Assessment & Management of Biliary Disorders Flashcards
What does the biliary tract do?
transports bile from liver to bile duct and then to duodenum
What does the gallbladder do?
Stores Bile which was originally made by hepatocytes or liver cells.
What is the purpose of bile?
Emulsifies fat for digestion and to be absorbed by small intestine
Sphincter that controls bile flow into intestine?
Sphincter of Oddi
Gallbladder contraction is regulated by _________ which secrete due to ______.
Hormones which secrete due to fat
What does the pancreas produce?
Endocrine and Exocrine Hormones for digestion
Endocrine hormones by the pancreas?
Insulin - released by beta cells. lowers blood glucose levels due to it being the key
Glucagon - released by alpha cells and raises blood glucose when called upon
Somatostatin - released by delta cells. hypoglycemic effect since it can interfere with glucagon
Exocrine hormones secreted by pancreas?
lipase - fat breakdown
amylase - carb breakdown
trypsin - protein breakdown
secretin - stimulates sodium bicarb and bile secretion to decrease GI movement
Two major gallbladder disorders
Cholecystitis
Cholelithiasis
Cholecystitis definition?
Calculous or acalculous meaning
Acute or chronic inflammation of the gallbladder
Means with or without stones.
How can acalculous cholecystitis develop?
Can occur after surgery, burn, or trauma
What is Cholelithiasis?
Why are they such a problem?
Means gallstones caused by bile or cholesterol
Can lead to a bile back up and inflamed GB
Could also block pancreatic duct too causing pancreatitis
How are pigment bile stones formed
What might trigger this?
Bile pigment precipitates to form stones which have to be surgically removed bc they do not dissolve
Cirrhosis
Bile tract infections
How do cholesterol stones form?
Decrease in synthesis of bile acid leading to more cholesterol which combines with bile and then forms the stone
Risk factors of cholelithiasis or stones
Yoyo diets
Female, fat, and fair
Hormone replacements
Obesity
Progesterone from pregnancy
Will cholelithiasis have a lot of symptoms that the patient notices?
What is the Murphy’s sign?
No, it is mostly asymptomatic.
There may be pain in the RUQ of the abdomen which radiates to the right shoulder or back.
Might have abdominal distention, N/V after fatty foods. Fever and flatulence could occur.
Murphy sign may happen due to contraction of the GB when breathing in and pain upon palpitation.
What could gallstones mimic?
A heart issue. Especially nitro doesn’t work.
Biliary Colic means
contraction of the GB and spasms
Upon physical examination, what is noticeable?
Jaundice Clay stool Pruritus Vitamin deficiency Elderly may not have any pain or fever Steatorhea or fat in stool with bad smell
Lab trends that will increase
WBC due to infection
Bilirubin bc it is not being excreted and causes jaundice
Amylase and Lipase if pancreas involved
Cholesterol
AST and LDH if liver involved
Diagnostic tests done
3/4
ultrasound and CT
ERCP - looks at gallbladder through esophagus
Cholescintigraphy - heptabiliary scan to asses patency of bile duct
What is bowel rest?
What needs to be watched?
Taking a break from eating food by mouth, so NPO.
Watch for F&E
How can we get the stones out without surgery?
5
Gallstones can be dissolved
T-tube retrieval
ERCP - frequent
E Lithotripsy - breaks it up
E Shock Wave Lithotripsy - breaks it up using high energy sound waves
How can we get stones out WITH surgery?
Laparoscopic Cholecystectomy assisted with a robot
Open Cholecystectomy
Small incision
Choledochostomy
Cholecystostomy
What happens if the gallbladder is removed tho?
The hepatocytes will just continuously drain the liver. Body will adjust to it
Once a stone is removed, what will be done?
Stone Biopsy
After any surgery, will you probably have respiratory issues?
Yes.
Why might there be nutrition issues
They just don’t want to eat. But we don’t want them to develop an ileus.
Why might there be bleeding after surgery?
Always an issue after large surgery. May use a JP drain and suture it in. Or a t-tube drain.
DVT after surgery?
Very high. Due to age and obesity too
What are some routine post op things you need to do?
Deep breathing and coughing. Plus splinting
Repositioning.
Check vitals.
Check labs. Feel pulses and feel for all major assessments.
Input and Output.
Pain scales.
Why would the patient be having right shoulder pain after surgery?
How to help them?
CO2 inflation after lapcoly. It doesn’t have an outlet due to it rising now.
Get them a heating pad.
If there are respiratory issues what can you do?
Raise the HOB. Administer O2 with order. Check the tension lines
If there are a lot of NG drains and tubes what should you do?
Just assess for patency and make sure there’s no tension or mechanical issues with them if the patient can’t breath.
When a patient is post op, what should their fat intake be? The rest of their diet?
Recommendations for food tracking?
Very low fat
Otherwise a normal diet but just go very slow with it
Small meals
Keep a diary so you can keep track of what foods bother you
What symptoms should you report if they are present after surgery?
Urine and stool changing color
N/V
Any issues with the surgical site of course too
What type of activity can they do?
As tolerated.
Why might we use a t-tube?
Where is it placed? Why?
And if the flow is established?
How soon before and after a meal do we use it?
To explore the bile duct.
Placed above the abdomen to avoid the bail draining all at once & re-establish normal flow
And if the flow is established we can give them food.
Use 1-2 hours before & after the meal
What is peritonitis?
How is it treated?
Do you need to switch the dressing?
Symptoms of it?
When bile leaks.
Treat with long term antibiotics.
In this case , yes. The bile can hurt the skin.
Drainage, pain, fever, and jaundice.
Disorders of the Pancreas :)
….
What is pancreatitis characterized by?
What does it cause?
When the pancreas digests itself
Causes inflammation, necrosis, and hemorrhage
In pancreatitis there is hyper-secretion of enzymes. What does hyper-secretion mean in this case?
Too much secretion of amylase and lipase
Different types of pancreatitis
acute and chronic
What is acute pancreatitis?
Most common enzyme?
How serious is this?
self digestion of pancreas by its own enzymes.
especially by trypsin (breaks down proteins)
Very serious can be life threatening.
Acute pancreatitis mild presentation? severe presentation?
interstitial edema of pancreatitis is mild
necrosis is severe
How does acute pancreatitis even happen?
It can start with gallstones causing an obstruction that backs all the way up to the pancreas. When this happens, the pancreas erodes and leads to hemorrhage.
Why is the mortality rate high for acute pancreatitis?
Alcohol?
Bc people who have this issue usually have comorbid factors and bad health
Alcohol is one of the worst things that can be an issue here and make it worse.
Risk factors for pancreatitis includes anything that can affect the flow of enzymes.
Alcohol
Bile tract disease (leading to obstruction)
Peptic ulcer disease
Meds
Which meds are the ones who are risk factors for pacreatitis?
3
Jinuvia
Viatta
which cause inflammation
And Tetractyin which is a hyperglycemic drug
What type of pain is present with acute pancreatitis?
When will it hurt more?
What will the patient most likely do?
Abdominal pain on the left that radiates to the stomach, back, and chest (or the trunk). very rigid.
Hurts more when laying down and after eating
Pt will try to protect their abdomen and not eat
What are some other symptoms or cofactors of acute pancreatitis
3
N/V
Lowered BP from hemorrhage
respiratory issues & hypoxia
When assessing the patient with these symptoms of pancreatitis what should you ask?
Do you have a history of
gallstones
alcohol abuse
viral infection
Why will the serum amylase & lipase levels be increase in pancreatitis?
The increase of amylase and lipase shows their hyper-secretion
What will the WBC be in pancreatitis? Why?
What will the liver enzymes in blood look like? why?
What will will bilirubin look like ? why?
WBC increase due to infection
Due to hyper-secretion enzymes increase
Bilirubin increase bc it cannot be cleared and therefore jaundice presents
Why will BG be like in pancreatitis? and why?
Why does H&H fall?
Bc the pancreas cannot regulate insulin and glucagon anymore
H&H falls due to hemorrhage
What will calcium and magnesium look like in pancreatitis? and why?
Calcium and magnesium are decreased due to fat necrosis
Why might shock occur with pancreatitis?
What about hypotension?
How to treat?
Both due to hemorrhage
May need to do blood replacement therapy
How to decrease the obstruction of the bile tract?
Do a biliary drain.
What is chronic pancreatitis?
Major cause?
When there are years of acute episodes
It is progressive and causes necrosis
Major cause is alcohol
What will pain in chronic pancreatitis feel like?
But is pain always present?
Upper left abdominal pain and back pain that reoccurs and gets worse
No, pain is not always present. the person may not feel anything and feel ok
Will this person with chronic pancreatitis gain or lose weight? why?
Lose weight due malabsorption due to impaired fat and protein digestion
What will their stool be like?
Steatorrhea or fatty stool
What lab values are present in chronic pancreatitis?
Same as acute
Increase in amylase and lipase
Increase BG
Decrease H&H
WBC increase
Bilirubin increase
Low calcium
Low magnesium
What is an ERCP and why might they use it
Goes down esophagus to get a better look .
Could find and remove a gallstone or just observe
Why use a CT, MRI or ultrasound?
It can show a stone or other issue
Why get a fecal fat sample?
Will show steatorrhea or fat in stool which is a symptom of biliary/pancreatic disorder
When managing pancreatitis of any kind, how will we allow the organ to rest?
How do we get rid of N/V?
What should the diet be like?
NPO , no food by mouth. Instead do tube feedings.
Give antiemetics for N/V
Diet needs to be bland, low fat so avoid fatty foods. no stimulants.
Avoid stress!
How do we monitor their hydration status?
Check BP
I&O
Labs
What type of fluid might we run for pancreatitis?
Lactated ringers due to its electrolyte concentration
What position should we allow them to take?
What class of meds do we give?
Any position they want really. Let them do whatever they gotta do. Just don’t let them sit in one spot forever if they don’t move due to pressure
Parental opioids (give by injection)
Why should we get them a spirometer?
They will be uncomfortable so by giving them a spirometer it is more incentive and real for them to breath
What should diet look like between pancreatic episodes
Get the protein up
low fat
Why are these patient more prone to patient ulcers?
Bc they lay in bed and don’t want to eat anything
Why do we give morphine sulfate for Pancreatitis ?
for pain
Why do we give antibiotics for Pancreatitis?
the necrosis of the pancreas
Why do we give anticholinergics for Pancreatitis?
Decreases intestinal motility and flow of pancreatic enzymes
why give Zantac or Prisolec for Pancreatitis?
decreases gastric secretions
Why give insulin for Pancreatitis?
Bc the pancreas can’t produce it bc of beta cells not working
When do we give pancreatic enzymes?
In between attacks
Main surgical procedures done for Pancreatitis?
ERCP
Cholecystectomy
RouxenY (pancreaticojejunostomy) Whipple resection (pancreaticoduodenectomy)
RouxenY (pancreaticojejunostomy)
Creates an egg-like stomach pouch. Attaches to small intestine and bypasses stomach to attach to small intestine
Whipple resection (pancreaticoduodenectomy)
This removes head of the pancreas, duodenum, and gallbladder and re-stitches what is left to side of the pancreas?
How to manage hypovolemia complication of pancreatitis?
ascites
suction
hemorrhage
ascites with diuretics
gastric suction
hemorrhage so blood replacement and surgery
Should patients with chronic pancreatitis drink alcohol and cafeeine
no and we need to educate them
What is a pseudocyst?
abscess?
a fake cyst filled with fluids
a pus filled lesion.
Both are risk for infection
What is complication of Diabetes with pancreatitis
insulin and BG. also not wanting to eat
What might you see if there is a left lung effusion(more fluid) and atelectasis (collpase)
ascites
coughing
