Disorders of the appendix, gall bladder, and pancreas

Question 1

Which of the following is a major complication of persistent gastroesophageal reflux?

• heartburn
• chest pain
• hoarseness
• strictures

Answer 1

Strictures.

Persistent gastroesophageal reflux may lead to strictures of the esophagus. Strictures are caused by a combination of scar tissue, spasm, and edema. Heartburn, chest pain, and hoarseness are symptoms of gastroesophageal reflux, not complications of persistent gastroesophageal reflux.

Question 2

what are two of the major causes of gastric irritation and ulcer formation

Answer 2

1. aspirin or NSAIDs

2. H. pylori

Question 3

What is the most serious complication of appendicitis that we should be concerned for?

Answer 3

o Untreated: The most serious complication is perforation, leading to peritonitis and possible sepsis and shock.

Peritonitis: widespread painful inflammation of abdominal wall

Question 4

clinical manifestations of appendicitis

Answer 4

Epigastric and RIGHT LOWER QUADRANT abdominal pain

o Nausea, vomiting, decreased appetite

Question 5

Diagnosis and treatment of appendicitis

Answer 5

o	Diagnosis
•	History and physical
•	Lab studies: increase WBC
•	Imaging: CT scan
o	Treatment: 
•	Pain management
•	Surgical removal and antibiotics are standard treatment

Question 6

What is appendicitis

Answer 6

Common acute problem in young adults (10% of pop).

It’s caused by a blockage of hollow portion of appendix; most commonly by calcified stone composed of feces
o Blockage leads to increased pressure in appendix, decreased blood flow to tissues of appendix, bacterial growth inside appendix causing inflammation Causes tissue injury + death
o Inflammation of the vermiform appendix

Question 7

What is another word for cholelithiasis

Answer 7

Gallstones (this is the most common biliary disorder)

Question 8

Risk factors for cholelithiasis (gallstones)

Answer 8

o RISK FACTORS: Obesity, middle age, female, Native American ancestry, and gallbladder, pancreas, or ileal disease

Question 9

cholelithiasis can sometimes (not often) lead to Cholecystitis. What is Cholecystitis?

Answer 9

Inflammation of gallbladder associated with cholelithiasis

o Stones lodged in neck or cystic duct (blockage of cystic duct with gallstones)
• Causes buildup of bile in gallbladder, increase pressure in gallbladder leading to severe colicky RIGHT UPPER ABDOMINAL pain*

o Concentrated bile, pressure, bacterial infection irritate + damage gallbladder wall leading to inflammation + swelling of gallbladder w/ spread of proteolytic pancreatic enzymes that autodigest the pancreas
• Causing reduced blood flow cell death d/t inadequate O2

o Can be acute or chronic

o More common in whites & American Indians

Question 10

Clinical manifestations of cholelithiasis

Answer 10

Clinical Manifestations
o Severe abdominal pain – biliary colic, accompanied by tachycardia, diaphoresis & exhaustion
o Residual tenderness in RUQ
o Attacks occur 3 to 6 hrs after a heavy meal or when lying down
o If total obstruction – symptoms related to bile obstruction (E.G.: Steatorrhea (d/t insufficient bile to digest fat), pruritis (d/t bile buildup in blood), dark amber urine, jaundice, clay colored stools, fever

Question 11

What is “biliary colic”

Answer 11

the term used to describe a type of pain related to the gallbladder that occurs when a gallstone transiently obstructs the cystic duct and the gallbladder contracts.

Question 12

Diagnostic testing for Cholecysitits and cholelithiasis

Answer 12

o Cholecystitis: diagnosed by classic symptoms
• RUQ abdominal pain, nausea, vomiting. fever
• Labs: increase WBC + elevated bilirubin
• Abdominal ultrasound: gallstones, fluid surrounding gallbladder, gallbladder wall thickening, dilation of bile duct

o Oral cholecystography, ultrasound, hepatobiliary (HIDA) scan (HAS HIGH SENSITIVITY)
• HIDA: nuclear imaging procedure to evaluate health + fxn of gallbladder
• Radioactive tracer injected thru accessible vein, then allowed to circulate to liver, where it is excreted into biliary system + stored by gallbladder + biliary system
• Absence of disease: gallbladder visualized within 1 hr of injection of radioactive tracer
• If gallbladder not visualized within 4 hours after injection, indicates either cholecystitis or cystic duct obstruction

o Endoscopic retrograde cholangiopancreatography (ERCP): use of endoscopy + fluoroscopt to diagnose + tx certain problems of biliary or pancreatic ductal systems
• Endoscope: view inside of stomach + duodenum, inject radiographic contrast into ducts in biliary tree + pancreas so they can see on x-rays
o Percutaneous transhepatic cholangiography (PTC): radiologic technique used to visualize anatomy of biliary tract
• Contrast medium injected into bile duct in liver, x-ray taken after
o ↑ Bilirubin due to obstruction
o CT scan used if perforation, gangrene suspected
o Uncomplicated cholecystitis – excellent prognosis (25% require surgery or develop complications)
o Delayed Dx of acute cholecystitis increases morbidity + mortality
o Cholelithiasis & Cholecystitis: may present as single episode or reoccur on multiple occasions

Question 13

what is the function of the gallbladd

Answer 13

to store bile

Question 14

what is bile made of?

Answer 14

pigments and bile salts (help to emulsify fat)

Question 15

What are potential complications of Cholelithiasis & Cholecystitis

Answer 15

o Abscess
o Pancreatitis
o Gallbladder rupture

Question 16

What is the treatment of Cholelithiasis & Cholecystitis

Answer 16

Most often, surgical removal of gallbladder (either 1)Traditional cholecystectomy, 2) Cholecystostomy (open gallbladder to remove stones or pus), or 3) LAPAROSCOPIC CHOLECYSTECTOMY=GOLD STANDARD).

Also:
o Medications: antibiotics, analgesics & antispasmodics
o NPO until symptoms subside
o Gastric decompression – NGT
o Weight reduction diet if desired
o Avoidance of fatty foods, fried foods (before + after procedure)

Question 17

What would be supportive measures for a PT about to undergo a gallbladder surgery?

Answer 17

o Supportive measures prior to surgery:
• Fluid resuscitation, Pain management, Antibiotics to target enteric organs
• Keeping patient NPO until symptoms subside and gastric decompression. Weight loss is also an option if desired

Question 18

Pancreatitis

Answer 18

inflammation of pancreas resulting in auto-digestion of tissue

Question 19

Acute Pancreatitis

Answer 19

• An acute inflammation that usually resolves clinically & histologically
• Autodigestion follows premature activation of pancreatic enzymes (trypsin, protease amylase, lipase) within pancreas leading enzymes to digest pancreatic tissue leading to massive inflammation, bleeding, necrosis
• Damaging products (i.e. Cytokines + prostaglandins) are released by tissue necrosis + lead to inflammatory response
• Early activation of excessive pancreatic enzymes

Question 20

Etiology of acute pancreatitis

Answer 20

Etiology and risk factors
•	Alcoholism
•	Gallstones
•	Abdominal trauma
•	Operative trauma
•	Drug use
•	Infection
•	Unknown

Question 21

Chronic Pancreatitis

Answer 21

Characterized by histological changes/diminished function of the organ (ETOH (ALCOHOL ABUSE) is major cause)
–>cellular changes within pancreas

-It is irreversible and tends to progress, resulting in serious loss of exocrine & endocrine pancreatic function as well as deterioration of pancreatic structure.
• Pancreatic insufficiency - ↓ enzyme production→ malabsorption of fats & proteins
• Decrease insulin production

Question 22

Clinical manifestations of chronic pancreatitis

Answer 22

-Periods of exacerbations and remissions
o	Constant dull epigastric pain
o	Steatorrhea (fatty clay colored stool) from malabsorption of fats
o	Severe weight loss
o	Onset of symptoms of DM (b/c pancreas insufficiently produces insulin)
o	History of:
•	Biliary disease
•	Chronic ETOH
•	Physical trauma 
•	PUD
o	Medications

Question 23

Diagnosis of acute pancreatitis

Answer 23

Acute Pancreatitis is based on history of abdominal pain, risk factors, physical exam and diagnostic findings
• ↑ ↑ Serum bilirubin (d/t biliary obstruction)
• ↑ Liver enzymes
• ↑ pancreatic enzymes (amylase, lipase, trypsin)
• ↑ WBC
• ↑ Serum glucose (b/c pancreas insufficiently produces insulin)
• ↓ Ca++
• Mg++
• Abdominal ultrasound: dx pancreatitis
• Contrast-induced CT scan: most reliable, greatest visualization
• Abdominal & chest x-rays: differentiate from other disorders; detect pleural effusion

Question 24

Treatment of acute pancreatitis

Answer 24

• Pain Management (Opioids)
• ↓ Pancreatic secretions
o ↓ stimulation of the pancreas & enzymes & allow it to rest
o NPO & NG suctioning (decompress abdomen)
• Decompress abdomen, Remove irritants & ↓ pancreatic secretions
• Reducing vomiting & gastric distention (allows pancreas to rest by decreasing stimulation of the pancreas and pancreatic enzymes)
• Control Fluid & Electrolyte imbalances
o Maintain adequate circulating blood volume - volume expanders, √ urine output
o When no longer NPO, progressive diet – ↑ CHO, ↓ fat, ↑ protein
o Prevent infection - antibiotics should be started early

Question 25

What usually initiates appendicitis?

Answer 25

An obstruction of the lumen of the appendix (appendicitis is caused by a blockage of the hollow portion of the appendix, most commonly by a calcified “stone” made of feces. This blockage leads to increased pressures within the appendix, decreased blood flow to the tissues of the appendix, and bacterial growth inside the appendix causing inflammation)