Hepatic System: Cholelithiasis and Bile Duct Issues

Question 1

What is Cholelithiasis?

Answer 1

• The presence of gallstones in the gallbladder

Question 2

What is Choledocholithiasis?

Answer 2

• The presence of at least one gallstone in the common bile duct

Question 3

What is Cholangitis?

Answer 3

• Redness, inflammation of the bile duct system

Question 4

What is Cholecystitis?

Answer 4

• Redness, inflammation of the gallbladder

Question 5

What is a Cholecystectomy?

Answer 5

• Removal of the gallbladder

Question 6

What causes gallstones to form?

Answer 6

• Gallstones may form if bile contains too much cholesterol, too much bilirubin, or not enough bile salts.
• They may also form if the gallbladder does not empty completely or often enough

Question 7

What are the 5 F’s that are risk factors for gallstones?

Answer 7

• Fair
• Fat
• Forty
• Fertile
• Female

Question 8

Why is fertility a factor in gallstone formation?

Answer 8

• Increased estrogen is thought to increase cholesterol levels in bile and decrease gallbladder contraction

Question 9

What are the clinical manifestations of cholelithiasis?

Answer 9

• 30 mins after eating there will be complaints of
  
  • Pain in the URQ
    
    • Fullness, abdominal distension, may occur after fatty meal
  • N/V
  • Leukocytosis
  • Sometimes fever

Question 10

When would acute s/s occur and what are they?

Answer 10

• They would occur with inflammation, obstruction or infection of the biliary organs.
• S/S
  
  • Fever
  • Palpable abdominal mass
  • Severe URQ pain that radiates back or to the right shoulder
  • N/V

Question 11

What is biliary colic?

Answer 11

• Biliary colic is a common presentation of a stone in the cystic duct or common bile duct of the biliary tree.
• Colic refers to the type of pain that “comes and goes,” typically after eating a large, fatty meal which causes contraction of the gallbladder.
• However, the pain is usually constant and not colicky.

Question 12

When do biliary colic episodes of severe pain with N/V usually occur?

Answer 12

• Several hours after a heavy meal

Question 13

What are two diagnostic tests for cholelithiasis?

Answer 13

• CT scan
• Murphy’s sign

Question 14

Explain Murphy’s Sign.

Answer 14

• Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area.
• If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive

Question 15

What are two drugs used to dissolve small gallstones?

Answer 15

• Ursodiol (on the drug list!)
• Chenodiol

Question 16

What is the cause of Cholangitis?

Answer 16

• Choledocholithias

Question 17

What is Charcot’s triad?

Answer 17

• Charcot’s triad is the manifestation of biliary obstruction with upper abdominal pain, fever and jaundice.

Question 18

What can Charcot’s triad advance to?

Answer 18

• Raynaud’s pentad

Question 19

What are the s/s of Raynaud’s pentad

Answer 19

• Same as Charcot’s triad with the addition of confusion and hypotension

Question 20

What is the treatment for Cholangitis?

Answer 20

• Correction of coagulopathy (obstruction)
• Restore fluid and electrolyte balance
• Abx
• Biliary drainage w/ Endoscopic Retrograde Cholangiopancreatography (ERCP)

Question 21

What is an Endoscopic Sphincterotomy?

Answer 21

• A procedure that cuts the sphincter between the common bile duct and pancreatic duct.
• This procedure uses a catheter and wire to remove gallstones or any other blockages

Question 22

What is an ERCP?

Answer 22

• ERCP combines X-rays and an endoscopic procedure to help doctors diagnose and treat gallstones and other bile or pancreatic duct problems

Question 23

Explain an ERCP with sphincterotomy procedure.

Answer 23

• Pass endoscope through mouth, esophagus, stomach and into the duodenum
• Pass into the sphincter of Oddi to access pancreatic and bile ducts
• Remove stones or stent narrow ducts

Question 24

If stones cannot be removed via endoscope, what is another procedure that may be used, and how does it work?

Answer 24

• Extracorporeal shock-wave lithotripsy (ESWL)
• In conjunction with bile acids, It will disintegrate gallstones with high-energy shock waves
• Process takes about 1-2hrs

Question 25

Pain in the right shoulder could be referred pain from…

Answer 25

• Liver
• Duodenal ulcer

Question 26

Pain in the back left shoulder could be referred pain from…

Answer 26

• The pancreas

Question 27

Lower back pain can be indicative of what conditions?

Answer 27

• Pancreatitis
• Renal issues

Question 28

Cholecystitis pain can be triggered by what type of meal?

Answer 28

• High fat or
• High volume meal

Question 29

Rebound tenderness is also called…

Answer 29

• Blumberg’s sign

Question 30

Why does cholecystitis result in jaundice and clay-colored stool?

Answer 30

• If the bile ducts are blocked, bile will not enter the digestive tract (clay-colored stool) and bilirubin will back up into the blood stream (jaundice)

Question 31

What is steatorrhea?

Answer 31

• The excretion of fat with the feces owing to reduced absorption of fat by the intestine

Question 32

What digestive enzyme breaks down fat and what organ produces it?

Answer 32

• Lipase
• Pancreas

Question 33

What is a cholecystectomy?

Answer 33

• Removal of the gall bladder

Question 34

What is the suggested post cholecystectomy diet?

Answer 34

• Soft, bland foods are easiest to digest:
  
  • bananas, white rice, boiled potatoes, plain pasta, dry toast, and crackers.
• Gradually, the diet can advance add more flavorful foods.
• Your body will have problems digesting fat right after surgery

Question 35

Why is it important to have the pt ambulate after surgery?

Answer 35

• Ambulation stimulates circulation which can help stop the development of stroke-causing blood clots.
• Walking improves blood flow which aids in quicker wound healing.
• The gastrointestinal, genitourinary, pulmonary and urinary tract functions are all improved by walking.

Question 36

What action indicates proper bowel function after surgery?

Answer 36

• Flatulence

Question 37

What is a Cholecystostomy tube?

Answer 37

• It is a tube that is inserted through the abdominal wall into the gallbladder, and serves as a drain to an inflamed gallbladder in patients with acute cholecystitis

Question 38

What is a “T-tube”?

Answer 38

• A draining tube placed in the common bile duct after Common Bile Duct (CBD) post gallbladder removal.
• It provides external drainage of bile into a controlled route allowing time for the healing process

Question 39

What type of suction is attached to a T-tube in the bile duct?

Answer 39

• Jackson-Pratt

Question 40

What color should the drainage form a T-tube be?

Answer 40

• Yellow-green (bile colored), anything else needs to be investigated.

Question 41

How is pain controlled post cholecystectomy?

Answer 41

• NSAIDs
• Morphine

Question 42

Why would anticholinergics be used post cholecystectomy?

Answer 42

• To slow bowel activity and help the healing process

Question 43

Why is atropine used post cholecystectomy?

Answer 43

• Bradycardia is a known problem in laparoscopic cholecystectomy especially during gall bladder dissection
• Atropine increases the heart rate and improves the atrioventricular conduction by blocking the parasympathetic influences on the heart

Question 44

What fat-soluble vitamins should be taken post cholecystectomy and why?

Answer 44

• Vitamins A, D, E, K
• Gallbladder removal results in lower absorption rates of these vitamins

Question 45

What mineral absorption may be reduced by cholecystectomy?

Answer 45

• Magnesium
• Iron
• Calcium

Question 46

What do bile salts do?

Answer 46

• If the gallbladder is still present, bile salts help to promote gallbladder and liver function by reducing inflammation of the bile ducts and help normalize blood flow.
• They help dissolve gallstones
• They also help relieve gas and bloating that can be caused by gallbladder problems