Gallbladder Flashcards
main functions of bile
Bile has two main functions:
• Aiding in digestion
• Eliminating certain waste products (mainly hemoglobin and excess cholesterol) from the body
bile is __ end-product
bile is cholesterol end-product
how are cholic acid and chenodeoxycholic acid turned into bile salts
cholic acid and chenodeoxycholic acid are conjugated with AA (glycine and taurine) to create primary bile salts
bile acid malabsorption leads to _
bile acid malabsorption leads to diarrhea
what can be done if the regular 95% of bile acids are not reabsorbed e.g. due to ileum issues
meds can be taken to help absorb bile salts
if a lot is lost, body can make more, but there will be consequences (e.g. gallstones)
how is gallbladder connected to the liver
via biliary tract
what is biliary tract/tree
a system of vessels that directs digestive juices from the liver, pancreas, and gallbladder through a bile duct into the small intestine.
describe the structure of biliary tree /flow of bile form liver
the liver makes bile and moves it via the common hepatic duct into the cystic duct, the 2 merged together to form a common bile duct which leads to the pancreatic duct
gallstones can block any of the ducts listed above
Bile leaves liver via __
Bile leaves liver via common hepatic duct
what causes the release of bile from the gallbladder?
Cholecystokinin (CCK) is released following food ingestion, and stimulates gallbladder to contract
CCK also tells Sphincter of Oddi to relax
functions of the gallbladder `
- Removal of water, increasing concentration
- Storage of bile
- Control of delivery of bile salts into small intestine
what is cholestasis
impaired bile flow
either due to bile flow being blocked or because liver isn’t producing enough
what is Cholelithiasis
• Cholelithiasis is the medical
term for gallstone condition
what is Cholecystectomy
• Cholecystectomy surgical removal of the gall bladder (-ectomy is a suffix = removal)
what is Cholecystitis
• Cholecystitis is inflammation of the gallbladder (-itis is a suffix = inflammation)
can pt eat fat and fat soluble vit after having gallbladder removed?
even if the gallbladder is removed, the patient will still be able to absorb fat-soluble vit, it will just take time for their bile production to get adapted to the new configuration
low fat diet has to be followed post-op for a couple of weeks and then pt can go back to eating fat (most of them, some don’t adapt)
Types of hepatobiliary disorders associated with PN (PNALD):
- Steatosis
- Cholestasis
- Gallbladder stones→cholecystitis
What nutritional strategies might prevent PNALD?
A. Avoid overfeeding B. GIR <8mg/kg/min C. Use Intralipid ILE D. Aim for <1g lipid/kg/d E. A & D only F. All of the above
E. A & D only
B. explained: GIR <5, preferably less than 3; not 8
D. explained
source of oil in intralipid is soybean
->high in omega-6-> proinflammatory
-> contains phytosterols that are similar to cholesterol-> can be used for bile production but it will be slow and inefficient-> can get inflamed
more than 1g can be administered if a better oil source is used
what strategies can be used to treat PNALD?
A. Encourage oral intake/EN to promote proper bile circulation
B. Cycle PN to give liver a break from being stimulated by insulin in response to PN
C. Decrease ILE <1g/kg/d
D. Decrease dextrose
E. All of the above
E. All of the above
PN is cycled to give liver a break from being stimulated by insulin in response to PN
what are the possible constituents of gallstones?
- cholesterol (most common),
* bile salts, bile pigments or both
Cholethiasis symptoms
- Some stones are small-> asymptomatic
* Large stones-> Inflammation (cholecystitis), obstruction (stones get squeezed-> get stuck)
what are the 3 types of stones
• Cholesterol common (80%)
• Yellow stones: pure cholesterol (10%),
• Grey-white to black: pigment stones, mixed stones very rare
mostly precipitate
Describe the most common type of gallstones
Cholesterol common (80%)
o Cholesterol is insoluble in water. Normally it is overcome by phospholipids
and bile salts.
o Brown yellow in color
o Too much cholesterol-> cannot be corrected by phospholipids and salts-> CH precipitates
o The concentration of phospholipids and bile salts relative to cholesterol is thought to be the critical factor in determining the solubilization and saturation of cholesterol.
o Supersaturated bile can lead to precipitation of cholesterol crystals
Describe Yellow stones
Yellow stones: pure cholesterol (10%),
• Typical cholesterol stones, yellow, brown and green
Describe Grey-white to black stones
- Grey-white to black: pigment stones, mixed stones
- very rare
- mostly precipitate, not stones
- Bilirubin, cholesterol plus calcium carbonate, phosphates
potential 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
factors resulting in developing bilirubin pigment stones
will be found in someone who has problems with RBC very rare o Hemolytic anemia o Thalassemia genetic o Cirrhosis o TPN o Cystic fibrosis
Factors associated with cholesterol stones
not causes, but increase the risk o Heredity o Western diet o Cholesterol hypersecretion: - Female sex (estrogen) - Drugs (cholesterol lowering meds) - Obesity (cholesterol synthesis) - Rapid weight reduction (mobilisation of tissue cholesterol) o Gallbladder stasis: - Long-term TPN (biliary stasis) - Pancreatic insufficiency o Decrease in bile acids - Ileal disease (e.g., Crohn’s disease) o Disease states: - Diabetes (T2 pt tend to be overweight-> high blood TGs)
Types of diagnostic tests and their descriptions
• Ultrasonography: usually 1st test
• Plain x-ray of abdomen
- Only 10% of stones are radio-opaque
•Cholecystogram
- Radio-opaque die given orally, dye excreted by liver and into gallbladder, x-ray
•Endoscopic retrograde cholangiopancreatography (ERCP)
- Allows for evaluation of the biliary ducts
- can also sample tissue, mechanical lithotripsy
- can clear ducts using sphincterotomy
- often used for treatment, not diagnosis as it is very invasive
•Cholangiography x-ray with a dye
ERCP basics
- Diagnose and treat problems of the biliary tract.
- Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and pancreatic ducts
What is Choledocholithiasis and its consequences
Choledocholithiasis = Gallstone passes through the cystic duct and lodges in common bile duct or in the head of the pancreas
- Bile no longer carried into the duodenum pain
- Excretion of bile pigments in urine.
Choledocholithiasis symptoms
• Dark-colored urine (due to bilirubin accumulation-> builds up in the blood-> excreted by kidneys)
• Clay-colored stool
• Marked disturbance digestion and absorption of lipids
• Severe upper right quadrant pain
• Jaundice and liver damage: If uncorrected
• Pancreatitis: If stone blocks ampulla of
Vater
What are the causes of cholecystitis
Inflammation of the gallbladder
Typical cause: usually stones (obstruction of the cystic duct)
Other causes: • Infection • Ischemia • critical illnesses • sepsis • shock • burns • cancer
Symptoms of cholelithiasis, cholecystitis and choledocholithiasis
• Pain in epigastrum near mid-line, radiates around to scapula region, constant (upper R quadrant)right upper
quadrant
• Nausea, sweating
Additional symptoms: acute cholecystitis ◼ Fever ◼ Pain upon coughing ◼ Tender over gallbladder area ◼ Vomiting not as common (can still be present)
choledocholithiasis medical treatment
- ERCP is the most common treatment
- Medication (oral) -for smaller stone and functioning gallbladder: Chenodiol and ursodiol (bile acids) dissolve the stone (18-24 mo.)
- Ultrasound (lithotripsy) mechanical fragmentation using shock wave and laser beams; it can then be
- Laparoscopic-cholecystectomy: removal of gallbladder
- Percutaneous cholecystostomy: Percutaneous cholecystostomy is a minimally invasive image-guided intervention performed under local anesthesia consisting in the placement of a catheter in the gallbladder lumen with the purpose of decompressing the gallbladder, reducing the patient’s symptoms and the systemic inflammatory response
- ERCP with sphincterotomy, stents
Patient is diagnosed with cholecystitis, most
common cause:
A. Cystic duct obstruction
B. Common bile duct obstruction serious and painful
C. Obstruct of pancreas
A. Cystic duct obstruction
In case of Common bile duct obstruction we will see dark urine and clay coloured stool-> more serious and painful
Diet that is recommended for pt with gallstones
- Low fat diet <30% total kcal as fat to relieve symptoms (pain,steatorrhea)
- Follow low-fat diet before surgery or other tx (e.g., ERCP)
- Following a very low-fat diet can cause more stones to form!
Is low fat diet that is recommended to pts with gallstones nutritionally adequate?
- Usually adequate (follows AMDR)
- Fat soluble vitamins need monitoring or use water-miscible form if long-term symptoms; but generally the diet is nutritionally complete
- High fibre may help to prevent stones from forming (soluble fiber binds cholesterol in the intestine, preventing it’s absorption)
What is the cause of acute attack?
usually an obstruction (cystic or common bile duct)
What is the treatment in acute attack?
NPO and bowel rest (goal = inactive gallbladder)
Is PN required in acute attack?
assess the nutritional risk to decide
• Consider inadequate intake past 7 d (many of them are in pain and haven’t been eating for a while)
• Indigestion, decreased ability to digest fat, and increased abnormal pain = decreased food intake and altered nutritional status
• Significant weight loss
• do SGA/NRS screen
• PN will not be appropriate in pts who are going for surgery right away in acute attack, decision for surgery is usually made in 24-48h
Is Laparoscopic cholecystectomy invasive
not at all
what is removed, what is left in Laparoscopic cholecystectomy?
gallbladder removed
liver and bile duct is left
Pre-surgery guide
Evening before:
do not want them fasted, otherwise can lead to insulin resistance
• fed state prevents insulin resistance e
• Eat/drink normally up until midnight.
• Clear fluids up to 2 h prior to surgery
• sometimes are asked 100g of CHO night before surgery (carb loading)-> 100g in juice
• No carb loading in diabetic pts
Morning of surgery
• Do not eat any food
• Drink 1 CHO drink* (50 g CHO) QUICKLY (5 min) 2-3 h b/f surgery
Maltodextrin reccs in surgery
we want pts to be in fed state during the surgery to avoid insulin resistance and surgical stress response-> administer maltodextrin
WHAT: 50g maltodextrin
• Commonly seen:
50g sachet, diluted in 400ml, with osmolality of 260-285 mOsm/kg
• WHEN: 2 hours before induction
• HOW? No Sipping- has to be drank at once as siping will not induce fed state
post-surgery diet
- pt can eat anything they want
because liver and biliary tract are still there -> fat digestion is possible
hospital diet is also low in fat and pts won’t eat all of it, thus they can eat regular diet
ONS post-op
Nutrition support reserved for:
- Severe cases such as pancreatitis or - Extended postoperative period and bowel rest are indicated.
Post-discharge diets
• Low fat diet initially, then return to healthy “normal” diet
• Patient likely did NOT follow healthy diet before. Will need tips for “normal” diet
• After surgery most patients will adapt to regular diet
- Bile from liver continues to enter duodenum via common bile duct
- May take several months to adjust to new bile flow
- Diarrhea is VERY common-> warn them about it
• Individual tolerance mediates amount of fat after cholecystectomy-> Reduce fat enough to relieve symptoms
• Restricted fat diet provides ~30% of energy
• Aim for modest animal protein intake; even plant protein has decent amount of fat (advice to decrease protein intake)
- 1oz or 25g lean meat=2g fat
even plant protein has
• Avoid high fat foods, fried foods
Post-discharge suggestions
- Small, frequent meals usually tolerated best initially
- Choose lean meat
- Trim fat from meat/poultry
- Grains/starches, little fat (<2g fat/serving). Limit baked goods.
- Fruit/veg, no fat
- Milk & milk products, choose low fat, aim for 1% to have some fat to help absorb fat-soluble vitamins
- Little added fats initially (0-1 tsp/meal may be tolerated)→ progress to 2-3 tbsp/d
- Fried fatty foods likely to cause discomfort
at first (but there are some pt in whom it will be forever protein intake) - Need to be flexible i.e., some foods allowed, but limited frequency e.g., regular cheese on one day, nothing else high in fat that day
- Low fat diet may be temporary
- Keep food diary and monitor symptoms
diarrhea treatment
- Soluble fibre
- Psyllium
- Adequate fluids
sources of soluble fibre
avocado apple barley carrots edamame oranges pears potatoes psyllium oat bran, oatmeal
• 11-year-old girl admitted with right quadrant epigastric pain
• Dx: cholecystitis
• Tx: scheduled for laparoscopic cholecystectomy (lap chole) tomorrow morning.
She is scheduled for surgery tomorrow, what might be the best dietary treatment today?
A. PPN
B. CPN would just
C. ONS
D. Low fat diet
E. NPO
E. NPO
it is acute and she is not malnourished-> NPO; more food would just cause more stress
