Cyndi - Week 4 - Exam 2 Flashcards
what is bilirubin?
yellow‐colored compound, produced when hemoglobin is broken down (by spleen)
what is unconjugated bili?
water insoluble, transported to liver by albumin
what is conjugated bili?
changed to soluble by liver
• A component of bile
• Excreted in stool and urinef
where is bile formed and what does it do?
formed in hepatocytes (if liver damaged → problem)
• aids in fat digestion in the small intestine
where is bile excreted/reabsorbed?
Some excreted in stool, some reabsorbed in portal vein
what is in bile? where is it stored?
- Contains conjugated bilirubin
* Stored in gallbladder
T/F the body makes 750 - 1000 mL of bile and holds in the gallbladder
TRUE
what is the gallbladder?
a storage place for bile
how does the gallbladder know when to release bile?
• Stimulated to release bile into the duodenum by secretion of CCK (cholecystokinin - digestive enzymes -stomach msg from fat to get bile)
what are the three common gallbladder problems?
Motility disturbances biliary sludge (so concentrated/thick → can turn into stones → no movement) biliary stasis (no movement)
what is cholelithiasis?
‐ presence of gallstones in gallbladder
what is cholecystitis?
‐ gallbladder inflammation, obstruction, infection
• Biliary Sludge
• Biliary colic
what is choledocholithiasis?
• Gallstones occluding the common bile duct
what are the risk factors for gallbladder dysfunction?
- Age >40
- Female gender, estrogen level, multiparous
- Low calorie diets (stressing system)
- Fatty, high cholesterol foods
- Obesity, sedentary lifestyle
- Disturbances in metabolism (Diabetics, Pregnant, multiparous, menopausal, or using birth control using pills)
what is an easy way to remember the risk factors (5 F’s)?
- female
- > 40
- fertile
- fat
- flatulance
what are the clinical manifestations of acute cholecystitis?
- RUQ pain – guarding, radiation
- May occur after a meal
- Murphy’s sign (radiating pain)
- Fever (inflammation)
- Nausea, vomiting, anorexia
- Jaundice may occur
- Rupture of gallbladder relieves pain!
TEST: what are the main clinical manifestations for acute cholecystitis?
N + V + A
what are the clinical manifestations of chronic cholecystitis?
- Chronic inflammation
- Calculi
- Fibrosis or thickening of gallbladder
what is acute acalculous cholecystitis?
- inflammation of gallbladder without stones
- could be sludge or viral infection
TEST: what are risk factors of acute acalculous cholecystitis?
- Prolonged immobility or fasting (not moving)
- TPN (no food - gallbladder not effective)
- Diabetes (hormones/insulin ↑/↓; infect easier)
what are the complications of cholecystitis?
- Choledocholithiasis
- Gangrenous gallbladder
- Pancreatitis
what are the diagnostic labs of cholecystitis?
- WBCs
- Erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP) -inflammation
- Liver function tests (ALT,AST, Bilirubin,Alk phos)
what are the diagnostic (radiology) tests of cholecystitis?
- AbdominalCT, MRI, X‐ray, and/or ultrasound
- Hepatobiliary iminodiacetic acid (HIDA scan, aka cholecystogram)
- Endoscopic retrograde cholangiopancreatography (ERCP)
what is the acute care admission treatment indications for cholecystitis?
• NPO/ possible NGT for bowel and pancreas rest
• IV fluids
• Meds
TEST bowel rest and IVF
what meds are used for acute cholecystitis?
- ATBs
- antiemetics
- PPIs
- Questran (removes cholesterol → body doesn’t have to respond to fat)
- oral meds to dissolve gallstones,
pain meds –dilaudid recommended (morphine, codeine can cause spasms) - anticholinergics (slow motility)
what are the procedures to treat cholecystitis? (5)
• ERCP, Extracorporeal Shockwave Lithotripsy (ESWL), T‐tube, intraoperative cholangiography, direct cholelitholysis therapy
what are the surgery decisions for cholecystitis?
- open versus laparoscopic removal of the gallbladder
• Post‐op lap chole may have referred pain due to the CO2 used during surgery
what is the discharge teaching for cholecystitis?
- May need dietary changes initially, with small meals, ↓ fat
- Short tem activity restrictions, may shower in 1‐2 days
what are the functions of the pancreas?
exocrine function and endocrine function
what are the exocrine functions of the pancreas? TEST
Pancreatic juices –
Amylase, lipase, trypsin (protein), elastase, phospholipase A, kallikrein
what are the endocrine functions of the pancreas?
Islets of Langerhans
• Alpha cells (glucogon)
• Beta cells (insulin)
• Delta cells (hormone that inhibits release of A+B)
what is pancreatitis?
acute or chronic inflammation
•Acute (reversible) versus chronic (progressive‐fibrosis)
what are the risk factors of pancreatitis?
- Genetic (ie: cystic fibrosis)
- Trauma (penetrating wound)
- Alcohol abuse***
- Biliary tract dysfunction
- Men and women equal risk
- Viruses
- Hypercalcemia, hypertriglyceridemia
- Toxins (ie: smoking, insecticide exposure, etc.)
what are the characteristics of the inflammatory process of pancreatitis?
acute inflammatory response
multi-organ failure - pancreatic enzyme in area of pancreas - liver, stomach, lungs - at risk for ARDS***
what are the characteristics of the obstruction of pancreatic ducts?
- Pancreatic ischemia
- Gallstones
- Autodigestive effects (Pancreas enzymes in the wrong area cause destruction)
T/F 5 - 10% of chronic alcohols get pancreatitis
TRUE - ↑ digestive enzymes released too quickly and too much
what are clinical manifestations of acute pancreatitis?
- Severe pain, epigastric; may radiate to back
- Nausea, vomiting
- Abdominal distention (fluids backing up), hypoactive sounds, changes in stool from fat malabsorption
- Diaphoresis
- Dyspnea, shallow respirations (hurts)
- Low grade fever
- Tachycardia
- Hypotension (fluids in wrong place → shock)
- Jaundice
- Leukocytosis (↑ WBC → fight off infection)
- GreyTurner, Cullen’s sign
what is Grey Turner sign?
bluish flank discoloration - leaking through; not in the right place - at risk for shock
what is Cullen’s sign?
bluish peri-umbilical discoloration - at risk for shock
what are the clinical manifestations of chronic pancreatitis?
Progressive or recurring •Persistent or recurrent mid‐epigastric pain •“Heavy” •“Cramp like” •Weight loss •Malnutrition •Hyper‐ or hypoglycemia •Steatorrhea – “foul, fatty, frothy” stools
where is chronic pancreatitis most prevalent? test
age 30 - 40 years old
- 3x more common in African Americans and those that smoke
what is an important teaching to give patients with chronic pancreatitis?
- must have enzymes with every meal and snack
* *test**
what are the diagnostic labs for pancreatitis?
- Amylase
- Lipase
- Glucose
- Calcium
- WBCs
- Triglycerides
- AST/ALT
- Ranson Criteria (tool to assess severity of pancreas upon admission then 24-48 hrs later)
what are the diagnostic tests (radiology) for pancreatitis?
•CT scan •Ultrasound •HIDA scan •MRI (magnetic resonance imaging) •ERCP (endoscopic retrograde cholangiopancreatography) •MRCP (magnetic resonance cholangiopancreatography
what is the tx for pancreatitis?
- Pain management
- IV fluids – usually 200‐250 mL/hour
- NPO – introduce low‐fat small meals ‐ slowly after pain improves
- NG tube – possible if vomiting or ileus, or to reduce pancreatic secretions
- Medications
what meds are used to tx pancreatitis?
o TPN (possibly‐for sustained or recurrent)
o Pancreatic enzymes (when taking po, if needed),
o Others for symptoms
what is the patient education for pancreatitis?
- stop drinking
- resources (AA, Family member)
- pancreatic enzymes
- prevent complications
what are the complications of pancreatitis?
ARDS, pneumonia, hypoglycemia, hyperglycemia, pseudocyst, shock, necrotic pancreas
what are the characteristics of pancreatic cancer?
Poor prognosis
•Death within 5‐12 months
• 5% survival to 5 years
• peak 65 - 80 y/o
what are the clinical manifestations of pancreatic cancer?
same as pancreatitis
• Severe pain, epigastric; may radiate to back
• Nausea, vomiting
• Abdominal distention (fluids backing up), hypoactive sounds, changes in stool from fat malabsorption
• Diaphoresis
• Dyspnea, shallow respirations (hurts)
• Low grade fever
• Tachycardia
• Hypotension (fluids in wrong place → shock)
• Jaundice
• Leukocytosis (↑ WBC → fight off infection)
• GreyTurner, Cullen’s sign
what are the risk factors of pancreatic cancer?
- High‐fat diet, red meat, nitrites
- Smoking ‐ 2‐3X more likely
- Age
- Diabetes
- Exposure to chemicals
- Family history/genetic predisposition (5‐10%)
what are the 4 diagnostic tests used for pancreatic cancer?
• Tumor markers in serum (Elevated CA 19‐9 and CEA tumor marker) • CT • Transabdominal ultrasound • Endoluminal ultrasound (EUS) - Alternative to CT and more refined • Endoscopy - Visualize obstruction of ducts - ERCP (gold standard) - Biopsy - Samples of pancreatic secretion
what is the treatment for pancreatic cancer?
- Patient care same as for pancreatitis
- Medications – same as for pancreatitis
- Combination treatment
what are the surgical options for pancreatic cancer?
Radical Pancreaticoduodenectomy or Whipple procedure
what is the combination treatment for pancreatic cancer?
•Radiation therapy
- Shrink tumor
- Pain relief ‐palliative
•Chemotherapy has limited success (response rates <15%)
what is a whipple procedure (radical pancreaticoduodenectomy)?
Removal of head of pancreas, gallbladder, duodenum, part of stomach, lymph nodes → Reconnection of remaining pancreas and digestive organs
TEST: what’s the most common procedure to treat cholecystitis?
lap chole
TEST: what’s the highest priority of taking care of someone with pancreatic cancer?
pain
TEST: what kind of treatment would you have for pancreatic cancer?
palliative
radiation
chemo
Whipple
TEST: if someone has had a chole, other than giving them pain meds, what’s a NI you would wanna do?
- move
- Cough, Turn, Deep breath q 2 hr
TEST: why does a patient have clay colored stools?
bile isn’t getting there → bilirubin
TEST: where is the pain for acute pancreatic pain?
epigastric pain
TEST where does pain radiate for pancreatitis? gallbladder?
back and right shoulder
TEST: what do lipase and amylase do?
digest fat and starches
TEST: Teaching point for pancreatitis?
stop drinking
TEST: gallbladder teaching?
small, frequent meals
lower fat
TEST: if they show up with cholecystitis?
N + V + A
- guarding
