Exam 2: Chapter 50 - Gallbladder

Question 1

Calculi, or gallstones, usually form in the gallbladder from

Answer 1

the solid constituents of bile and vary greatly in size, shape, and composition

Question 2

Two major types of gallstones?

Answer 2

Those composed predominatly of pigment and those composed primarily of cholesterol

Question 3

Pigment stonrs probably form when

Answer 3

unconjugated pigments in the bile precipitate to formr stones (10-25% of all cases)

Risk of developing stones increased in patients with cirrhosis, hemolysis, and infections of the biliary tract

Question 4

Pigment stones cannot be

Answer 4

dissolved and must be removed surgically.

Question 5

How do cholesterol stones form?

Answer 5

When there is a decreased bile acid synthesis and increased cholesterol synthesis in the liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form stone

Cholesterol-satured bile predisposes to the formation of gallstones and acts as an irritant that produces inflammatory changes in the mucosa of the gallbladder.

Accounts for 75% of cases

Question 6

What does the gallblader do?

Answer 6

Stores and released bile. Breaks down fats

Question 7

Where does bile come from?

Answer 7

Liver

Question 8

The patient with gallbladder disease resulting from gallstones may develop two types of symptoms

Answer 8

1. Those due to disease of gallbladder itself
2. Those due to obstruction of the bile passages by a gallstone/

Symptoms may be acute or chronic.

Question 9

What is released from the pancreas?

Answer 9

Lipase Actin, Trypsin

Question 10

What may occur because of these stones?

Answer 10

Epigastric didstres, such as fullness, abdominal distention and vague pain in the upper right quadrant of the abdomen

Question 11

What happens if the gallstone obstructs the cystic duct?

Answer 11

the gallbladder becomes distended, inflamed, and eventually infected. Develops a fever and palpable abdominal mass.

Question 12

What is bilary colic?

Answer 12

Occurs if gallstone obstructs the CBD . this results in excruciating upper right abdominal pain that radiates to the back or right shoulder.

This is usually associated with N/V and noticeable several hours after a meal.

Question 13

Cholelithiasis Risk Factors

Answer 13

Cystic Fibrosis

Diabetes

Frequent Changes in Weight

Ileal REsection or Disease

Low-Dose Estrogen Therapy

Obesity

Rapid Weight Loss

Question 14

When does Jaundice occur?

Answer 14

Due to the obstruction of the common bile duct.

Bile is no longer carried to the duodenum, which is absorbed by the blood, and gives the skin and mucous membranes a yellow color. Accompanied with itching of the skin

Question 15

Urine Color because of blockage?

Answer 15

Feces are no longer colored with bile pigments, appear grayish or clay colored

Urine also presents a dark color.

Question 16

Obsturction of bile flow intereferes with absorption of

Answer 16

fat soluble vitamins A, D, E, and K.

Question 17

What diagnostic studies may be performed in patients with bilary disorders?

Answer 17

Magnetic Resonance Cholangiopancreatography (MRCP)

Cholecystogram, Cholangiogram

Celiac Axis Arteriography

Laparoscopy

Ultrasonography

Helical Computed Tomography and MRI

Endoscopic Retrograde Cholangiopancreatography

Endoscopic Ultrasound

Serum Alkaline Phosphate

Gamme-Glutamyl, Gamma-Glutamyl Transpeptidase, Lactate Dehydrogenase

Cholesterol Levels

Question 18

What does MRCP do?

Answer 18

Visualizes the biliary tree and capable of detecting biliary tract obstruction

Question 19

Use of CHolecystogram?

Answer 19

Visualize gallbladder and bile duct

Question 20

Use of Celiac Axis Areriography

Answer 20

Visualize liver and pancreas

Question 21

Use of Laparoscopy

Answer 21

Visualize anterior surface of liver, gallbladder, and mesentery through a trocar

Question 22

Use of Ultrasonography

Answer 22

Show size of abdominal organs and presence of masses

Question 23

Use of Helical CT and MRI

Answer 23

Detect neoplasms;

Diagnose cysts, pseudocysts, abscess, and hematomes.

Determines severity of pancreatitis based on presence of necrosis.

Question 24

Use of Endoscopic retrograde cholangiopancreatography

Answer 24

Visualize bilary structures and pancreas via endoscopy

Question 25

Use of endoscopic ultrasound?

Answer 25

Identify small tumors

Question 26

Use of Serum Alkaline Phosphatase

Answer 26

In absence of one disease, measure biliary tract obstructurtion

Question 27

Why is Gamma-Glutamyl, Gamma-Glutamyl Transpeptidase, Lactate Dehydrogenase used?

Answer 27

MArkers for biliary stasis; also elevated in alcohol abuse

Question 28

Cholesterol levels in biliary obstruction and parenchymal liver disease?

Answer 28

Elevcated in biliary obstruction

Decreased in parenchymal liver disease

Question 29

Abdominal X-Rays and Gallstones

Answer 29

This may be obtained to exclude other symptoms. However, only 10-15% of gallstones are calcified sufficiently to be visible on such X-Ray studies

Question 30

Gallstones and Ultrasonography

Answer 30

Rapid and accurate and can be used with patients with liver dysfunction and jaundice. Most accurte if you fast overnight so gallbladder is distended. 90% accuracy to detect calculi in gallbladder or dilated common bile duct.

Question 31

Gallbladder and Cholescintigraphy

Answer 31

This is used succesfully in diagnosis of acute cholecytitis or blockage of a bile duct.

Radioactive agent administerd through IV which is taken through hepatocytes and excreted through biliary tract. Biliary tract then scanned. More expensive and exposed pt to radiation. Used when ultrasonography is not conclusive.

Question 32

Gallbladder and Oral Cholecystography

Answer 32

Used if Ultrasound equipment not available.

Iodine contast given 10-12 hours before X-Ray study. Normal gallbladder fills with thise radiopaque substance. If gallstones present, they appear as shadow on Xray image

May be used as part as evaluation for those who have been treated with dissolution therapy (use of medications to break up/dissolve gallstones) or lithotripsy (disintegration of gallstones by shock waves)

Question 33

Gallstones and Endoscopic Retrograde Cholangiopancreatography (ERCP)

Answer 33

Permits direct visualization of structures that previously could be seen only during laparotomy. Views the hepatobiliary system via a side-viewing flexible fiberoptic endoscope inserted through esophagus to the descending duodenum.

Fluroscopy and multiple x-rays are used during ERCP to evaluate presence and location of ductal stones. Catheter goes through endoscope into the common bile duct for gallstone extraction.

Patient takes nothing by mouth for several hours before the procedure. Moderate sedation is used.

Not recommended for the evalution of suspected common bile duct stones but can be used to reat confirmed choledocholithiasis

Question 34

What is Percutaneous Transhepatic Cholangiography (PTC)?

Answer 34

Rarely used. Reserved for those where ERCP is unsafe due to previous surgery involving biliary tract. Has been replaced by ERCP and MRCP

Involves the injection of dye directly into the biliary tract. Pt is under moderate sedation while also fasting. Needle inserted to liver from right side. Successful entry noted when bile is aspirated or on injection of contrast iagent. Bile isaspirated and samples are sent for bacteriology.

Water soluble contrast agent injected to fill biliary system. Multiple x-rays taken. Delayed x-ray views can identify abnormalities of more distant ducts. Before removal, as much dye and bile as possible are aspirated.

Question 35

What is Cholecystectomy and Laparoscopic Cholecystectomy?

Answer 35

Cholecystectomy is the removal of the gallbladder. Has been replaced by Laparoscopic Cholecystectomy. That is the removal of the gallbladder through a small incision through the umbilicus.

Question 36

Medications for Cholelithiasis

Answer 36

Ursodeoxycholic Acid and Chenodeoxycholic Acid

Question 37

Best way to remove a gallbladder stone?

Answer 37

Laproscopic cholecystectomy

Question 38

Diet after removing a stone?

Answer 38

Low-fat fluids. Cooked Fruits, Rice, Tapioca, Lean Meats, Mashed Poptatoes, Non-Gas Forming Vegetables, Bread, Coffee

Pt should avoid eggs, cream, pork, friend foods, cheese, rich dressings, gas-forming vegetables, and alcohol. Fatty foods may induce an episode of cholecystitis

Question 39

Why are Ursodeoxycholic Acid (UDCA) and Chenodeoxycholic Acid (CDCA) used?

Answer 39

Have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol.

UDCA has fewer side effects. Acts by inhibiting the synthesis and secretion of cholesterol. 6-12 months therapy is required. This method is indicated for patients who refuse surgery or for whom surgery is contraindicated

Question 40

Why is MTBE used?

Answer 40

It is a solvent that is used to dissolve gallstones.

Solvent can be infused throgh: a tube or catheter inserted percutaneously directly into the gallbladder; Through a tube or drain inserted through a T-tube tract to dissolve stones not removed at the time of surgery; endoscopically with ERCP; or via a transnasal bilary catheter

Question 41

What is the first method for removing a stone by instrumentation?

Answer 41

A catheter and instrument with a basket attacched are threaded through the T-tube tract or fistula formed at the tibe of T-tube insertion; the basket is used to retrieve and remove the stones lodged in the common bile duct

Question 42

What is the second method for removing a stone by instrumentation?

Answer 42

ERCP endoscope.

After endoscope inserted, cutting instrument is passed through the endoscope into the ampulla of Vater of the common bile duct. Another instrument with a small basket or balloon at its tip may be inserted through the endoscope to retrieve the stones.

Useful in diagnosis and treatment of patient who may have syptoms after biliary tract surgery, pts with intact gallbladders, and patients for whom surgery is particularly hazardous

Question 43

What is Intracorporeal Ltihotripsy?

Electrohydraulic Lithotripsy?

Answer 43

THis is laser pulse technology. Laser pulse directed under fluroscopic guideance that can distinguishes stones and tissue. Produces mechanical shock wave.

Electrohydraulic Lithotripsy uses probe with two electrodes that deliver electric sparks creating expansion of liquid environment surrounding gallstones. Results in pressure waves that cause stones to fragment. This can be done percutaneously with a basket or balloon catheter system or by direct visualization through an endoscope.

Question 44

What is Extracorporeal Shcok Wave Lithotripsy?

Answer 44

Used for nonsurgical fragmentation of gallstones. Uses repeated shock waves directed at the gallstone in the gallbladder or CBD to fragment it.

Waves transmitted to body through fluid-filled bag or by immersing patient in water bath. After they’re broken up, fragments can be spontaneously passed from gallbladder or CBD, removed by endoscope, or dissolves with oral bile acid.

Question 45

What is done Preoperatively?

Answer 45

Chest X-Ray, Electrocardiogram, and Liver Function tests may be performed in addition to imaging studies.

Vitamin K may be given. Education is important.

Question 46

Where might pain be felt in a patient after laparoscopic surgery?

Answer 46

Right shoulder or scapular surgery

Heating pad is recommended for 15-20 minutes hourly

Question 47

What is Cholecystectomy?

Answer 47

Gallbladder is removed through an abdominal incision after the cystic duct and artery are ligated.

Question 48

What is Choledochostomy?

Answer 48

REserved for the patient with acte cholecystitis who may be to ill to undergo a surgical procedure. Incision in the common duct, usually for removal of stones. After stones evacuated, tube inserted into the duct for drainage of bile until edema subsides

Question 49

What is Laparoscopic Cholecystectomy?

Answer 49

Standard of therapy for symptomatic gallstones. If CBD is thought to be obstructed,ERCP with sphincterotomy may be performed.

Small incision or puncture made through abdominal wall at the umbilicus. Abdominal CAvity insufflated with CO2 to assist with inserting laparoscope. Fiberoptic scope is inserted through small umbilical incision. Cystic duct is dissected and CBD is vidualized by ultrasound or cholangiography. Cystic artery is dissected free and clipped. Gallbladder separated from the hepatic bed. Stone forceps can also be used to remove or crush larger stones.

Conversion to open procedure occurs if there in inflammation around gallbladder.

Pts are drowsy afterwards.

Question 50

What is a Cholecystectomy?

Answer 50

Gallbladder removed through an abdominal incision after the cystic duct and artery are ligated.

Drain can be placed close to gallbladder bed is there is a bile leak. Drain is typically maintained if there is excess oozing or bile leakage.

Question 51

What is Small-Incision Cholecystectomy?

Answer 51

Surgical procedure in which gallbladder is removed through a small abdominal incision. Can also be used to remove larger gallbladder stones. Drains may or may not be used.

Controversial because it limits exposure to all involved biliary structures

Question 52

What is a Choledochostomy?

Answer 52

Reserved for pt with acute cholecystitis and may be too ill to undergo a surgical procedure.

Incision made in the common duct, usually for removal of stones. Tube inserted after for drainage of bile until edema subsides. Laparoscopic cholecystectomy is planned for future date after acute inflammation has resolved

Question 53

What is Surgical Cholecystostomy?

Answer 53

Cholecystostomy performed when patients condiiton precludes more extensive surgery or when acute inflammatory is severe.

Gallbladder surgically opened, stone and bile removed, and drainage tube is secured with a purse-string suture.

Drainage tube connected to drainage system to prevent bile from leaking. AFter recovery from acute episode, patient may return for laparoscopic cholecystectomy

Question 54

What is Percutaneous Cholesystostomy?

Answer 54

Percutaneous cholecystostomy has been used in treatment and diagnosis of acute cholecystitis in patients who are poor risks for any surgical procedure or for general anesthesia.

Under anesthesia, a fine needle is inserted through abdominal wall and liver edge into gallbladder under guideance of ultrasound or CT. Bile is aspirated to ensure adequate placement of needle and catheter inserted into gallbladder to decompress biliary tract.

Question 55

Symptoms of biliary tract disease in older adults includes signs of

Answer 55

Septic shock, oliguria, hypotension, AMS, tachycardia, and tachypnea

Question 56

After surgery, patient is encouraged to eat what type of diet?

Answer 56

That is low in fats and high in carbs and proteins.

Fat restriction is lifted in 4-6 weeks.