Upper GI - Cholelithiasis and Cholecystitis Flashcards
Describe the structures and functions of the GI system, specifically, the liver, pancreas and gallbladder.
Liver (see previous deck) is Part of the biliary tract. The hepatic duct comes out of the liver and drains bile which is produced in the liver – joins with the cystic duct which comes out of the gallbladder, joins with the hepatic duct and they become the common bile duct- the common bile duct. The pancreas has the pancreatic duct that drains enzymes into the bottom of the common bile duct – then the common bile ducts drains through the sphincter of Audi into the duodenum (1st portion of small int.)
Pancreas:
Exocrine (pancreatic enzymes contributing to digestion) and endocrine functions (Islets of Langerhans secreting insulin, glucagon, somatostatin, and pancreatic polypeptide
Bilirubin Metabolism
-Bilirubin is a pigment derived from the breakdown of old RBC.
-Because it is insoluble in water (can’t dissolve in water), it must be bound to albumin to be transported to the liver ‘in an unconjugated form”.
-Once it’s in the liver, bilirubin is conjugated with glucuronic acid; it is now in its water-soluble conjugated form and it is excreted in bile.
-Makes urine and stool pigmented. Stool dark and urine yellow
Bile also consists of water, cholesterol, bile salts, electrolytes and phospholipids. Bile salts are needed for fat emulsification and digestion when secreted
Bilirubin is in bile, important to know for what happens if bile is blocked
Explain the etiology, pathophysiology, clinical manifestations, complications, collaborative care and nursing management of patients with:
Cholelithiasis, cholecystisis, and disorders of the pancreas
Pancreas and liver are connected by the common bile duct = disorders of one of them often impact the other
Cholelithiasis
def: Gallstones, the most common disorder of the biliary system
Risk factors:
-Family hx of gallstones
-Being 40+
-Female gender
-overweight/obese
-High fat/high cholesterol diet
-Taking meds that contain estrogen (most meno women taking supplemental estrogen, less commonly contraceptive pills because it’s a much smaller amount and younger women produce their own estrogen)
Gall stones are precipitates of:
-Cholesterol (mostly)
-Bile salts
-Bilirubin
-Calcium
-Protein
cause: unknown
-Some conditions ex. Infection and disturbances in the metabolism of cholesterol upset the balance, so when bile is secreted by the liver and is super saturated with cholesterol, the bile in the gallbladder is too. When this supersaturation happens, precipitation of cholesterol occurs.
-Immobility, pregnancy, and inflammatory and obstructive lesions of the biliary system all decrease bile flow. This can lead to gallstones
-The stones can remain in the gall bladder or migrate to the cystic or common bile ducts
Blockages:
-When the bile in the gall bladder can’t escape it may lead to Cholecystitis.
-When the bile in the gallbladder can’t drain = cholecystitis =inflammation in the gallbladder (either in the lining or through the whole wall of it). It is commonly associated with obstruction caused by gallstones or biliary sludge.
Common blockage is the cystic duct (beside gallbladder)
Less common but more serious blockage- block in the duct between liver and small int. = cholangitis – blocks bile flow from the gallbladder and the liver and causes pain, jaundice, fever (infection)
If pancreatic duct blocked = blocks flow of digestive fluid into small int = pancreatitis
Prolonged blockage of any of these ducts can cause severe damage to the gallbladder, liver, or pancreas. And can go on to become fatal
Cholitis and cholestasis are treatable, not fatal. But if they are blocking outflow from the liver or pancreas, they can become much more severe
Cholecystitis
def: Gallbladder inflammation caused by obstruction preventing bile outflow
-happens when bile becomes trapped and builds up in the gallbladder when gallstones block the tube that drains bile from the gallbladder.
Acalculous cholecystitis
-is a form of cholecystitis caused by dysfunction or hypokinesis of gallbladder emptying.
-causes:
prolonged immobility
fasting
prolonged TPN
diabetes
Bacteria (streptococci, E. coli, salmonella)
During an acute attack, the gallbladder is edematous and hyperemic
May be distended with bile and pus
Cystic duct is usually involved and may be occluded
Clinical Manifestations: cholecystitis
ACUTE
1 pain and tenderness
2 n,v
3 leukocytosis (high WBC, fever)
4 jaundice
Positive Murphy’s sign on abd assessment – a manoeuver that elicits a sudden, sharp pain in the RUQ abd when palpated on deep inspiration
This pain spreads towards your right shoulder. referred pain is because of irritation of right phrenic nerve
CHRONIC
-repeated (1-3x) attacks without removing the gallbladder
-Fat intolerance, dyspepsia, heartburn and flatulence
BILIARY COLIC
-Spasms due to stones lodging or moving through the ducts. Not usually “colicky” but steady
-usually accompanied with excruciating RUQ pain that radiates to the back or right shoulder, nausea and vomiting x 1 hour, with residual pain x 3-6h.
-Can be associated with tachycardia, diaphoresis and prostration
-Attacks occur approx. 3-6 hours after a heavy meal or when the client assumes a recumbent position.
Clinical manifestations caused by obstructive bile flow
-Jaundice
-amber urine which foams when shaken
-clay coloured stools
-Pruritis
-Intolerance for fatty foods
-Bleeding tendencies
-Steatorrhea (excessive amounts of fat in your poop, float, looser)
Labs:
Elevated WBC
Elevated CRP
Elevated LFTs
Blocked bile duct= high bilirubin (dt bile backing up to the liver)
Liver enzumes esp. ALT
Lipase elevated if gall bladder has also caused pancreatitis
Describe the purpose of key diagnostic and lab tests involved in evaluating the liver, gallbladder and pancreas.
Diagnostic Studies for gallbladder disordrs
ultrasound
Labs:
LFTs increase if liver is affected
AST, Esp ALT
Elevated WBC
Elevated lipase
Direct or indirect Serum bilirubin increases depending on where the stone is
Complications: with both Cholecystitis and Cholelithiasis
Cholecystitis and Cholelithiasis
Most common complications in older clients and those with diabetes are:
-Gangrenous cholecystitis
-Bile peritonitis
-Cholangitis – inflammation of the bile ducts
-Fistulas- abnormal connection between an organ/vessel and other structure, usually the result of injury, surgery, or infection
-IBD such as colitis or Crohns disease are an example of a disease that leads to fistulas between one loop of intestine and another
-Fistulas can be between arteries and veins as well – Biliary fistula is where bile flows along an abnormal connection of bile ducts into nearby hollow structures . Types of bliary fistulas include bilioenteric (connection into duodenum), thoracobiliary (connection to pleural space or bronchus) (rare)
-Gangrenous cholecystitis
-Subphrenic abscess- pus-filled cavity in the subphrenic region (area below the diaphragm but above the colon and liver). This infection can occur as complication of abd surgery, acute pancreatitis and trauma
-Rupture of the gallbladder leading to Peritonitis- inflammation of peritoneum, the thin tissue lining inner wall of the abdomen and lining internal organs. Inflammation of abd organs caused by irritating substances from a perforated gallbladder or gastric ulcer by rupture of a cyst or irritation from blood from internal bleeding
Conservative Therapy
tx
(1)
Endoscopic retrograde cholangiopancreatography (ERCP):
-Endoscope through the mouth
-Dye is injected , xrays to study the ducts of pancreas and liver
-Sphincterotomy/ papillotomy –endoscope is passed thru the duodenum with electrodiathermy knife attached to the endoscope. The sphincter of Oddi is widened and a basket is used to retrieve the stone(s) but is usually dumped in the duodenum to be passed in the stool
-Clears stones from the CBD in approx. 90% of patients
(2)
Extracorporeal shock-wave lithotripsy (ESWL)
-High enery shockwaves to disintegrate stones
(3)
Dissolution Therapy: Ursodeoxycholic acid
Drug Therapy
Cholecystitis
drugs:
-analgesics
-antiemetics
-anticholinergics (relax smooth muscle and decrease ductal tone)
-antibiotics (reduce sepsis, to buy time)
Nutrition
-Low fat,
-high-fiber
-high-calcium diet
-avoided dairy products, fried foods, rich pastries, gravies and nuts
-Small frequent meals recommended
Surgical Therapy
remove gallbladder
Laparoscopic cholecystectomy
Incisional cholecystectomy
Transhepatic Biliary Catheter
-Needle into abd, thru liver, into the bile duct, guides catheter in that stays in common bile duct
-Pt under sedation, not awake
-Catheter either reestablishes bile flow into duodenum or reroutes the bile so it drains into a bag outside the body (CHOICE DEPENDS ON EXTENT AND POSITION OF OBSTRUCTION). didn’t mean to use caps
-Relieves bile duct blockage caused by overgrowth of cancer cells and malignant cells cannot be removed by surgery. Likelihood of bleeding, so check INR before sx (risk if high INR)
Collaborative Care: Review
Cholecystitis
Acute Cholecystitis episode focus on:
-maintenance of fluid and electrolyte balance.
-Treatment supportive and symptomatic
-Gastric decompression
If nausea/vomiting is severe
-Anticholinergics
decrease secretion.
counteract smooth muscle spasms.
-Analgesics
Pain management
-antibiotic treatment
prevent sepsis
Collaborative Care: Review
Cholelithiasis:
Treatment Depends upon stage of disease
-Bile acids are used to dissolve stones
-2 nonsurgical approaches for stone removal
-ERCP with sphincterotomy
-ESWL- Extracorporeal shock-wave lithotripsy
Treatment of choice: Laparoscopic cholecystectomy
-Removal of gallbladder through one of four
puncture holes
-Minimal postoperative pain
