pancreaitis/cholecystitis Flashcards
Gallbladder Disease
The most common disorder of the biliary system is cholelithiasis (stones in the gallbladder)
Cholecystitis (inflammation of the gallbladder) is usually associated with cholelithiasis
Gallbladder disease is a common health problem in New Zealand
Cholelithiasis occurs more commonly in women, multiparous women and persons over 40 years of age
Other factors that increase the likelihood of gallbladder disease are:
sedentary lifestyle
a familial tendency
obesity
Cholecystitis
Cholecystitis is an acute inflammation of gallbladder
It is often associated with cholelithiasis (gallstones in the gallbladder)
and can be acute or chronic
Aetiology & Pathophysiology
Cholecystitis is commonly associated with obstruction caused by gallstones or biliary sludge
It is usually caused by obstruction of bile outflow by gallstones
The bile remaining in the gallbladder initiates a chemical reaction – autolysis & oedema occur, blood vessels in gallbladder are compressed compromising it’s blood supply
Perforation may result
Bacteria plays minor role in acute cholecystitis
Secondary infection of bile with EColi occurs in approx 60% of patients
Inflammation can also occur in the absence of obstruction with gallstones
It sometimes occurs after major surgical procedures, severe trauma or burns
It is thought to be the result of alterations in fluid & electrolytes and in regional blood flow in the visceral circulation
Bile stasis (lack of gallbladder contraction) & increased viscosity of bile are contributing factors
The mucous lining or entire wall of the gallbladder becomes inflammed
During an acute attack, the gallbladder is oedematous and hyperaemic. It may become distended with bile or pus
The cystic duct is often involved and may become occluded
The wall of gallbladder becomes scarred after an acute attack
There is decreased functioning of the gallbladder if large amounts tissue are fibrosed
Cholelithiasis
Gallstones are usually formed in gallbladder from solid constituents of bile
They vary greatly in size, shape and composition
The incidence of gallstones increases after the age of 40 years
They occurs 4 times more frequently in women
Pathophysiology of Gallstones
There are 2 major types of gallstones – pigment and cholesterol
The actual cause of gallstones is unknown but they are known to develop when the balance that keeps cholesterol, bile salts & calcium in solution is altered so that precipitation of these substances occurs
The conditions that alter the balance include infection & disturbances in the metabolism of cholesterol
Stones may remain in gallbladder or migrate to cystic duct or common bile duct – can lodge and cause obstruction
Clinical Manifestations – Acute and Chronic Cholecystitis
initial symptoms of acute cholecystitis include indigestion and pain and tenderness in the right upper quadrant, which may be referred to the right shoulder and scapula
The patient may also experience nausea and vomiting, restlessness and sweating
Because there is an inflammatory process occuring in the gallbladder, the patient will probably have leucocytosis and a fever
Symptoms of chronic cholecystitis include a history of fat intolerance, dyspepsia, heartburn and flatulence
Clinical Manifestations - Cholelithiasis
Symptoms of cholelithiasis may be severe or absent
The severity depends on whether stones are stationary or mobile and whether obstruction is present
The severe pain (result of gallbladder spasm) is called “biliary colic” although the pain is rarely colicky
The pain can be excruciating and last for an hour. The patient experiences residual tenderness in right upper quadrant when the pain subsides
The pain attacks often occur after a ‘fatty’ meal and/or when the patient is lying down.
Pain beginning postprandially, is often described as intense and dull, and may last from 1-5 hours. From onset, the pain increases steadily over about 10 to 20 minutes and then gradually wanes when the gallbladder stops contracting and the stone falls back into the gallbladder.
The pain is constant in nature and is not relieved by emesis, antacids, defecation, flatus, or positional changes. It may be accompanied by diaphoresis, nausea, and vomiting.
The pain is often accompanied by tachycardia and sweating.
When bile is totally blocked other manifestations arise. These can include:
obstructive jaundice dark amber urine no urobilinogen in urine clay coloured stools pruritis intolerance for fatty foods bleeding tendencies steatorrhoea Refer to the chapter Problems of indigestion, absorption and elimination in your text to determine why a person may experience these signs and symptoms when bile flow is obstructed.
Pancreatitis
Acute pancreatitisis an acute inflammatory process of the pancreas
The degree of inflammation varies from mild oedema to severe haemorrhagic necrosis
It occurs most commonly in middle-aged men and women but affects more men than women
The severity depends on the extent of pancreatic destruction and it can be life-threatening
Causes of Acute Pancreatitis
The majority of cases of pancreatitis are caused by gallstones and excessive consumption of alcohol
Other less common causes are post ERCP, trauma (postsurgical, abdominal), viral infections (e.g. mumps),and penetrating duodenal ulcers
Certain drugs are also known to cause pancreatitis e.g. cortico-steroids, thiazide diuretics, oral contraceptives and NSAIDs
Some metabolic disorders e.g. hyperparathyroidism, renal failure are known to cause pancreatitis
Sometimes there is no known cause
Pathphysiology of Pancreatitis
The most common pathogenic mechanism is autodigestion of the pancreas by it’s own proteolytic enzymes especially trypsin
The pancreatic cells may be injured or the pancreatic enzymes are activated in the pancreas rather than the intestine
The exact mechanism by which chronic alcohol intake predisposes to pancreatitis is not fully understood
It is thought that alcohol increases the production of digestive enzymes in the pancreas and/or increases the sensitivity to the hormone cholecystokinin (CCK). CCK stimulates the production of pancreatic enzymes
Clinical Manifestations of Pancreatitis
Abdominal pain is the predominant symptom of acute pancreatitis
The pain is severe and is usually located in the upper abdomen. It commonly radiates from the left side and through or around to to the back (due to distension of pancreas, peritoneal irritation and obstruction of the biliary tract)
The pain has a sudden onset and can be described as deep, piercing, and continuous
The pain aggravated by eating and is not relieved by vomiting and may be accompanied by flushing, cyanosis, and dyspnoea
Other manifestations include:
nausea and vomiting
low grade fever, leucocytosis, hypotension, tachycardia, jaundice
decreased or absent bowel sounds
crackles in lungs
discoloured skin around umbilicus or flanks if internal bleeding present
