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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
Higher ____ favours cholesterol solubility, and will DECREASE stone formation
bile salt
26
Colours of "pure cholesterol" yellow stones?
-Typical, yellow, brown and green
27
Characteristics of grey-white to black/mixed stones?
- Often a mix of bilirubin, and cholesterol w/ calcium carbonate and phosphates - 1-3 cm in diabeter
28
_____ dictates the obstruction of ducts
size
29
Medical factors associated with cholesterol stones?
- Drugs - Ileal disease - Long-term TPN
30
Diet/Lifestyle/Demographic factors associated with cholesterol stones?
- Northern europe, N and S America - Female - Diabetes - Obesity - Weight reduction - Very high energy diet
31
How will obesity and very high energy diets lead to cholesterol stones?
Will increase the amount of bile acids needed to digest excess energy
32
_____ may favour gallstone formtation
Hypertriglyceridemia
33
What is the link of gallstone formation and T2DM?
- May be obese - May have higher TGs - Neuropathy which may impact the efficiency of bile which is removed from the gallbladder
34
What are the factors associated with the development of bilirubin pigment stones?
- Chronic hemolysis - TPN - Thalassemia - Cirrhosis - Age
35
What is thalassemia?
Genetic blood disorder where the body makes abnormal form or inadequate amounts of hmg
36
What are some common causes of gallstones?
- 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
What is cholecystitis? What is it usually caused by?
The acute or chronic inflammation of the gallbladder | -Gallstones
38
What are other causes of cholecystitis?
- Critical illness - Sepsis - Shock - Burns - Cancer
39
What is choledocholithiasis?
- 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
What is all related to eachother?
CCC - Cholelithiasis - Cholecystitis - Choledocholithiasis - -> All are likely to have gallstones
41
Whay are the symptoms of gallbladder issues(CCC)?
- Pain in epigastrum near mid-line, radiates around to scapula regions, constant in the upper R quadrant - Nausea, sweating and vomiting
42
What are the additional symptoms seen in acute cholecystitis?
- Fever - Pain upon coughing - Tender over gallbladder area - Vomiting not as common
43
How are gallstones medically diagnosed?
- Ultrasonography - CT or MRI to locate stones - X-ray - Cholecytogram (dies) - Endoscopic retrograde cholangiopancreatography (ERCP)
44
What is ERCP?
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
Biochemistry to interpret infection?
CBC or white cell counts
46
Biochemistry to interpret Jaundice or obstruction?
Bilirubin
47
Biochemistry to interprent Inflammation?
CRP or ESR
48
What is ESR?
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
3-key complications of cholelithiasis?
1) Biliary obstruction (choledocholithiasis) 2) Inflamation (cholecystitis) 3) Inflammation of biliary ducts (cholangitis)
50
Symptoms of biliary obstruction?
- 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
Why is urine dark and stool clay coloured?
Dehydration and fat malabsorption
52
Pathophysiology of cholecystitis inflammation?
- 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
Cholangitis is _____ to obstruction fo the common bile duct
secondary
54
What should be considered for nutritional risk?
- Consider inadequate intake past 7-days - Significant weight loss? - Nutrition support?
55
What should be considered for Nutritional consultation?
- Assist with food pattern changes to adequate level - Provide education on low-fat nutrition prescription - Nutrition support may be required in severe pancreatitis
56
What is often prescribed as nutritional therapy?
-Reduced/low fat diet
57
Indications of reduced/low fat diet?
- Fat malabsorption and maldigestion - Cholecystitis - Pancreatitis
58
Considerations for reduced/low fat diet?
- Ensure nutritional adequacy | - Monitor fat soluble vitamins, or use miscible form if longterm symptoms
59
What is considered "low/reduced" fat?
20-30%, which is quite normal | --> More that we don't want a HIGH fat diet
60
What mediates the amount of fat after a cholecystectomy?
Individual tolerance
61
What kind of diet, besides being low/reduced fat, should be administered ASPA?
Full fluid diet
62
Fluid requirements?
1ml /kcal, and adjust for losses by fever or diarrhea
63
Protein requirements?
Modest
64
Fat requirement?
Aim for 30% of energy
65
Fat guidelines?
- 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
Lean meat has ____ g fat/25 g meat (1oz)
2
67
Practical suggestion for nutrition intervention?
- 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
Is the low fat diet for life?
No, only initially then can return to a normal, healthy, diet
69
Which medications will dissolve smaller stones in a functioning gallbladder?
- Chenodiol - Ursodiol - -> Will take 18-24 mos to disolve
70
Other ways of treating gallstones?
- Ultrasound - Laparoscopic-cholecystectomy - Percutaneous cholecystostomy drainage of gallbladder - Biliary stents to clear ducts
71
What is the purpose of ERAS?
-Will help manage post-surgery glycemic levels, may attenuate their stress hormones after surgery, can promote healing and attenuate post-op catabolism.
72
Evening before ERAS protocol?
- Eat/drink normally to midnight | - Clear fluids up to 2h prior to surgery
73
Examples of clear fluids allowed 2h prior to surgery?
- 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
Morning before surgery ERAS protocol?
- Do not eat any foods | - Drink 1 CHO drink (50 g CHO) quickly (5 mins) 2-3 hrs before surgery
75
Example of post-op nutrition day 1-3 s/p cholecystectomy?
- Clear fluids first, sipped - Full fluids, but avoiding high fat - Can use EN products, low in fat
76
Example of post-op nutrition day 3 s/p cholecystectomy?
- if tolerating fluids, low-fat diet | - Small meals depending on tolerance
77
When is nutrition support reserved for?
- Severe cases of pancreatitis | - Extended post-op period where bowel rest is indicated
78
Are peppermint and turmeric valid alternative medicines?
- No | - Turmeric may improve liver function, but will worsen gallbladder disorders

Clinical Nutrition 2 (21 decks)

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