Module 3 Flashcards
Cholecystitis is
an acute inflammation of the gallbladder wall, which is usually the result of an impacted calculus within the cystic duct, causing inflammation proximal to the obstruction.
Cholecystitis without gallstones, acalculous cholecystitis, is
a very serious disease with high morbidity and mortality rates. It usually occurs in patients who are already critically ill because of trauma, burns, surgery, or sepsis and who have had no oral intake or have been supplemented with hyperalimentation. Patients present with severe pain and tenderness in the epigastrium or right upper quadrant (RUQ) of the abdomen accompanied by nausea, vomiting, fever, and leukocytosis.
percentage of pt with cholelithiasis that don’t require tx
50%
The risk of requiring a cholecystectomy increases with
age as a consequence of complications secondary to the lithiasis.
most common gallstone
cholesterol, account for 75%
six Fs
fat, female, forty (age 40 years), flatulent, fertile, and fat-intolerant
After age 50, the gender distribution of cholelithiasis is
equal.
Pregnancy also predisposes women to cholelithiasis, presumably because of
the increased abdominal pressure and increased cholesterol levels during the third trimester.
The gallbladder is of primary importance in the development of gallstones because it
provides an arena for bile stasis and allows time for the slow crystallization of cholesterol
Biliary cholesterol is increased by ingestion of
estrogen and oral contraceptives, multiparity, and inflammatory terminal ileal disease, which decreases the bile acid pool.
black pigment gallstones
Black-pigmented stones are formed within the gallbladder and are commonly associated with hemolytic diseases, cirrhosis, long-term parenteral hyperalimentation. Black-pigmented stones are more fragile and seem to crush more easily than cholesterol stones.
brown pigmented gallstones
Brown pigmented stones are composed of alternating layers of calcium bilirubinate and calcium fatty acids. Chronic bacterial infections are believed to be partly responsible for the formation of brown pigmented stones because the enzymes the bacteria produce predispose the patient to this type of stone formation. Brown stones are typically found within the intrahepatic ducts and are rarely found within the gallbladder.
acute cholecystitis subjective
indigestion
nausea
vomiting (esp after meal high in fat)
acute, colicky pain RUQ or epigastrium
referred pain in middle of back, right shoulder
acute cholecystitis objective
involuntary guarding of RUQ
positive murphys (painful splinting with deep inspiration or palpation of it causes transient resp arrest)
low grade fever
mild jaundice
hypoactive bowel sounds
suspect gallbladder perforation if
rebound tenderness
shaking chills
increased fever
acute cholecystitis diagnostic testing
mild WBC elevation (15,000)
elevated liver enzymes
alk phos high
bili high
gold standard diagnosis of acute cholecystitis
abdominal US
cholelithiasis tx
avoid foods high in fat
if poor surgical risk- dissolution of stones by po ingestion of ursodiol - typically recur.
acute cholecystitis initial tx
rehydration via IV, abx, analgesics, gi rest
if vomiting persists- NG tube
2nd/3rd gen cephalosporin
tx of choice acute cholecystitis
early surgical intervention
The most common complications of acute cholecystitis are
empyema and perforation.
Acute pancreatitis is defined as a
cute inflammation of the pancreas and the surrounding tissues resulting from the release of pancreatic enzymes. These enzymes cause a chemical burn in the retroperitoneal spaces, which leads to systemic toxicity.
80% of all hospital admissions for acute pancreatitis are the result of
biliary tract disease (passing of a gallstone) or alcoholism
Mild acute pancreatitis normally
improves within 48 to 72 hours and does not involve other organ systems. There is minimal interstitial edema, with only occasional microscopic acinar cell necrosis.
Severe, acute pancreatitis is often
associated with complications and multisystem organ failure. It can be a life-threatening condition, and the patient may require monitoring in the intensive care unit (ICU).
acute pancreatitis subjective
abrupt onset of deep epigastric pain, persists hours- days
radiate straight thru back
aggravated by coughing, lying supine, improves when seated lying forward
pt appears ill
acute pancreatitis objective
epigastric severe tenderness, guarding, no rigidity
decreased bowel sounds
elevated HR
low inspiratory effort
high BP
The diagnosis of pancreatitis is made on the basis of 3 things
the presence of abdominal pain, elevated serum amylase and/or lipase levels, and imaging findings consistent with acute pancreatitis
the gold standard for acute pancreatitis diagnosis is an
elevated serum amylase level (up to three times the normal value);
other lab abnormal acute pancreatitis
WBC btw 12-15
high Hct
decreased Ca
high CRP (esp with pancreatic necrosis)
elevated liver enzymes
ranson’s criteria for assessing severity of pancreatitis
At admission or at time of diagnosis:
1.Age older than 55 years
2.White blood cell count greater than 16,000/mcL
3.Blood glucose greater than 200 mg/dL
4.Base deficit greater than 4 mEq/L
5.Serum lactate dehydrogenase (LDH) greater than 350 IU/L
6.Aspartate transamine (AST) greater than 250 U/L
severe if 3 met
tx acute pancreatitis
maintain fluid status
pain control with demerol
npo with ng tube if vomiting
intro clear liquids when pain free
tx severe pancreatitis
typically in ICU
fast 2-4 weeks, TPN
6-8 L/day IV
correct glucose only if over 250
Chronic pancreatitis is defined as
a slowly progressive inflammatory process that results in irreversible fibrosis of the pancreas with destruction and atrophy of the exocrine and endocrine glandular tissue.
Chronic relapsing pancreatitis is defined as
acute attacks that occur in the setting of chronic pancreatitis and are usually precipitated by a specific event such as binge drinking or the passage of a stone.
causes of chronic pancreatitis
alcoholism
autoimmune dx
genetic mutation
high triglycerides
severe malnutrition
tropical chronic pancreatitis
The tropical, or nutritional, form of chronic pancreatitis is almost exclusively found in tropical countries. In these countries, the disease begins in early childhood and results in death in early adulthood because of complications. This type of pancreatitis also involves large intraductal calculi and a high susceptibility to pancreatic cancer. Malnutrition has a significant role, but it is not the sole cause because many areas with comparable malnutrition do not have equal prevalence of the disease. Key features of tropical pancreatitis include abdominal pain, maldigestion leading to steatorrhea, and diabetes.
Pancreatic insufficiency can be confirmed by the
bentiromide (nitroblue tetrazolium–para-aminobenzoic acid [NBT-PABA]) test
Cirrhosis is result of
hepatocellular injury involving the entire liver, resulting in fibrosis, nodular regeneration, and distorted hepatic architecture. Cirrhosis is considered permanent and irreversible.
In the Western Hemisphere, cirrhosis is a
leading cause of death in individuals older than age 40.
There are three consequences of alcohol abuse:
fatty liver, alcoholic hepatitis, and alcoholic cirrhosis.
fatty liver
fatty liver is a reversible condition where large vacuoles of triglycerides accumulate in the hepatocytes. The accumulation of fat in the liver causes an inflammatory reaction in the liver called steatohepatitis and is a precursor of cirrhosis.
most common type of cirrhosis in USA
alcoholic
Primary biliary cirrhosis (PBC) is a
disease that almost exclusively affects women aged 40 to 60. It is an autoimmune disease that causes destruction of the intrahepatic bile ducts, resulting in cholestasis. Autoimmune disorders such as scleroderma, Raynaud’s syndrome, autoimmune thyroid disease, celiac disease, and Sjögren’s syndrome have been linked to the development of PBC.
Primary sclerosing cholangitis (PSC) is
most common in men aged 20 to 40 and is associated with inflammatory bowel disease (75%), as well as with the histocompatibility antigens HLA-B8, HLA-DR3, and HLA-DR4
other causes of cirrhosis
wilson’s dx
hemochromatosis
Micronodular (Laennec’s) cirrhosis is
characterized by regenerative nodules that are 1 cm in diameter or less, no bigger than normal liver lobules.
normally caused by alcoholic cirrhosis
Macronodular cirrhosis is characterized by .
larger nodules (diameters of 5 cm), which may be multinodular with varying size nodules and may contain central veins. These nodules are surrounded by broad fibrous bands of varying thickness, which correspond to the postnecrotic type of cirrhosis associated with chronic hepatitis
cirrhosis subjective
weakness anorexia weight loss fatigue
menstrual abnormalities
upper GI bleeding
cirrhosis objective
enlarged firm liver edge palpable below right costal margin
spider nevi, muscle wasting
caput medusae- varcisoe veins radiating from umbilical area
cirrhosis labs
macrocytic anemia
increased PT
elevated liver enzymes
GGT elevation
cirrhosis tx- etoh induced
abstinence from etoh
dietary supplementation
irreversible chronic liver dx tx of choice
liver transplant
PBC tx
symptomatic- pruritus tx with cholestyramine
hereditary hemochromatosis tx
weekly phlebotomies until depletion of iron stores
low iron diet
wilson’s dx tx
limit dietary intake of copper (legumes, animal organs, shellfish)
Infertility is defined as
the failure to achieve pregnancy despite regular unprotected sexual intercourse for at least 12 months
woman considered infertile if 35 years and older and
has not achieved pregnancy in 6 months
Primary infertility refers to
a woman who is unable to bear a child, either due to failure to become pregnant or to carry a pregnancy to a live birth.
Secondary infertility applies to
a woman who has delivered at least one child, but subsequently fails to become pregnant or to carry a pregnancy to a live birth.
age at which couples are most fertile
25 yrs
male infertility main cause
Testicular defects in spermatogenesis account for up to 80% of male infertility cases,
female cause of infertility
ovulatory disorders
endometriosis
pelvic adhesions
tubal obstruction
hyperprolactinemia
In general, infertility is caused by one of four conditions:
the inability to produce healthy gametes (sperm or eggs);
the failure of healthy gametes to come into close physical proximity, thus preventing fertilization;
the inability of the fertilized egg to attach to the uterine lining successfully; and the inability of a woman to carry a pregnancy to term postimplantation.
most common genetic defects associated with infertility
turner’s syndrome
Klinefelter’s syndrome
male infertility risk factors
testicular infection
genetic defects
radiation exposure
tobacco smoking
hyperthermia
semen analysis in men
most important diagnostic study in men
should be done before invasive testing of female partner
analyze: sperm concentration, motility and morphology
normal sperm count
between 40-300 million/mL of semen
below 15 indicates infertility
normal motility sperm
40%, at least 25% demonstrate progressive forward mobility
normal morphology sperm
size/shape of sperm
4-14% must have normal to be considered adequate
female infertility testing
progesterone levels at different times to confirm ovulation
LH levels
examination of vaginal discharge
FSH level day 3 of cycle
prolactin level
progesterone challange
The progesterone challenge test, in which medroxyprogesterone acetate 10 mg is given daily for 5 days and the induction of uterine bleeding is monitored in the week after treatment, confirms adequate production of estradiol (estrogen)
