biliary Flashcards
coalathiatis - and symptoms or no?
stones in gallbladder. usually asymptomatic.
how to detect coalathiatis (koalas need ultrasound)
ultrasound, and need to fast for about 6 hours.
The primary function of the gallbladder is
to store and concentrate bile.
Bile is comprised of
bile salts, bilirubin, phospholipids, cholesterol, bicarbonate and water.
Bile salts mix with ingested fats to
promote absorption of fats from the gastrointestinal tract.
Bicarbonate and water are needed in the gastrointestinal tract to (bi is the great neutralizer)
help neutralize stomach acid, as digestion and absorption require an alkaline environment.
After it’s formation in the liver, bile flows into
After it’s formation in the liver, bile flows into the hepatic duct.
The sphincter of Oddi surrounds the ampulla of Vater. (oddi and vader)
needs to relax to let bile out.
Cholelithiasis formation
Stones d/t precipitation➔ bile ➔ obstruction ➔Sx
Cholecystitis (think itis)
Inflammation of the gall bladder ➔obstruction ➔Sx.
Cholangitis (chang in the ducts is an emergency)
Inflammation of the bile ducts ➔obstruction ➔Sx. this is an emergency.
Cholecystectomy
Removal of gall bladder (open, laparoscopic, T-tube care)
Cholecystitis - s/sx - hurts before or after eating?
Food stimulation moves stone to block duct
Pain after meals (high fat)
Nausea, belching, flatulence, indigestion
Cholecystitis - s/sx - pain, bowel sounds (itis in my right-is)
Epigastric pain, decreased or absent bowel sounds. right upper quadrant and chest pain.
cholecystitis - skin
Bile flow blocked leads to bile salts on skin, pruritus
Mild jaundice (bile is obstructed form liver)
Clay colored stools, dark foamy urine, steatorrhea (fatty stools)
Strictures
Cholecystitis-Kehr’s sign (Chole says Kerry on, right?)
Pain radiates to right shoulder with breathing
Cholecystitis- Murphy’s sign (murphy inspired the upper right)
Pain on deep inspiration with RUQ palpation
Cholecystitis - diagnostics and what blood tests? (Chole is a cutie)
Amylase, lipase, CBC (WBC), LFT’s
Abdominal ultrasound, CT
Cholecystitis - treatment
NPO, IV hydration
NGT suction with N/V
T-Tube insertion if no resolution or worsening Sx
Cholecystectomy if tolerated
low fat diet
Cholecystitis - meds (Cole and the 4 As)
Antibiotics
Analgesics (opiate –demerol versus morphine)
Anticholinergic (decrease motility and acid)
Antispasmotics (decrease GI spasms and therefore pain)
Cholecystitis - complications
Gall bladder perforation
Peritonitis (secondary)
Pericholecystic abscess (15% mortality)
Empyema
Suppurative cholecystitis ➔sepsis/shock
gallstones
Super saturated bile stasis, precipitates
Cholesterol orcalcium bilirubinate (pigment) gallstones
gallstones - who gets them
More prevalent in women than men, obesity, rapid weight loss post pregnancy/multiple pregnancy, use of estrogens, rich/fatty foods, Mexican American or American Indian
gallstones - causes (hard livin gal)
High fat/low fiber diet, heavy drinking, infection, CAD, intestinal disorders, smoking
smoking and coffee - (friends with gale)
decrease risk of gallstones
gallstones - s/sx - and if symptoms, when do they start?
can be asymptomatic OR Abrupt, episodic pain epigastric/RUQ
Pain beginning in the abdomen and radiating to the chest, back and shoulders
N/V, tachycardia, diaphoresis
Attacks start after meals and usually at night
gallstones - diagnostics (Erp is a good gal)
Ultrasound, oral cholecystogram, endoscopy, ERCP
gallstones - treatment (gals like hot water)
Heat, sips of water, analgesics, non-surgical or surgery (ERCP, cholecystectomy)
Complications: empyema, peritonitis, duct or liver injury/damage
gallstones - prevention
Exercise, diet, avoid modifiable risks
ERCP
throat is numbed bc tube goes down throat. pt is under conscious sedation. bed rest for 4 hours after procedure. NPO until gag. 30-45 degrees.
T-tube
T-tubes are colonized after 24 hrs so there is a high rate of infection.
T-tube nursing - how often to change dressing?
Assess and measure drainage
Change dressing daily
Assess skin
Assess for peritonitis
Assess for leaks
Cholangitis (chang is bacteria in my ducts)
very serious. Bacterial inflammation of bile ducts
Associated with stones
Predisposition with stagnant bile flow; pancreatic CA; procedures (ERCP, contrast injections), T tube infections (90% are colonized within one week)
Cholangitis - s/sx (Chang loves charlotte P, the FJ)
Charcot’s triad (abdominal pain, fever, and jaundice)
Intermittent chills & fever
Abdominal pain
Jaundice (sudden onset)
RUQ tenderness
Elevated WBC, bilirubin, AST, ALT
Cholangitis - treatment
IV antibiotics
EMERGENCY GB decompression
ERCP
PTC (percutaneous transhepatic cholangiography)
Surgery NOT done (20-60% mortality
Cholangitis - complications (Chang has an abscess)
Hepatic abscess (15%) empyema
Primary Sclerosing Cholangitis (think sclerosis)
Narrowing and hardening of the bile ducts which leads to a back up pressure and obstruction of the bile ducts.
Increased pressure leads to liver inflammation, fibrosis and cirrhosis of the liver
Primary Sclerosing Cholangitis (inflammed bile duct) linked with (Chang is primarily friends with UC students)
ulcerative coalitis - 70%
Primary Sclerosing (bile ducts inside and outside liver become scarred) - risk factors - gender and age only?
Risk factors: Ulcerative colitis (UC), male 30-40 years and family history, microbiome issues, genetics, environmental
Primary Sclerosing - s/sx (same)
RUQ pain, jaundice, fatigue, pruritis, cirrhosis, LFT changes (alk phos elevates first, then bilirubin, and finally ALT, AST
Cholecystectomy - Laparotomy
Hospitalized
Prevent/minimize pulmonary complications
ICS, TCDB, splinting, ambulate
Proactive pain management with PCA opioids, splinting
NPO, NGT, antiemetics
T tube or C tube, wound drain, incision care
Patient discharge education
Pain, wound, tubes, diet, activity restrictions
Cholecystectomy - Laproscopic “lap choley” - when can I lift stuff and drink alcohol?
Ambulatory surgery
Multiple stab wounds, insuffation with CO2, cameras, laser, “bagged” and removed
Fever pulmonary complications
Pain management
Less trauma, less pain
Free air in abdomen, absorbs, ambulate
Patient discharge education
Pain management, wounds, tubes, diet (low fat) , activity resumption
No lifting > 20 pounds for 10 days
No alcohol for 2 months
Report signs of obstruction or infection
Foods to Avoid Cholecystitis or Cholelithiasis - high in cholesterol (and what else)
Dairy
Whole milk, ice cream, butter, cheese, cream
Fried, fatty foods
Rich pastries
Gravies
Nuts and chocolate
Egg yolks and avocado
foods to avoid - gas forming veggies
Gas Forming Vegetables
Onions
Broccoli
Cauliflower
Sauerkraut
Radishes
Cucumbers
Beans
cholysystitis - what type of pain? (Chole’s shoulder hurts)
pain radiates to shoulder. can have this without obstruction
who usually gets cholycyitis? (Chole is really old)
usually really old or sick. immobile. it’s not very common. sludgy bile. could be cancer, opioids. can be from infection as well. worry is rupture and periotonitis.
