (Useful for diagnosing pancreatitis, 3x
above normal range) Lipases also increase in
the blood and can result of a serious complication
of fatty necrosis of the pancreas.
 ETIOLOGY
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion veum
Hypercalcemia, Hyperlipidemia
ERCP
DRUGS
CLINICAL MANIFESTATIONS
- Nausea and Vomiting
- Gradual/Sudden Severe epigastric pain
Pain radiates to the back (tripoding relieves pain),
After heavy meal/ Alcohol
- Tachycardia
- Jaundice
- Fever
-Bluish/ Purplish discoloration = + Hemorrhagic
pancreatitis
If on the flank (Back): Grey Turner’s Sign
If on periumbilical area: Cullen’s Sign
lmcmmmlz.
 Diagnostic Tests
1. Blood:
A. Serum Amylase
N°: 25-150 IU/L
Result: Above normal indicates injury of the
pancreas

B. Serum Lipase
N°: 10-140 IU/L
Result: Above normal indicates Pancreas
injury after 3 days above normal in the
blood
 Diagnostic Tests
2. X-ray
3. Ultrasound
4. CT scans and MRI
 Medical Management
1. Nasogastric Tube for feeding
2. Administration of IV fluids
3. Antiemetic agents
4. Analgesia (Morphine)
5. Urinary Catheterization
6. Daily Serology (CBC, Amylase,
Electrolytes, Urea, and
Creatinine)
7. Hourly Vital signs
 Nursing Management
1. Nasogastric Tube for feeding
2. Administration of IV fluids
3. Antiemetic agents
4. Analgesia (Morphine)
5. Urinary Catheterization
6. Daily Serology (CBC, Amylase,
Electrolytes, Urea, and
Creatinine)
7. Hourly Vital signs
 Chronic Pancreatitis
Chronic pancreatitis is an inflammatory
disorder characterized by progressive
destruction of the pancreas. As cells are
replaced by fibrous tissue with repeated
attacks of pancreatitis, pressure within the
pancreas increases.

The result is obstruction of the pancreatic and

common bile ducts and the duodenum. In
addition, there is atrophy of the epithelium of
the ducts, inflammation, and destruction of
the secreting cells of the pancreas.
 Chronic Pancreatitis
Alcohol consumption in Western societies
and malnutrition worldwide are the major
causes of chronic pancreatitis.
 Clinical Manifestations
- Nausea and Vomiting
- Gradual/Sudden Severe epigastric pain
Pain radiates to the back (tripoding relieves pain),
After heavy meal/ Alcohol
- Tachycardia
- Jaundice
- Fever
-Bluish/ Purplish discoloration = + Hemorrhagic
pancreatitis
If on the flank (Back): Grey Turner’s Sign
If on periumbilical area: Cullen’s Sign
- Steatorrhea (As a result, digestion, especially of
proteins and fats, is impaired)
- Pancreatic Calculi
- Weight loss
 Diagnostic Tests
1. Endoscopic Retrograde Cholangiopancreatography
(ERCP) is the most useful study in the diagnosis of chronic
pancreatitis. It provides details about the anatomy of the
pancreas and the pancreatic and biliary ducts.
It is also helpful in obtaining tissue for analysis and
differentiating pancreatitis from other conditions, such as
carcinoma
2. X-ray
3. Ultrasound
4. CT scans and MRI
5. A glucose tolerance test evaluates pancreatic islet cell
function and provides necessary information for making
decisions about surgical resection of the pancreas.
 Medical Management
-The management of chronic pancreatitis depends on
its probable cause in each patient.

Treatment is directed toward preventing and

managing acute attacks, relieving pain and
discomfort, and managing exocrine and endocrine
insufficiency of pancreatitis
 Pancreatic Cysts
- As a result of the local necrosis that occurs because of acute
pancreatitis, collections of fluid may form close to the pancreas.

These fluid collections become walled off by fibrous tissue and

are called pancreatic pseudocysts.

Pseudocysts are amylase-rich fluid collections contained within a

wall of fibrous granulation tissue that occur within 4 to 6 weeks
after an episode of acute pancreatitis.

They are a result of pancreatic necrosis, which produces a

pancreatic ductal leak into pancreatic tissue weakened by
extravasating enzymes
 Pancreatic Cysts
Pseudocysts are the most common type of pancreatic ”cyst.”

Less common cysts occur as a result of congenital anomalies or

secondary to chronic pancreatitis or trauma to the pancreas.

Diagnosis of pancreatic cysts and pseudocysts is made by

ultrasound, CT scan, and ERCP. ERCP may be used to define the
anatomy of the pancreas and evaluate the patency of pancreatic
drainage
Cancer of the Pancreas
Pancreatic cancer is the fourth leading cause
of cancer death in men in the United States
and the fifth leading cause of cancer death in
women.
 Risk Factors
- African American males
- Cigarette smoking
- Exposure to industrial chemicals or toxins in the
environment
- Diet high in fat, meat, or both are associated risk
factors

- The risk of pancreatic cancer is greater in those with

a history of increased pack years of cigarette
smoking.
- Diabetes, chronic pancreatitis, and hereditary
pancreatitis are also associated with pancreatic
cancer
Clinical Manifestations
Pain
Jaundice
Weight loss
Vague upper or midabdominal pain or
discomfort that is unrelated to any GI
function and is often difficult to describe.
Ascites
 Diagnostic Tests
1. Endoscopic Retrograde
Cholangiopancreatography (ERCP)
2. X-ray
3. Ultrasound
4. CT scans and MRI
5. A glucose tolerance test evaluates pancreatic
islet cell function and provides necessary
information for making decisions about surgical
resection of the pancreas.
 Nursing Management
1. Pain management
2. Attention to nutritional requirements
3. Skin care and nursing measures are directed
toward relief of pain and discomfort associated
with jaundice, anorexia, and profound weight
loss.
4. Specialty mattresses are beneficial and protect
bony prominences from pressure.
Tumors of the head of the
pancreas

Tumors of the head of the pancreas comprise 60% to

80% of all pancreatic tumors .

Tumors in this region of the pancreas obstruct the

common bile duct where the duct passes through the
head of the pancreas to join the pancreatic duct and
empty at the ampulla of Vater into the duodenum.

The tumors producing the obstruction may arise from

the pancreas, the common bile duct, or the ampulla of
Vater
 Diagnostic Tests
Diagnostic studies may include
duodenography, angiography by hepatic or
celiac artery catheterization, pancreatic
scanning, PTC, ERCP, and percutaneous
needle biopsy of the pancreas. Results of a
biopsy of the pancreas may aid in the
diagnosis.
Clinical Manifestations
Pain
Jaundice
Weight loss
Steatorrhea
 Medical Management
-Preoperative preparation includes
adequate hydration, correction of
prothrombin deficiency with vitamin K,
and treatment of anemia to minimize
postoperative complications

- Enteral or parenteral nutrition and

blood component therapy are frequently
required.

- pancreaticoduodenectomy is used for

potentially resectable cancer of the head
of the pancreas
 Nursing Management
- Preoperatively and postoperatively, nursing
care is directed toward promoting patient
comfort, preventing complications, and
assisting the patient to return to and maintain
as normal and comfortable a life as possible.
- Closely monitors the patient in the ICU after
surgery
- Monitor Vital signs
- Monitor ABG
- Monitor Laboratory output
- Monitor urine output
- Monitor nutritional status and risk of bleeding
- Support the patient’s psychological and
emotional status, along with the SO
 Pancreatic Islet Tumors
At least two types of tumors of the pancreatic islet cells are
known: those that secrete insulin (insulinoma) and those in
which insulin secretion is not increased (nonfunctioning islet
cell cancer).

All of these types of tumors combined are termed

neuroendocrine tumors

Insulinomas produce hypersecretion of insulin and cause an

excessive rate of glucose metabolism.

The resulting hypoglycemia may produce symptoms of

weakness, mental confusion, and seizures. The 5-hour
glucose tolerance test is helpful to diagnose insulinoma and
to distinguish a diagnosis of NET from other causes of
hypoglycemia.
 Surgical Management
If a tumor of the islet cells (a type of NET) has been
diagnosed, surgical treatment with removal of the
tumor is usually recommended

The tumors may be benign adenomas, or they may be

malignant.

Complete removal usually results in almost immediate

relief of symptoms. In some patients, symptoms may
be produced by simple hypertrophy of this tissue rather
than a tumor of the islet cells.

In such cases, a partial pancreatectomy (removal of the

tail and part of the body of the pancreas) is performed.
 Nursing Management
❖ Prepare patient for surgery

❖ Be alert for symptoms of hypoglycemia and be

ready to administer glucose as prescribed if
symptoms occur.

❖ Postoperatively, the nursing management is the

same as after other upper abdominal surgical
procedures, with special emphasis on
monitoring serum glucose levels.

❖ Patient education is determined by the extent of

surgery and alterations in pancreatic function.
 Hyperinsulinism
➢ Hyperinsulinism is caused by overproduction of insulin by the
pancreatic islets.

➢ Symptoms resemble those of excessive doses of insulin and are

attributable to the same mechanism: an abnormal reduction in
blood glucose levels.

➢ Clinically, it is characterized by episodes during which the

patient experiences unusual hunger, nervousness, sweating,
headache, and faintness; in severe cases, seizures and episodes
of unconsciousness may occur.

➢ The findings at the time of surgery or at autopsy may indicate

hyperplasia (overgrowth) of the islets of Langerhans or a
benign or malignant tumor involving the islets that is capable of
producing large amounts of insulin
 Clinical Manifestations
➢ Symptoms resemble those of excessive doses of
insulin and are attributable to the same mechanism:
an abnormal reduction in blood glucose levels.

➢ Clinically, it is characterized by episodes during

which the patient experiences unusual hunger
➢ nervousness
➢ Sweating
➢ Headache
➢ faintness
➢ in severe cases, seizures and episodes of
unconsciousness may occur.
 Clinical Manifestations
➢ Symptoms resemble those of excessive doses of
insulin and are attributable to the same mechanism:
an abnormal reduction in blood glucose levels.

➢ Clinically, it is characterized by episodes during

which the patient experiences unusual hunger
➢ nervousness
➢ Sweating
➢ Headache
➢ faintness
➢ in severe cases, seizures and episodes of
unconsciousness may occur.
 Clinical Manifestations
➢ Occasionally, tumors of nonpancreatic origin
produce an insulinlike material that can cause
severe hypoglycemia and may be responsible for
seizures coinciding with blood glucose levels that
are too low to sustain normal brain function (i.e.,
lower than 30 mg/dL [1.6 mmol/L])

➢ All of the symptoms that accompany spontaneous

hypoglycemia are relieved by the oral or parenteral
administration of glucose. Surgical removal of the
hyperplastic or neoplastic tissue from the pancreas
is the only successful method of treatment. About
15% of patients with spontaneous or functional
hypoglycemia eventually develop diabetes.
 Ulcerogenic Tumors
Some tumors of the islets of Langerhans are associated
with hypersecretion of gastric acid that produces ulcers
in the stomach, duodenum, and jejunum.

This is referred to as Zollinger-Ellison syndrome.

The hypersecretion is so excessive that even after
partial gastric resection, enough acid is produced to
cause further ulceration.
If a marked tendency to develop gastric and duodenal
ulcers is noted, an ulcerogenic tumor of the islets of
Langerhans is considered
 Clinical Manifestations
➢ Nausea
➢ Vomiting
➢ Diarrhea
➢ burning discomfort or pain in the upper abdomen.
 Diagnostic Tests

➢ The diagnostic test for this disorder includes

measuring a blood gastrin level. Imaging tests
may include CT scan or MRI, EUS or upper
endoscopy

➢ Scintigraphy and positron emission tomography

(PET)/CT are sensitive and specific tests for this
disease
 Medical Management
• These tumors, which may be benign or malignant, are treated by
excision, if possible.

• Frequently, however, removal is not possible because of

extension beyond the pancreas and because the tumors are often
quite small and difficult to locate.

• Acid hypersecretion in patients with gastrinoma can be managed

with proton pump inhibitors and this is often the first-line
treatment intervention.

• Highly selective vagotomy may make management easier in

some patients and should be considered in those with surgically
untreatable or unresectable gastrinoma.

• Total gastrectomy for Zollinger-Ellison is not indicated

• Embolization or radiofrequency ablation may also be used to
control the tumor.
References
• Bope, E. T., & Kellerman, R. D. (Eds.). (2015). Conn’s current therapy. Philadelphia, PA: Saunders.
• Comerford, K. C. (2015). Nursing 2015 drug handbook. Philadelphia, PA: Wolters Kluwer.
• Doherty, G. (2015). Current diagnosis and treatment: Surgery (14th ed.). New York: McGraw-Hill.
• Dudek, S. G. (2013). Nutrition essentials for nursing practice (7th ed.). Philadelphia, PA: Lippincott
Williams & Wilkins.
• Eliopoulos, C. (2018). Gerontological nursing (9th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.