Chapter 37: Alterations in Function of the Gallbladder and Exocrine Pancreas

Question 1

Cholelithiasis

Answer 1

• Also called gallstones
• Etiology includes Native Americans > American Caucasians and Women > men (2:1)
• Adults May be asymptomatic and not need treatment
• Children Usually from an underlying condition and need gallbladder removed

Question 2

Chronic Cholelithiasis

Answer 2

• BILARY COLIC
• Related to intermittent obstruction of cystic duct
• Precipitated by a meal (infrequent schedule)
• Persistent epigastric or right upper abdominal pain, often radiates to back
• Nausea, vomiting, sweating, flatus
  Increases steadily for >15 minutes, lasts several hours, then slowly decreases
• Fatty food intolerance, belching, bloating, and epigastric burning
• Diagnosis: ultrasound
• Treatment includes Watchful waiting, Cholecystectomy (surgical removal of the gallbladder), Chemical dissolution of gallstones, and Lithotripsy (mechanical breaking up of gallstones within the gallbladder)

Question 3

Cholecystitis

Answer 3

• Inflammation of the gallbladder wall
• Causes fibrosis and thickening
• Related to continued presence of gallstones
• 2 types (Acute, Chronic)

Question 4

Etiology of Acute Cholecystitis

Answer 4

• Acute inflammation of the gallbladder wall
• Etiology includes:
• Cholelithiasis present in 90% of patients
• Obstruction of cystic duct present in almost all patients: related to stasis of bile
• Bacterial infection may be present

Question 5

If Acute Cholecystitis is untreated

Answer 5

• If untreated, escalates; gangrene may occur
• Rupture

= Peritonitis

• Septic shock
• Localized abscess (empyema)
• Cholecystoenteric fistula (fistula between gallbladder and GI tract)

Question 6

Clinical Manifestations and Diagnosis of Acute Cholecystitis

Answer 6

• Clinical manifestations include severe right upper abdominal pain: radiates to back; abdominal tenderness; fever; leukocytosis, mild elevations of bilirubin and serum transaminases
• Diagnosis is made through abdominal ultrasound (presence of stones, thickened gallbladder wall) and HIDA scan, CT, MRCA, and ERCP

Question 7

Treatment of Acute Cholecystitis

Answer 7

• Laproscopic cholecystectomy: mainstay of therapy
• Antibiotics (if bacterial infection)
• Percutaneous catheter drainage or endoscopic drainage with stent placement (obstruction)
• Gangrene, empyema, or emphysematous changes: surgical emergencies
• Pain management
• Chemodissolution (nonsurgical): use of bile acids/organic solvents to dissolve gallstone
• Lithotripsy (nonsurgical): Breaking up of gallstones using shockwaves; Stones

Question 8

Acalculous Cholecystitis

Answer 8

• Occurs in patients without preexisting gallstones
• Males >50 years
• Tends to occur in the setting of major surgery, critical illness, trauma, burn-related injury, or TPN
• Rapid development of gangrene, perforation, emphysematous cholecystitis, and empyema

Question 9

Acute Pancreatitis

Answer 9

• Inflammation of the pancreas (Autodigestion of the pancreas from enzyme activation)
• Predisposing factors (Biliary tract disease, hypertriglyceridemia, ethanol-associated (66%))
• 3 pathways ( Obstruction of the pancreatic duct by a stone or other cause (usually unknown), Acinar cell injury, Defective intracellular transport)

Question 10

Clinical Manifestations of Acute Panreatitis

Answer 10

• Steady, boring pain in epigastrium or LUQ
• Increases in intensity
• Severe tenderness on palpation
• Radiates or penetrates to back
• Nausea and vomiting
• Abdominal distention
• Hypoactive bowel sounds
• Low-grade fever

Question 11

Diagnosis of Acute Pancreatits

Answer 11

• Laboratories use lipase preferred test (Increase in amylase and lipase during first 12 hr (indictative), Elevated aminotransferases, alkaline phosphatase and bilirubin)
• Abdominal X-Ray (Ileus pattern; “sentinel loop”: distended loop of small bowel in area of pancreas)
• Adominal Ultrasound
• CT of abdomen (GOLD STANDARD;:allows remarkable detail, Prognostic assessment: Ranson’s criteria)

Question 12

Treatment for mild to moderate Acute Pancreatitis

Answer 12

• Reduce pancreatic secretions
• Conservative management
• Withhold oral feedings
• Nasogastric suction for adynamic ileus
• IV fluid replacement
• Analgesics

Question 13

Treatment for Severe Acute Pancreatitis

Answer 13

• Usually in ICU
• Nutritional replacement: prevents tissue breakdown, may need TPN
• Calcium and magnesium administration
• Control of hyperglycemia (insulin)
• Prevent respiratory failure, acute renal failure, intraabdominal sepsis
• Mechanical ventilation and hemodialysis may be needed
• Bacterial infection: antibiotics and aspirate fluid cultured; usually indicates poor prognosis
• Surgical intervention (abscess or hemorrhage) (Necrosectomy: debridement of devitalized tissue) (Pancreatectomy: major pancreatic resection) (Drains usually present)

Question 14

Complications of Severe Acute Pancreatitis

Answer 14

• Pseudocyst: collection of fluid within or adjacent to pancreas (Fever, tachycardia, abdominal mass, and tenderness; Management: endoscopic or surgical drainage)
• Pancreatic ascites: persistent leak in pancreatic duct into pleural space and mediastinum (Painless and massive, Detected by ultrasound or CT, fluid analysis obtained by aspiration, Treatment: prolonged parenteral nutrition, stent)