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fnn 401 final > Gallbladder and pancreas > Flashcards

Gallbladder and pancreas Flashcards

1
Q

What is the role of the gallbladder?

A

it stores bile and delivers it to the SI

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2
Q

Inflammation of the gallbladder can lead to 3 things:

A
  1. gallstones (cholelithiasis)
  2. tumours
  3. scarring of the bile duct
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3
Q

what are 4 risk factors of gall stones?

risk factors for cholesterol gall stones?

risk factors for bilirubin stones?

A

for gall stones:
1. female
2. rapid weight loss
3. obesity
4. native american and other ethnic groups

for cholesterol gall stones:
1. inflammatory bowel disease
2. diabetes
3. cystic fibrosis
4. bariatric surgeries
5. fat restricting diets
6. cholesrerol lowering medications

for bilirubin stones:
1. liver disease
2. blood disorders (sickle cell anemi)

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4
Q

formation of gall stones can occur in 2 places:

A
  1. gallbladder
  2. biliary duct
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5
Q

what is biliary sludge?

A

cholesterol crystal + calcium salts

considered a precursor to gall stones (softer and more gel like)

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6
Q

what is biliary stasis?

A

slowdown of bile flow from the liver to the gall bladder

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7
Q

what are the 3 types of cholelithiasis (gall stones)?

A
  1. cholesterol stones (80% of cases) - when bile becomes supersaturated with cholesterol, it crystallizes and forms gallstones
  2. pigment stones - bilirubin + calcium salts
  3. mixed stones
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8
Q

___ % of patients with gall stones are asymptomatic

A

70%

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9
Q

what is the most common treatments for gall stones?

A

laparoscopic cholecystectomy

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10
Q

what are 4 causeses of gallstones?

A
  1. too much absorption of water from bile
  2. too much absorption of bile acids from bile
  3. too much cholesterol in bile
  4. inflammation of epithelium
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11
Q

what is choledocholithiasis?

A

biliary obstruction

when gall stone lodges in common duct or head of pancreas

it is secondary to biliary cirrhosis

bile pigments ends up in urine, RUQ pain, clay coloured stool, madigestion of fat. if not corrected, biliary back up can lead to jaundice, liver damage, stenosis

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12
Q

what is cholecystitis?

A

inflammation of the gallbladder secondary to obstruction, infection, and ischemia

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13
Q

what is cholangitis?

A

inflammation of the biliary ducts secondary to obstruction of the common bile duct

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14
Q

what are the nutritional implications of cholelithiasis

A

indigestion
decreased ability to digest fat
increased ab gas
diarrhea post surgery

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15
Q

what nutrition assessment do you do for cholelithiasis?

A

weight
weight history
diet
lab values
medications

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16
Q

what are the nutrition interventions for cholelithiasis?

A
  1. low fat (< 30% energy as fat)
  2. modest protein until surgery
  3. small frequent meals until surgery
  4. inactive during acute attacks - NPO - advance ow fat liquids
  5. post surgery - return to normal diet - may take some time to adjust
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17
Q

what is the exocrine function of the pancreas?

A

to secrete enzymes and other substances directly into the intestinal lumen.

Helps aid in digestion of protein, fats, CHO

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18
Q

What are 5 factors that stimulate pancreas secretion?

What are 5 factors that inhibit pancreas secretion?

A

stimulating factors:
1. CCK –> lipase, amylase, protease, bicarb fluid, gall bladder contraction
2. secretin
3. gastrin
4. VIP
5. cephalic phase of eating

inhibiting factors:
1. GLP1
2. PP
3. YY
4. OXM

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19
Q

what are the 3 stages of acute pancreatitis pathophysiology?

A
  1. autodigestion via prematurely activated enzymes (get into blood stream)
  2. immune cell and cytokine activation –> inflammatory response
  3. inflammation –> fascular permeability –> hemorrhage
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20
Q

What is pancreatitis?

A

inflammation of the pancreas

Intrapancreatic activation and release of enzymes causing autodigestion of pancreas and surrounding areas

Can be acute or chronic

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21
Q

Pancreatitis is characterized by 4 things:

A
  1. edema
  2. fat necrosis
  3. autodigestion
  4. hemmorhage of pancreatic tissue
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22
Q

Which endocrine disorder can be linked to pancreatitis?

A

diabetes!

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23
Q

what are 5 aspects of pancreatitis presentation?

A
  1. ab pain/nausea/vomiting
  2. +/- ilius of stomach or intestine
  3. pain in LUQ radiating to midback
  4. distended, tender ab
  5. +/- fever
  6. steatorrhea
24
Q

acute pancreatitis can be classified as:

A

mild
moderate
severe

acute interstitial vs. acute hemmorhagic

25
Q

how do you diagnose acute pancreatitis?

A

symptoms
labs
imaging

26
Q

what is the difference between acute interstitial pancreatitis and acute hemorrhagic pancreatitis?

A

acute interstitial:
- 80-85%
- gland architecture is preserved but edematous
- lots of inflammatory cells

acute hemorrhagic pancreatitis:
- 15-20%
- marked necrosis
- fat necrosis
- vascular inflammation and thrombosis

27
Q

what are 5 common causes of acute pancreatitis?

A
  1. gallstones
  2. alcohol
  3. ERCP
  4. trauma (blunt ab trauma)
  5. drugs
28
Q

what are the common causes of pancreatitis?

A

IGETSMASHED

idiopathic
gallstones
ethanol (alcohol)
trauma
steroids
malignancy/mumps
autoimmune
scorpion stink
hypercalcemia
ERCP
drugs

29
Q

What are 5 signs and symptoms of acute pancreatitis?

A
  1. ab pain
  2. worsening pain with food intake
  3. nausea
    vomiting
  4. low grade fever
30
Q

what are diagnostic markers of acute pancreatitis?

A

elevated pancreatic enzymes (amylase and lipase) 3x higher than high end of normal

31
Q

what do we use to diagnose acuse pancreatitis?

A

CT
MRI

32
Q

how do you treat acute pancreatitis?

A

remove cause (gallstone or alcohol).

if mild:
- IVF for rehdyration and electrolyte replacement
- BP management
- analgesics for pain
- Oral feeding as tolerated after nausea/vomiting subsides
- Often NPO for up to a week, then slow intro of O - start with low fat oral diet and small meals to limit exocrine function
- ead up to 1.2-1.5 g of protein per day and 25-35 cals/kg/day

if moderate/severe:
- antibiotics, NPO, nutrition support within 1-2 days as soon as patient is stable
- standard polymeric formula

33
Q

how much protein to have for acute pancreatitis?

A

1.2-1.5 g

34
Q

how much calories to have for acute pancreatitis?

A

25-35 kcal/kg

35
Q

what are 4 nutrition implications of pancreatitis?

A
  1. high metabolic state
  2. digestive capacity
  3. steatorrhea
  4. vitamin D and E (fat soluble)
36
Q

what route do you feed in severe AP?

A

ideally gastric route.
if patient doesnt tolerate that, then NJ route

or jejunum (below ligament of treitz)

37
Q

how do you initiate feed for acute pancreatitis

A

within 1-2 days
continuous rate
standard polymeric formula

38
Q

how has feeding for acute pancreatitis evolved?

A

used to be that we fed TPN

then jejunal

now say can feed NG - there is no difference

39
Q

when should you start eating again after acute pnacreatitis? chronic pancreatitis?

A

acute pancreatitis = 3-7 days after pain has stopped

chronic pancreatitis = as soon asyou can

foods containing fat should be reintroduced slowly

40
Q

Is chronic pancreatitis reversible?

A

no

41
Q

Chronic pancreatitis can be characterized by:

A
  1. fibrosis
  2. calcification/stones
  3. loss of islet and acinar cells
  4. ab pain
  5. exocrine/endocrine insufficiency
  6. pain (increased by food and alcohol intake)
42
Q

exocrine/endocrine insufficiency during chronic pancreatitis is associated with 3 items:

A
  1. steatorrhea
  2. weight loss
  3. malnutrition
43
Q

What are 5 risk factors of chronic pancreatitis?

A
  1. toxic metabolic (alcoholism, smoking, hypertriglyceridemia)
  2. genetic mutations
  3. autoimmune pancreatitis
  4. obstructive (i.e. cancer)
  5. idiopathic
44
Q

Why does exocrine insufficiency occur in CP?

A

there is a loss of acinar cell mass OR
pancreatic duct obstruction

this leads to:
1. decreased digestive enzyme levels
2. decreased ductal bicarbonate secretion

45
Q

what are 5 ongoing nutrition issues with exocrine insufficiency in CP?

A
  1. glucose control (30-50% have DM)
  2. maldigestion
  3. steatorrhea (lipase < 10% norm)
  4. need enzyme supplements like lipase, protease, amylase (cotazyme or viokase)
  5. chronic anorexia
46
Q
A
47
Q

what is the metric for diagnosing steatorrhea

A

fecal fat excretion > 7 g/day

*occurs when pancreatic lipase secretion
<10% normal

48
Q

what is the primary cause of weight loss in CP

A

fat maldigestion

49
Q

what is amylorrhea

A

excess starch in stool

occurs when there is carb maldigestion in exocrine insufficiency in CP

50
Q

what is azotorrhhea

A

excess nitrogen in urine

occurs when there is protein maldigestion in exocrine insufficiency in CP

51
Q

what is normal fecal fat?

A

2-7 g fat/24 hours

> 7 g fat/24 hours, when taking 100-150 g/day is suggestive of malabsorption

52
Q

what is the 3 pronged approach to managing CP?

A
  1. PERT (pancreatic enzyme replacement therapy)
  2. assess and correct nutrition deficiencies
  3. avoid alcohol and maintain adequate diet

Other suggestions:
- surgery
- pain management
- endoscopic treatment to remove stones, place stents

may not require NS - it will depend on endo/exo function

53
Q

how to use PERTS to manage CP?

A

can be enteric coated vs uncoated - coating helps with digestion of protein, starch, and fat

use with gastric acid suppressants like PPIs

have them with meals

54
Q

what are the nutrition recommendations for CP?

A

goal - minimize and prevent further damage

high energy - 35 cal

high protein - 1.2-1.5 g/kg

Fat usually doesnt need to be restricted if on PERT. but if steatorrhea persists, restrict fat in diet

try MCT oil!!

ongoing assessment

medication to reduce gastric acid secretion

55
Q

MCT oil is recommended to help treat:

A

Chronic pancreatitis

fnn 401 final (4 decks)

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