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Clinical Nutrition 2 > Cholelithiasis, Cholecystitis & Pancreatitis > Flashcards

Cholelithiasis, Cholecystitis & Pancreatitis Flashcards

1
Q

How many million American have gallstones? What % of the population does this represent?

A
  • 20-25

- 10-15% of adult population

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2
Q

What is the leading cause of hospital admissions for Gi problems?

A

Gallstone disease

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3
Q

What is a “good” think about gall bladder diseases?

A

Very low mortality rate (0.6%)

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4
Q

Most gallstones are ____

A

clinically siltne t

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5
Q

Where is the gallbladder located?

A

Upper right quadrant, under the liver

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6
Q

What is the function of the gallbladder?

A

Fatty acids and or chyme in the duodenum will elicit the release of CCK, CCK will feedback to the gallbladder to trigger a release of bile acids to digest the remaining food

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7
Q

What are two big consequences of having decreased gallbladder function?

A

1) Decreased bile acids administered

2) Cause fat malabsorption, N/V and pain upon eating

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8
Q

What is the common bile duct?

A

The duct which stems from the liver, and can deliver bile to the gallbladder for storage or will go straight to join the pancreatic duct

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9
Q

How much bile acid in the common bile duct?

A

600-800 ml, includes cholic acid, chenodeoxy and cholic acid.

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10
Q

How much bile is stored in the gallbladder?

A

30-50 ml

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11
Q

What is a consequence if there is a blockage within the pancreatic duct?

A

The enzymes secreted from the acinar cells of the pancreas will build up and start digesting the pancreas –> Leading to pancreatitis

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12
Q

How are bile acids synthesized?

A

From cholesterol in hepatocytes

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13
Q

What is dissolved/transported in bile?

A
  • Bile acids and salts
  • Cholesterol
  • Phospholipids
  • Pigments (bilirubin)
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14
Q

What happens when there is disruptions in enterohepatic bile acid circulation?

A

May become deposited in the large intestine (not reabsorbed in the ileum) they will be unconjugated which may lead to inflammation and diarrhea

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15
Q

Discuss the first step in enterohepatic circulation (EHC)

A

1) Bile salts are secreted from liver or gallbladder through the common bile duct. 95% of them are old, recycled bile salts and 5% are new bile salts

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16
Q

Discuss the second step in EHC

A

2) After digestion, 95% of the bile salts will be reabsorbed by the small intestine

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17
Q

Discuss the third and final step in EHC

A

3) Reabsorbed bile salts are recycled by enterohepatic circulation, and finally 5% of bile acids will be lost in feces

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18
Q

What happens when more than 5% of bile acids are lost inf eces?

A

Cause inflammatory conditions

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19
Q

What is the sphincter of OdI/

A

The sphincter of the bile duct which leads into the duodenum. If this is blocked, we are in trouble

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20
Q

What is cholelithiasis?

A

Gallstones

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21
Q

What are gallstones formed from?

A
  • Cholesterol

- Bile salts, bile pigments or both

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22
Q

What is the difference between small and large stones?

A
  • Small stones are often asymptomatic
  • Large stones can lead to inflammation, obstruction and even necrosis –> Will often lead to extreme pain especially upon eating
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23
Q

What are the 3 main types of stones?

A
  • Cholesterol (most common)
  • Yellow stones (pure cholesterol)
  • grey, white black or mized
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24
Q

Formation of common cholesterol stones?

A

-Arises during solubility issues, as cholesterol increases (relative to water/bile acids) more stones will form.

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25
Q

Higher ____ favours cholesterol solubility, and will DECREASE stone formation

A

bile salt

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26
Q

Colours of “pure cholesterol” yellow stones?

A

-Typical, yellow, brown and green

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27
Q

Characteristics of grey-white to black/mixed stones?

A
  • Often a mix of bilirubin, and cholesterol w/ calcium carbonate and phosphates
  • 1-3 cm in diabeter
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28
Q

_____ dictates the obstruction of ducts

A

size

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29
Q

Medical factors associated with cholesterol stones?

A
  • Drugs
  • Ileal disease
  • Long-term TPN
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30
Q

Diet/Lifestyle/Demographic factors associated with cholesterol stones?

A
  • Northern europe, N and S America
  • Female
  • Diabetes
  • Obesity
  • Weight reduction
  • Very high energy diet
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31
Q

How will obesity and very high energy diets lead to cholesterol stones?

A

Will increase the amount of bile acids needed to digest excess energy

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32
Q

_____ may favour gallstone formtation

A

Hypertriglyceridemia

33
Q

What is the link of gallstone formation and T2DM?

A
  • May be obese
  • May have higher TGs
  • Neuropathy which may impact the efficiency of bile which is removed from the gallbladder
34
Q

What are the factors associated with the development of bilirubin pigment stones?

A
  • Chronic hemolysis
  • TPN
  • Thalassemia
  • Cirrhosis
  • Age
35
Q

What is thalassemia?

A

Genetic blood disorder where the body makes abnormal form or inadequate amounts of hmg

36
Q

What are some common causes of gallstones?

A
  • Too much absorption of water from bile
  • Too much absorption of bile acids from bile
  • Too much cholesterol in bile
  • Inflammation of the epithelium
37
Q

What is cholecystitis? What is it usually caused by?

A

The acute or chronic inflammation of the gallbladder

-Gallstones

38
Q

What are other causes of cholecystitis?

A
  • Critical illness
  • Sepsis
  • Shock
  • Burns
  • Cancer
39
Q

What is choledocholithiasis?

A
  • When stones block gallblader outlet (bile duct)
  • May block all the way down to the duodenum and may block pancreatic duct
  • A cause of pancreatitis
40
Q

What is all related to eachother?

A

CCC

  • Cholelithiasis
  • Cholecystitis
  • Choledocholithiasis
  • -> All are likely to have gallstones
41
Q

Whay are the symptoms of gallbladder issues(CCC)?

A
  • Pain in epigastrum near mid-line, radiates around to scapula regions, constant in the upper R quadrant
  • Nausea, sweating and vomiting
42
Q

What are the additional symptoms seen in acute cholecystitis?

A
  • Fever
  • Pain upon coughing
  • Tender over gallbladder area
  • Vomiting not as common
43
Q

How are gallstones medically diagnosed?

A
  • Ultrasonography
  • CT or MRI to locate stones
  • X-ray
  • Cholecytogram (dies)
  • Endoscopic retrograde cholangiopancreatography (ERCP)
44
Q

What is ERCP?

A

Use of an endoscope to check the gallstone formation by the duodenum. Sphincter of Oddi (May also be able to remove some stones at the stage)

45
Q

Biochemistry to interpret infection?

A

CBC or white cell counts

46
Q

Biochemistry to interpret Jaundice or obstruction?

A

Bilirubin

47
Q

Biochemistry to interprent Inflammation?

A

CRP or ESR

48
Q

What is ESR?

A

type of blood test that measures how quickly erythrocytes settle at the bottom of a test tube that contains a blood sample. Normally, red blood cells settle relatively slowly. A faster-than-normal rate may indicate inflammation in the body

49
Q

3-key complications of cholelithiasis?

A

1) Biliary obstruction (choledocholithiasis)
2) Inflamation (cholecystitis)
3) Inflammation of biliary ducts (cholangitis)

50
Q

Symptoms of biliary obstruction?

A
  • Dark-coloured urine
  • Clay-coloured stool
  • Marked disturbance in digestion and absorption of lipids
  • Severe upper right quadrant pain
  • Jaundice and liver damage
  • Pancreatitis
51
Q

Why is urine dark and stool clay coloured?

A

Dehydration and fat malabsorption

52
Q

Pathophysiology of cholecystitis inflammation?

A
  • Secondary to obstruction, infection and ischemia
  • Perforation of gallbladder, peritonitis
  • Perforation into another organ
  • Fistula to the duodenum, colon
  • Infection through ducts to liver, abscesses
53
Q

Cholangitis is _____ to obstruction fo the common bile duct

A

secondary

54
Q

What should be considered for nutritional risk?

A
  • Consider inadequate intake past 7-days
  • Significant weight loss?
  • Nutrition support?
55
Q

What should be considered for Nutritional consultation?

A
  • Assist with food pattern changes to adequate level
  • Provide education on low-fat nutrition prescription
  • Nutrition support may be required in severe pancreatitis
56
Q

What is often prescribed as nutritional therapy?

A

-Reduced/low fat diet

57
Q

Indications of reduced/low fat diet?

A
  • Fat malabsorption and maldigestion
  • Cholecystitis
  • Pancreatitis
58
Q

Considerations for reduced/low fat diet?

A
  • Ensure nutritional adequacy

- Monitor fat soluble vitamins, or use miscible form if longterm symptoms

59
Q

What is considered “low/reduced” fat?

A

20-30%, which is quite normal

–> More that we don’t want a HIGH fat diet

60
Q

What mediates the amount of fat after a cholecystectomy?

A

Individual tolerance

61
Q

What kind of diet, besides being low/reduced fat, should be administered ASPA?

A

Full fluid diet

62
Q

Fluid requirements?

A

1ml /kcal, and adjust for losses by fever or diarrhea

63
Q

Protein requirements?

A

Modest

64
Q

Fat requirement?

A

Aim for 30% of energy

65
Q

Fat guidelines?

A
  • 20% energy and choose foods w/ <3 g fat per serving, small frequent meals
  • Avoid high fat foods, fried foods, foods with strong odours
  • Low fat dairy products
66
Q

Lean meat has ____ g fat/25 g meat (1oz)

A

2

67
Q

Practical suggestion for nutrition intervention?

A
  • Follow CFG
  • Achieve ideal body weight
  • Avoid fried, fatty foods
  • Trim fat from meat/poultry
  • Avoid added fats (up to 1 tsp)
  • Drink adequate fluids
  • Minimal/moderate alcohol
68
Q

Is the low fat diet for life?

A

No, only initially then can return to a normal, healthy, diet

69
Q

Which medications will dissolve smaller stones in a functioning gallbladder?

A
  • Chenodiol
  • Ursodiol
  • -> Will take 18-24 mos to disolve
70
Q

Other ways of treating gallstones?

A
  • Ultrasound
  • Laparoscopic-cholecystectomy
  • Percutaneous cholecystostomy drainage of gallbladder
  • Biliary stents to clear ducts
71
Q

What is the purpose of ERAS?

A

-Will help manage post-surgery glycemic levels, may attenuate their stress hormones after surgery, can promote healing and attenuate post-op catabolism.

72
Q

Evening before ERAS protocol?

A
  • Eat/drink normally to midnight

- Clear fluids up to 2h prior to surgery

73
Q

Examples of clear fluids allowed 2h prior to surgery?

A
  • 850 ml Apple Juice
  • 1100 ml Commercial ice tea
  • 650 ml Cranberry cocktail
  • 1000 ml of lemonade, no pulp
  • 1000 ml of orange juice, no pulp
74
Q

Morning before surgery ERAS protocol?

A
  • Do not eat any foods

- Drink 1 CHO drink (50 g CHO) quickly (5 mins) 2-3 hrs before surgery

75
Q

Example of post-op nutrition day 1-3 s/p cholecystectomy?

A
  • Clear fluids first, sipped
  • Full fluids, but avoiding high fat
  • Can use EN products, low in fat
76
Q

Example of post-op nutrition day 3 s/p cholecystectomy?

A
  • if tolerating fluids, low-fat diet

- Small meals depending on tolerance

77
Q

When is nutrition support reserved for?

A
  • Severe cases of pancreatitis

- Extended post-op period where bowel rest is indicated

78
Q

Are peppermint and turmeric valid alternative medicines?

A
  • No

- Turmeric may improve liver function, but will worsen gallbladder disorders

Clinical Nutrition 2 (21 decks)

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