biliary obstruction, blockage of the common or cystic bile duct, usually caused by one or more gallstones. It impedes bile drainage and produces an inflammatory reaction. Less common causes of biliary obstruction include choledochal cysts, pancreatic and duodenal tumors, Crohn’s disease, pancreatitis, echinococcosis, ascariasis, and sclerosing cholangitis. Stones, consisting chiefly of cholesterol, bile pigment, and calcium, may form in the gallbladder and in the hepatic duct in persons of either sex at any age but are more common in middle-aged women. Increased amounts of serum cholesterol in the blood, such as occurs in obesity, diabetes, hypothyroidism, biliary stasis, and inflammation of the biliary system, promote gallstone formation. Cholelithiasis may be asymptomatic until a stone lodges in a biliary duct, but the patient usually has a history of indigestion and discomfort after eating fatty foods. A calculus biliary obstruction should be considered cancerous until proven otherwise. ▪ OBSERVATIONS: Biliary obstruction is characterized by severe epigastric pain, often radiating to the back and shoulder, nausea, vomiting, and profuse diaphoresis. The dehydrated patient may have chills; fever; jaundice; clay-colored stools; dark, concentrated urine; an electrolyte imbalance; and a tendency to bleed because the absence of bile prevents the synthesis and absorption of fat-soluble vitamin K. ▪ INTERVENTIONS: The patient in the acute care setting is placed in semi-Fowler’s position and is usually administered intermittent nasogastric suctioning, parenteral fluids with electrolytes and fat-soluble vitamins, and medication for pain. Antibiotics, anticholinergic and antispasmodic drugs, and a cholecystogram or ultrasound scan may be ordered. The blood pressure, temperature, pulse, and respirations are monitored, and the patient is helped to turn, cough, and deep breathe every 2 to 4 hours. Fluid intake and output are measured, and the color and character of urine and stools are noted. When the nasogastric tube is removed, the patient initially receives a low-fat liquid diet and progresses to a soft or normal diet, as tolerated; up to 2500 mL of fluids a day are encouraged or administered intravenously, unless contraindicated. Cholecystectomy is usually the definitive treatment, but in most cases surgery is delayed until the patient’s condition is stabilized and any prothrombin deficiency (caused by vitamin K malabsorption) is corrected.
