Gallbladder and pancreas

Question 1

What is the role of the gallbladder?

Answer 1

it stores bile and delivers it to the SI

Question 2

Inflammation of the gallbladder can lead to 3 things:

Answer 2

1. gallstones (cholelithiasis)
2. tumours
3. scarring of the bile duct

Question 3

what are 4 risk factors of gall stones?

risk factors for cholesterol gall stones?

risk factors for bilirubin stones?

Answer 3

for gall stones:
1. female
2. rapid weight loss
3. obesity
4. native american and other ethnic groups

for cholesterol gall stones:
1. inflammatory bowel disease
2. diabetes
3. cystic fibrosis
4. bariatric surgeries
5. fat restricting diets
6. cholesrerol lowering medications

for bilirubin stones:
1. liver disease
2. blood disorders (sickle cell anemi)

Question 4

formation of gall stones can occur in 2 places:

Answer 4

1. gallbladder
2. biliary duct

Question 5

what is biliary sludge?

Answer 5

cholesterol crystal + calcium salts

considered a precursor to gall stones (softer and more gel like)

Question 6

what is biliary stasis?

Answer 6

slowdown of bile flow from the liver to the gall bladder

Question 7

what are the 3 types of cholelithiasis (gall stones)?

Answer 7

1. cholesterol stones (80% of cases) - when bile becomes supersaturated with cholesterol, it crystallizes and forms gallstones
2. pigment stones - bilirubin + calcium salts
3. mixed stones

Question 8

___ % of patients with gall stones are asymptomatic

Answer 8

70%

Question 9

what is the most common treatments for gall stones?

Answer 9

laparoscopic cholecystectomy

Question 10

what are 4 causeses of gallstones?

Answer 10

1. too much absorption of water from bile
2. too much absorption of bile acids from bile
3. too much cholesterol in bile
4. inflammation of epithelium

Question 11

what is choledocholithiasis?

Answer 11

biliary obstruction

when gall stone lodges in common duct or head of pancreas

it is secondary to biliary cirrhosis

bile pigments ends up in urine, RUQ pain, clay coloured stool, madigestion of fat. if not corrected, biliary back up can lead to jaundice, liver damage, stenosis

Question 12

what is cholecystitis?

Answer 12

inflammation of the gallbladder secondary to obstruction, infection, and ischemia

Question 13

what is cholangitis?

Answer 13

inflammation of the biliary ducts secondary to obstruction of the common bile duct

Question 14

what are the nutritional implications of cholelithiasis

Answer 14

indigestion
decreased ability to digest fat
increased ab gas
diarrhea post surgery

Question 15

what nutrition assessment do you do for cholelithiasis?

Answer 15

weight
weight history
diet
lab values
medications

Question 16

what are the nutrition interventions for cholelithiasis?

Answer 16

1. low fat (< 30% energy as fat)
2. modest protein until surgery
3. small frequent meals until surgery
4. inactive during acute attacks - NPO - advance ow fat liquids
5. post surgery - return to normal diet - may take some time to adjust

Question 17

what is the exocrine function of the pancreas?

Answer 17

to secrete enzymes and other substances directly into the intestinal lumen.

Helps aid in digestion of protein, fats, CHO

Question 18

What are 5 factors that stimulate pancreas secretion?

What are 5 factors that inhibit pancreas secretion?

Answer 18

stimulating factors:
1. CCK –> lipase, amylase, protease, bicarb fluid, gall bladder contraction
2. secretin
3. gastrin
4. VIP
5. cephalic phase of eating

inhibiting factors:
1. GLP1
2. PP
3. YY
4. OXM

Question 19

what are the 3 stages of acute pancreatitis pathophysiology?

Answer 19

1. autodigestion via prematurely activated enzymes (get into blood stream)
2. immune cell and cytokine activation –> inflammatory response
3. inflammation –> fascular permeability –> hemorrhage

Question 20

What is pancreatitis?

Answer 20

inflammation of the pancreas

Intrapancreatic activation and release of enzymes causing autodigestion of pancreas and surrounding areas

Can be acute or chronic

Question 21

Pancreatitis is characterized by 4 things:

Answer 21

1. edema
2. fat necrosis
3. autodigestion
4. hemmorhage of pancreatic tissue

Question 22

Which endocrine disorder can be linked to pancreatitis?

Answer 22

diabetes!

Question 23

what are 5 aspects of pancreatitis presentation?

Answer 23

1. ab pain/nausea/vomiting
2. +/- ilius of stomach or intestine
3. pain in LUQ radiating to midback
4. distended, tender ab
5. +/- fever
6. steatorrhea

Question 24

acute pancreatitis can be classified as:

Answer 24

mild
moderate
severe

acute interstitial vs. acute hemmorhagic

Question 25

how do you diagnose acute pancreatitis?

Answer 25

symptoms labs imaging

Question 26

what is the difference between acute interstitial pancreatitis and acute hemorrhagic pancreatitis?

Answer 26

acute interstitial: - 80-85% - gland architecture is preserved but edematous - lots of inflammatory cells acute hemorrhagic pancreatitis: - 15-20% - marked necrosis - fat necrosis - vascular inflammation and thrombosis

Question 27

what are 5 common causes of acute pancreatitis?

Answer 27

1. gallstones 2. alcohol 3. ERCP 4. trauma (blunt ab trauma) 5. drugs

Question 28

what are the common causes of pancreatitis?

Answer 28

IGETSMASHED idiopathic gallstones ethanol (alcohol) trauma steroids malignancy/mumps autoimmune scorpion stink hypercalcemia ERCP drugs

Question 29

What are 5 signs and symptoms of acute pancreatitis?

Answer 29

1. ab pain 2. worsening pain with food intake 3. nausea vomiting 4. low grade fever

Question 30

what are diagnostic markers of acute pancreatitis?

Answer 30

elevated pancreatic enzymes (amylase and lipase) 3x higher than high end of normal

Question 31

what do we use to diagnose acuse pancreatitis?

Answer 31

CT MRI

Question 32

how do you treat acute pancreatitis?

Answer 32

remove cause (gallstone or alcohol). if mild: - IVF for rehdyration and electrolyte replacement - BP management - analgesics for pain - Oral feeding as tolerated after nausea/vomiting subsides - Often NPO for up to a week, then slow intro of O - start with low fat oral diet and small meals to limit exocrine function - ead up to 1.2-1.5 g of protein per day and 25-35 cals/kg/day if moderate/severe: - antibiotics, NPO, nutrition support within 1-2 days as soon as patient is stable - standard polymeric formula

Question 33

how much protein to have for acute pancreatitis?

Answer 33

1.2-1.5 g

Question 34

how much calories to have for acute pancreatitis?

Answer 34

25-35 kcal/kg

Question 35

what are 4 nutrition implications of pancreatitis?

Answer 35

1. high metabolic state 2. digestive capacity 3. steatorrhea 5. vitamin D and E (fat soluble)

Question 36

what route do you feed in severe AP?

Answer 36

ideally gastric route. if patient doesnt tolerate that, then NJ route or jejunum (below ligament of treitz)

Question 37

how do you initiate feed for acute pancreatitis

Answer 37

within 1-2 days continuous rate standard polymeric formula

Question 38

how has feeding for acute pancreatitis evolved?

Answer 38

used to be that we fed TPN then jejunal now say can feed NG - there is no difference

Question 39

when should you start eating again after acute pnacreatitis? chronic pancreatitis?

Answer 39

acute pancreatitis = 3-7 days after pain has stopped chronic pancreatitis = as soon asyou can foods containing fat should be reintroduced slowly

Question 40

Is chronic pancreatitis reversible?

Answer 40

no

Question 41

Chronic pancreatitis can be characterized by:

Answer 41

1. fibrosis 2. calcification/stones 3. loss of islet and acinar cells 4. ab pain 5. exocrine/endocrine insufficiency 6. pain (increased by food and alcohol intake)

Question 42

exocrine/endocrine insufficiency during chronic pancreatitis is associated with 3 items:

Answer 42

1. steatorrhea 2. weight loss 3. malnutrition

Question 43

What are 5 risk factors of chronic pancreatitis?

Answer 43

1. toxic metabolic (alcoholism, smoking, hypertriglyceridemia) 2. genetic mutations 3. autoimmune pancreatitis 4. obstructive (i.e. cancer) 5. idiopathic

Question 44

Why does exocrine insufficiency occur in CP?

Answer 44

there is a loss of acinar cell mass OR pancreatic duct obstruction this leads to: 1. decreased digestive enzyme levels 2. decreased ductal bicarbonate secretion

Question 45

what are 5 ongoing nutrition issues with exocrine insufficiency in CP?

Answer 45

1. glucose control (30-50% have DM) 2. maldigestion 3. steatorrhea (lipase < 10% norm) 4. need enzyme supplements like lipase, protease, amylase (cotazyme or viokase) 5. chronic anorexia

Question 47

what is the metric for diagnosing steatorrhea

Answer 47

fecal fat excretion > 7 g/day *occurs when pancreatic lipase secretion <10% normal

Question 48

what is the primary cause of weight loss in CP

Answer 48

fat maldigestion

Question 49

what is amylorrhea

Answer 49

excess starch in stool occurs when there is carb maldigestion in exocrine insufficiency in CP

Question 50

what is azotorrhhea

Answer 50

excess nitrogen in urine occurs when there is protein maldigestion in exocrine insufficiency in CP

Question 51

what is normal fecal fat?

Answer 51

2-7 g fat/24 hours > 7 g fat/24 hours, when taking 100-150 g/day is suggestive of malabsorption

Question 52

what is the 3 pronged approach to managing CP?

Answer 52

1. PERT (pancreatic enzyme replacement therapy) 2. assess and correct nutrition deficiencies 3. avoid alcohol and maintain adequate diet Other suggestions: - surgery - pain management - endoscopic treatment to remove stones, place stents may not require NS - it will depend on endo/exo function

Question 53

how to use PERTS to manage CP?

Answer 53

can be enteric coated vs uncoated - coating helps with digestion of protein, starch, and fat use with gastric acid suppressants like PPIs have them with meals

Question 54

what are the nutrition recommendations for CP?

Answer 54

goal - minimize and prevent further damage high energy - 35 cal high protein - 1.2-1.5 g/kg Fat usually doesnt need to be restricted if on PERT. but if steatorrhea persists, restrict fat in diet try MCT oil!! ongoing assessment medication to reduce gastric acid secretion

Question 55

MCT oil is recommended to help treat:

Answer 55

Chronic pancreatitis