Gallstones and Pancreatitis

Question 1

What are the 4 things bile id composed of?

Answer 1

1. bile acids and salts
2. cholesterol
3. phospholipids
4. bilirubin

Question 2

What is cholelithiasis?

Answer 2

Gallstones

Question 3

What are the 2 types of gallstones?

Answer 3

1. cholesterol stones (most common)
   Yellow, form due to solubility issues…high concentration of bile acids = better cholesterol solubility = lower stone formation
2. mixed, with bilirubin pigments
   black, grey

Question 4

What are the factors associated with cholesterol stones?

Answer 4

• female
• genetics
• drugs
• long term TPN
• diabetes
• obesity
• weight reduction

Question 5

What are the factors associated with bilirubin stones?

Answer 5

• chronic hemolysis
• TPN
• thalassemia
• cirrhosis
• age

Question 6

What is cholecystitis?

Answer 6

inflammation of the gallbladder

Question 7

What are the 4 causes of gallstones?

Answer 7

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 8

What is choledochilithiasis?

Answer 8

Stones that block the gallbladder outlet

Question 9

What are the symptoms of acute cholecystitis?

Answer 9

• fever
• pain upon coughing
• tender over gallbladder area

Question 10

What is the common biochemistry?

Answer 10

• infection: CBC
• jaundice or obstruction: bilirubin
• inflammation: CRP or ESR
• general health: electrolytes, glucose, CBC

Question 11

What is the main complication of cholelithiasis and what are the symptoms?

Answer 11

choledochilithiasis

• dark urine
• clay colored stool
• severe upright quadrant pain
• jaundice
• pancreatitis

Question 12

What are the complications of cholecystitis?

Answer 12

• secondary to obstruction, infection and ischemia
• perforation of gallbladder, peritonitis
• perforation into another organ
• fistula to duodenum, colon
• infection through ducts to liver, abscesses

Question 13

What are the indications for low fat diets?

Answer 13

• fat malabsorption and maldigestion
• cholecystitis
• pancreatitis

Question 14

How do you determine fluid needs?

Answer 14

1ml/kcal

Question 15

How much % energy should come from fat and how many g of fat is in 25g of meat?

Answer 15

30%

25g meat = 2g fat

Question 16

What are the 5 treatments possible?

Answer 16

• surgery (cholecystectomy): low fat diet first, then return to healthy normal diet
• medications for small stones and functioning gallbladder (ex: chenodiol and ursodiol - bile acids which help dissolve the stone)
• ultrasound (lithotripsy)
• laparascopic cholecystectomy
• percutaneous cholecystostomy drainage of gallbladder
• biliary stents to clear ducts (ERCP)

Question 17

What are the guidelines for the morning of the surgery?

Answer 17

Do not eat any food

Drink 1 CHO drink (50g) QUICKLY (in 5min)

Question 18

What are the alternative medicines for gallstones (2)?

Answer 18

• peppermint (dissolves gallstones)

- tumeric (improves liver function)

Question 19

What is the enzyme responsible for the autodigestion of the pancreas?

Answer 19

trypsinogen

Question 20

Chyme stimulates intestinal production of what 2 molecules?

Answer 20

secretin and CCK

Question 21

What is pancreatitis characterized as (3 things)?

Answer 21

• edema
• cellular exudate
• fat necrosis

Question 22

What are some of the symptoms of pancreatitis?

Answer 22

• autodigestion, necrosis, hemorrhage of pancreatic tissue
• upper abdominal pain radiating to back
• nausea, vomiting, abdominal distention, steatorrhea
• hypotension and dehydration

Question 23

What are the 3 main causes of acute pancreatitis?

Answer 23

• biliary tract disease/cholelithiasis
• alcoholism
• idiopathic

Question 24

What are the symptoms of acute pancreatitis?

Answer 24

• abdominal pain, nausea, vomiting
• SIRS, shock, fever, edema
• high blood levels of pancreatic enzymes
• high liver enzymes
• low blood calcium
• high TG

Question 25

What diet do we give someone with acute pancreatitis?

Answer 25

Low fat high carb and high protein foods
Clear fluids to begin with
No alcohol
Frequent small meals

Question 26

What are the 4 main causes of chronic pancreatitis?

Answer 26

• alcoholism
• cystic fibrosis
• chemical exposures
• recurrent acute

Question 27

How does alcohol cause chronic pancreatitis?

Answer 27

It damages acinar cells, stimulates secretin with induction of spasms in ducts, precipitation of protein in ducts

Question 28

What are the symptoms of chronic pancreatitis?

Answer 28

• abdominal pain
• malabsorption, steatorrhoea
• weight loss
• progression of high pancreatic enzymes followed by low concentrations

Question 29

What is the diet for chronic pancreatitis?

Answer 29

Low fat, high protein
CHO depends on islet function
No alcohol
Fat-soluble vitamins and B12

Question 30

What are the 3 common nutritional problems in acute severe pancreatitis?

Answer 30

• hyperglycemia and insulin resistance
• hyperTG
• electrolyte and micronutrient deficiencies

Question 31

What is the nutrition support for acute pancreatitis?

Answer 31

EN:
25kcal/kg
PRO 1.5g/kg
HB x 1.39
With sepsis (HB x 1.39+1.15)
Initiate within 48-72h admission
Initiate at 25ml/h, advance to reach 25kcal/kg over 24-48h

PN - only 5 days after admission
PRO 1.2-1.5g/kg
Intralipid less than 15-30% of kcal - give when TG<4.52mmol/L

Question 32

What is the nutrition support for chronic pancreatitis?

Answer 32

• don’t give extremely low fat…tolerance is the goal
• pancreatic enzymes have to be taken with food
• avoid alcohol, coffee, tea, spices
• treat with insulin if indicated

Question 33

What are the pancreatic enzyme replacement doses?

Answer 33

500-2500 U lipase/kg/meal
<10,000 U lipase/kg/d
1000-4000 U lipase/1g dietary fat per day at meals and snacks
**swallow without crushing, they only work if the pH is high enough, so must give antacids