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NURS 412 Final Exam > Cholelithiasis and Cholecystitis > Flashcards

Cholelithiasis and Cholecystitis Flashcards

1
Q

Liver Functions

A
  • Largest internal organ in the body; essential for life
  • metabolic functions include: carbohydrate, protein and fat metabolism; detoxification of the blood; steroid metabolism
  • Bile synthesis functions include; bile production and storage
  • Mononuclear phagocyte system function includes: breakdown of old RBCs, WBCs, bacteria, ect. Breakdown of Hgb to bilirubin and biliverdin
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2
Q

Biliary Tract

A
  • made up of the gallbladder and the duct system
  • Bibirubin
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3
Q

Common Bile Duct

A

Disorders of one often impact the other
Hepatic duct drains bile and this produced in the liver into the common bile duct, joins with the cystic duct which comes out of the gall bladder – becomes the common bile duct.
Pacreas has the pancreatic duct that drains into the common bile duct – together they drain through the spinchter of audi into the duodenum
Common bile duct connects the liver, the gall bladder and the pancreas before draining into the small intestine

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4
Q

Pancreas

A

Exocrine (pancreatic enzymes contributing to digestion) and endocrine functions (Islets of Langerhans secreting insulin, glucagon, somatostatin, pancreatic polypeptide)

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5
Q

Bilirubin Metabolism

A

Bilirubin is a pigment derived from the breakdown of old RBC. It is insoluble in water meaning it needs to be bound to albumin for its transport to the liver in an unconjugated form. Once it is in the liver it is conjugated with glucuronic acid – now it is in its conjugated form water soluble and is excreted in bile
Bile also consists of water, cholesterol, bile salts, electrolytes and phospholipids.
Bile salts are needed for fat emulsification and digestion

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6
Q

What is Cholelithiasis?

A

Stones in the gall bladder and the most common disorder of the biliary system

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7
Q

Biliary system

A

the organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile

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8
Q

Risk Factors for Cholelithiasis (6)

A
  1. overweight or obese
  2. high fat or high cholesterol diet
  3. 40 years of age or older
  4. taking medications that contain estrogen (more estrogen supplementation postmenopausally)
  5. having a family history of gallstones
  6. being female
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9
Q

Gall stones are precipitates of (5) and what is the predominant precipitate?

A
  • cholesterol
  • bile salts
  • bilirubin
  • calcium
  • protein
    Cholesterol type gall stones account for 90% of gallstones
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10
Q

What can contribute to Cholelithiasis and what can it turn into?

A
  • immobility, pregnancy, and inflammatory and obstructive lesions of the biliary system all decrease bile flow. This can lead to gall stones.
  • the stones can remain in the gall bladder or migrate to the cystic or common bile ducts.
  • when the bile in the gall bladder can’t escape it may lead to cholecystitis
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11
Q

Gall stones can get stuck in the: (4)

A
  1. Hepatic duct which carries bile out of the liver
  2. Cystic duct which carries bile to and from the gall bladder
  3. Common bile duct which collects bile from the cystic and hepatic ducts and carries it to the small intestine
  4. Blockage of the pancreatic duct can cause pancreatic enzymes to be trapped inside the pancreas which can be very painful and cause a dangerous inflammation known as pancreatitis
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12
Q

Complications of Blockage

A

A common complication of gall stones is blockage of the cystic duct sometimes gallstones make their way out of the bladder and into the cystic duct and the channel through which bile travels from the gall bladder to the small intestine.
Cholecystitis can occur of the flow in the cystic duct is severely impeded or blocked
A less common but more serious problem occurs if the gall stones become lodged in the bile ducts between the liver and the small intestine – cholangitis. Blocks bile flow from the gall bladder and the liver causing pain, jaundice and fever. Gall stones may interfere with the flow of digestive fluids into the small intestine leading to inflammation of the pancreas
Prolonged blockages of any of these ducts can cause sever damage to the gall bladder, liver or pancreas and can go on to become fatal

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13
Q

Cholecystitis. what is it and what is it commonly associated with?

A

Cholecystitis is inflammation of the gallbladder and is usually associated with obstruction caused by gallstones (cholelithiasis.

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14
Q

What is Acalculous Cholecystitis?

A

cholecystitis in the absence of obstruction. occurs most commonly in older adults and in patients who have trauma or extensive burns.

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15
Q

What causes acalculous cholecystitis? (5)

A

a) prolonged immobility
b) fasting
c) prolonged TPN
d) diabetes
e) bacteria (e-coli, salmonella)

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16
Q

The major pathologic condition of cholecystitis

A

inflammation

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17
Q

Most common cause of cholecystitis

A

gall stone obstruction preventing bile outflow

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18
Q

During an acute attack of cholecystitis:

A

gallbladder is edematous and hyperemic, may be distended with bile and pus, walls become scarred after an attack and decreased functioning can occur
cystic duct is usually involved and may be occluded

19
Q

Clinical Manifestations of Cholecystitis (4)

A
  1. pain and tenderness
  2. Jaundice
  3. Leukocytosis (high WBC) and fever
  4. N&V (biliary colic 3-6 hours after high fat meals, lasts up to an hour)
20
Q

Positive Murphys Sign

A

If suspecting gall bladder inflammation they will be palpating, listening to the abdomen, get pt to take deep breath in and as they go out – feel up under the rib cage. Positive murphys sign that ilicits pain when the RUQ is palapated. On deep inspiration it almost halts the inspiration because of the pain that is caused.
Abdominal rigidity

21
Q

Lab findings in Cholecystitis (6)

A

Elevated WBC
CRP elevated
Elevations in LFTs
High bilirubin
ALP may be elevated
Lipase elevated if gall bladder disease is causing pancreatitis

22
Q

Clinical Manifestations: Chronic Cholecystitis

A

Fat intolerance
Dyspepsia
Heartburn and Flatulence
Repeated attacks without removing the gall bladder . usually only see three attacks before the gall bladder is removed.

23
Q

Clinical Manifestations: Biliary Colic (4)

A
  • spasms due to stones lodging or moving through the ducts. Not usually “colicky” but steady
  • usually accompanies with excruciating RUQ pain that radiates to the back or right shoulder, nausea and vomiting x1 hour with residual pain x 3-6h.
  • can be associated with tachycardia, diaphoresis and prostration
  • Attacks occur approx 3-6hrs after a heavy meal or when the client assumes a recumbent position
24
Q

Clinical Manifestations caused by obstructive bile flow (7)

A
  • Jaundice
  • amber urine which foams when shaken (soluble bilirubin in urine)
  • clay coloured stools (blockage of flow of bile salts out of the liver)
  • pruritis (deposition of bile salts in skin tissues)
  • intolerance for fatty foods (no bile in small intestine for fat digestion)
  • bleeding tendencies (lack of or decreased absorption of vitamin K
  • steatorrhea (no bile salts in duodenum, preventing fat emulsion and digestion)
25
Q

Subphrenic Abscess

A

pus filled cavity in the subphrenic region which is the area below the diaphragm but above the colon and the liver. Can occur as a complication of abdominal surgery, acute pancreatitis and trauma

25
Q

Complications of Cholecystitis (7)

A
  1. Gangrenous cholecystitis
  2. Subphrenic abscess
  3. Acute pancreatitis
  4. Cholangitis
  5. Biliary cirrhosis
  6. Fistulas
  7. Rupture of the gallbladder leading to peritonitis
26
Q

Cholangitis

A

inflammation of the bile ducts

27
Q

Biliary cirrhosis

A

bile ducts in liver are slowly destroyed. Bile can backup into the liver and sometimes lead to irreversible cirrhosis of the liver

28
Q

Fistula

A

abnormal connection between and organ a vessel or an intestine or another structure. Cholitis or chrons disease. Injury can lead to fistulas. Biliary fistula – bile flows along an abnormal connection from the bile ducts into nearby hollow structures. Can lead into the small intestine, bronchus, peritoneal space

29
Q

Most common complications in older clients and those with diabetes are (2)

A
  • gangrenous cholecystitis
  • bile peritonitis
30
Q

What diagnostic test is commonly used to diagnose gall bladder disorders?

A

Abdominal Ultrasound

31
Q

If the common bile duct is blocked fully or partially, what lab values do you think would be affected?

A
  • LFTs elevated (ALT, AST)
  • Elevated ilpase and WBC
  • Indirect and direct serum bilirubin could be increased
32
Q

Conservative Therapy Cholecystitis (2)

A

Endoscopic retrograde cholangiopancreatography (ERCP)
Extracorporeal shock-wave lithotripsy (ESWL)

33
Q

ERCP

A

Clears stones from the CBD in approx 90% of patients
Allows for:
- visualization of the biliary system, placement of stents, sphincterotomy/papillotomy
procedure that enables your physician to examine the pancreatic and bile ducts. Bendable lighted tube (endoscope) thickness of index finger goes through mouth, into stomach and small opening (ampula) in the duodenum is idenfied and a small pastic tube is passed into this opening, contrast dye is injected and xrays are taken to study the ducts of the pancreas and liver
Sphincterotomy – passed through duodnem – sphincter of audi is widened with knife and basket is used to receive the stone or stones. Left in the duodenum.

34
Q

ESWL

A

high energy shock waves are used to disintegrate gallstones. Fragments pass through into the duodenum. Usually ESWL and oral dissolution therapy are used together

35
Q

Dissolution Therapy

A

Ursodeoxycholic acid

36
Q

Drug Therapy (4)

A

analgesics
antiemetics
anticholinergics (relax smooth muscle and decrease ductal tone)
antibiotics (reduce incidence of sepsis)
- in the case of obstruction fat soluble vitamins may be given

37
Q

Nutrition (3)

A
  • Low fat, high-fiber and high-calcium diet
  • Foods that are avoided are; dairy products, fried foods, rich pastries, gravies and nuts
  • small frequent meals are recommended
38
Q

Surgical Therapy

A
  • laparoscopic cholecystectomy
  • incisional cholecystectomy
39
Q

Transhepatic Biliary Catheter

A

What is it – inserting a needle through the skin, into the abdomen through the liver and into the bile duct. Wire is attached to the needle then guides the catheter into place. Takes hours. Catheter can either re-establish bile flow into the duodenum or reroute thebile so it drains into a bag outside the body. Choice depends on the obstruction
Purpose – relieve bile duct blockage. The relieve obstruction d/t to the overgrowth of cancer cells in the hepatic, pancreatic, or common bile ducts.
Obstrcution d/t gallstones are cleared by other means.
Precautions – done when cancer has progressed to the point where malignant cells cannot be removed by surgery. Often suffer from additional complications. Procedure should not be done on patient’s with blood clotting abnormalities. High INR

40
Q

Cholecystitis: Acute episodes focus on: (3)

A
  1. pain control
  2. antibiotic treatment
  3. maintenance of fluid and electrolyte balance
41
Q

Cholecystitis: treatment supportive and symptomatic

A
  • gastric decompression - if N&V is severe
  • anticholinergic - decrease secretion, counteract smooth muscle spasms
  • analgesics - pain management
42
Q

Cholelithiasis treatment

A
  • depends upon stage of disease
  • bile acids are used to dissolve stones - gallstones may occur
  • two nonsurgical approaches for stone removal, laparoscopic cholecystectomy

NURS 412 Final Exam (12 decks)

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