Biliary Disorders Flashcards
WHAT ARE THE 2 TYPES OF GALLBLADDER DISEASE?
CHOLELITHIASIS: Stones (obstruction)
CHOLECYSTITIS: Inflammation of the gallbladder
Pathophysiology
* Cause of gallstones unknown
* Develops when balance that keeps
cholesterol, bile salts, and calcium in solution is altered, leading to precipitation
* May be asymptomatic “silent cholelithiasis”
* The severity of symptoms depends on
whether the stones are stationary or
mobile and whether obstruction is
present.
* Cause pain as they pass through ducts * May lodge in ducts and produce an
obstruction → Cholecystitis
RISK FACTORS OF CHOLELITHIASIS (STONES)
(7)
** Female**
** Age > (Forty) 40 years**
** (Fat)obesity**
** Family history**
- multiparity pregnancya*
**oral contraceptive (estrogen therapy/birth control) - Immobility**
- inflammatory or obstructive lesions of
biliary system, ↓ bile flow (biliary sludge)
CLINICAL MANIFESTATIONS:
CHOLECYSTITIS/CHOLELITHIASIS
OBSTRUCTION & INFLAMMATION/infection
ACUTE SYMPTOMS occur w/ Obstruction and inflammation/infection
1. fever,
2. palpable abdominal mass,
3. Right upper quadrant (RUQ) → radiating to back/shoulder
4. nausea and vomiting;
5. Biliary colic: episodes of severe pain usually associated with nausea and vomiting, which usually occur several hours after a heavy meal; → limit fatty meal
6. Murphy’s sign: → When touched/pressure applied pt will gasp (inspiratory arrest) and hold breath d/t severe pain → used by ultrasound tech as a diagnostic sign
- **Obstruction (PRIORITY): Jaundice **may develop
due to blockage of the common bile duct; pruritus (due to deposition of bile salts in skin tissues);
Steatorrhea;
-clay colored stool, → decrease bilirubin
-dark tea colored urine → increase bilirubin
PRURITUS - itching of skin
Prevention of ACUTE CHOLECYSTITIS/ CHOLELITHIASIS (3)
- Rest,
- NPO,
- NG tube if severe N/V (Billiary Colic)
(to prevent further gallbladder stimulation)
MANAGEMENT/INTERVENTIONS OF GALLBLADER DISEASE
Diagnostic= Ultrasound + ERCP
* Nonsurgical removal:
By instrumentation - allows for direct removal via ERCP
* Intracorporeal lithotripsy: laser pulse
under fluoroscopic guidance
* Extracorporeal Shock Wave Lithotripsy
(ESWL): High-energy shock waves
disintegrate stones + Used in conjunction
with bile acids
* Bile acids (cholesterol solvents):
** ERCP with sphincterotomy**
(papillotomy) : direct visualization with opening of the sphincter of Oddi
- Surgical procedure:
*** Cholecystectomy - - Laparoscopic Cholecystectomy:
Treatment of choice**
Open (incisional) cholecystectomy
* Removal of gallbladder through right
subcostal incision
**T-tube ** inserted into common bile duct
during surgery when a CBD exploration
* Ensures patency of the duct
* Allows excess bile to drain
POST-OP CARE FOR
LAPAROSCOPIC CHOLECYSTECTOMY
Treatment of Choice
removal of gallbladder through 4 small incisions
- After laparoscopic cholecystectomy:
Faster recovery with ↓ pain; Fewer complications; May resume normal activities, work w/in 1 week
- Referred pain to the shoulder from CO2
- The CO2 can irritate the phrenic
nerve and the diaphragm, causing some difficulty in breathing - Sims’ position (left side with right knee flexed) - ambulation, analgesia
- Liquids day 1; Light meals several days
**Remove bandages the day after
surgery and then can shower **
Can shower 1-day post op then remove steri-strips
POST OP CARE FOR INCISIONAL (OPEN) CHOLECYSTECTOMY (8)
t-tube placement required to allow bile to drain because edema may cause obstruction
After several days, clamp the tube x 1 hr before each meal – expect soft,
brown formed stool
- After incisional cholecystectomy *
1. Maintain adequate ventilation;
Prevent respiratory complications (hypoventiilation d/t increase pain at surgical site
2. Administer analgesics as ordered and medicate to promote/
3. permit ambulation and activities, including deep breathing
4. Turn & encourage cough and deep breathing exercises [TCDB]
splinting to reduce pain**
**5. Clear Liquids to regular diet after return of bowel sounds
6. May need to restrict fats for 4–6 wks
7. No heavy lifting for 4–6 wks
8. D/c in 2–3 days
WHAT IS ACUTE PANCREATITIS?
WHAT CAUSES IT ? (4)
- Acute pancreatitis:
the pancreatic duct becomes** obstructed** (i.e. gallstones) & enzymes (activation of trypsinogen to
trypsin) back up into the pancreatic duct;
spillage of pancreatic enzymes into
surrounding pancreatic tissue causing
auto digestion and inflammation/
bleeding of the pancreas
Pancreatic digestive enzymes:
(amylase- carbs/ trypsin-protein/ lipase-fat)
Damage can vary from mild edema to severe fat necrosis → severe pain
Causes:
1. gallbladder disease (gallstones),
2. chronic alcoholic drinking
3. smoking,
4. hypertriglyceridemia (>1000 mg/dL)
(normal: <150)
CLINICAL MANIFESTATIONS OF
ACUTE PANCREATITIS
*** Severe abdominal pain / “Not
relieved with vomiting” **
* LUQ or midepigastrium—>back
* Abd guarding, N&V, low-grade fever,
leukocytosis, ↓ or absent bowel sounds,
hypotension, jaundice, confusion, and
agitation
* Ecchymosis in the flank
(Grey Turner’s sign) or
umbilical (Cullen’s sign) area
from seepage of blood-stained exudate
from the pancreas
COMPLICATIONS OF ACUTE PANCREATITIS
(10)(RPAP4HRS)
- respiratory distress d/t interferences w/ breathing
- ↑ risk (Pleural effusion, Atelectasis, Pneumonia),
- hypocalcemia d/t fat necrosis = ↑fatty acids combined w/ calcium = calcium salts → TETANY
- hyperglycemia (damage to beta cells ↓ insulin production)
- hypoxia,
- hypovolemia → bleeding
- renal failure → hypoxemia → ↓perfusion needed
- shock
MANAGEMENT/INTERVENTIONS
FOR ACUTE PANCREATITIS (5)
***1. Improved respiratory function: **TCDB = Turn & encourage cough and deep breathing exercises →
semi-Fowler’s position
2. Relief of pain and discomfort
→ minimizing or ↓ pancreatic enzyme by →
NG suction / NPO * **
→ ↓ acid secretion to prevent gastric acidic contents from entering the duodenum
**→ use H2 blocker or PPIs: ↓ pancreatic activities by
inhibiting gastric acid **
→ Parenteral nutrition (PN) if needed; TPN (Long-term) → Frequent oral care
*3. Bed rest:** Position changes
* Side-lying with HOB 45 degrees
4. Use of analgesics: morphine, fentanyl, dilaudid
5. Monitor fluid and electrolyte balance:
* Monitoring tetany → [CARDIAC MONITOR]-→ Symptomatic Hypocalcemia**→
* Chvostek’s sign
* Trousseau’s sign **
* Calcium gluconate to treat
WHAT IS CHRONIC PANCREATITIS?
WHAT ARE ITS CAUSES?
- Continuous, prolonged inflammatory, and fibrosing process of the pancreas (destruction of the pancreas)
*** Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting **
Weight loss (80%)- malabsorption /Steatorrhea
Chronic alcohol consumption= major cause
Causes:
Alcohol, gallstones, tumor,
pseudocysts, trauma, systemic disease
(e.g., systemic lupus erythematosus)
* Acute pancreatitis; idiopathic
CLINICAL MANIFESTATIONS OF
CHRONIC PANCREATITIS? (5)
- Severe upper abdominal pain & Back pain accompanied by Vomitting
- N/V
- Unable to digest food properly → wt loss (80%) (malabsorption)
- Steatorrhea
- Chronic Alcohol Drinker
*** Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting **
Weight loss (80%)- malabsorption /Steatorrhea
Chronic alcohol consumption= major cause
MANAGEMENT/INTERVENTIONS
OF CHRONIC PANCREATITIS
* Pain control- Analgesics for pain relief
(morphine/fentanyl transdermal patch/nonopioids methods)
* Diet : Bland, low-fat; Small, frequent meals;
*No smoking, No alcohol
*** Glucose intolerance/diabetes: **control
with insulin or oral hypoglycemic agents
* Pancreatic enzyme products (PEPs)
[2main interventions is enzyme replacement w/ tx like DM]
such as 1. Pancrelipase (Creon, Zenpep, and Pancrease) contain amylase (carbs), lipase (fat), and trypsin (protein) and are used to replace the deficient pancreatic enzymes
-**PEPs are taken with meals or with a snack. **
-Observe the patient’s stools for steatorrhea (effectiveness) = GOOD when normal stools have no Steatorrhea
(long term-weight gain); weight loss is good in long term
- Insulin and Diabetic medications d/t loss of endocrine function
RISK FACTORS FOR
PANCREATIC CANCER (3)
S/S (3) & Medical Treatment?
post-op care priority ?
** S/S: pain , jaundice d/t obstruction by tumor, weight loss [classic signs]**
- Risk factors: (3)
**cigarette smoking, older age, high fat diet ** - lesions: 70% (head of pancreas)
- Medical Tx : Chemotherapy, Radiation (limited) *
Surgery: Pancreatoduodenectomy aka
(Whipple’s Procedure) - Removal of gallbladder, stomach, duodenum, proximal jejunum, head of pancreas, & distal common bile duct
- Reconstruction: anastomosis of the remaining pancreas and stomach to the jejunum. Allowing bile into jejunum
*Post-op Care:
ABC priority
