Cholelithiasis and Cholecystitis

Question 1

Liver Functions

Answer 1

• 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

Question 2

Biliary Tract

Answer 2

• made up of the gallbladder and the duct system
• Bibirubin

Question 3

Common Bile Duct

Answer 3

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

Question 4

Pancreas

Answer 4

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

Question 5

Bilirubin Metabolism

Answer 5

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

Question 6

What is Cholelithiasis?

Answer 6

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

Question 7

Biliary system

Answer 7

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

Question 8

Risk Factors for Cholelithiasis (6)

Answer 8

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

Question 9

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

Answer 9

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

Question 10

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

Answer 10

• 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

Question 11

Gall stones can get stuck in the: (4)

Answer 11

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

Question 12

Complications of Blockage

Answer 12

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

Question 13

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

Answer 13

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

Question 14

What is Acalculous Cholecystitis?

Answer 14

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

Question 15

What causes acalculous cholecystitis? (5)

Answer 15

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

Question 16

The major pathologic condition of cholecystitis

Answer 16

inflammation

Question 17

Most common cause of cholecystitis

Answer 17

gall stone obstruction preventing bile outflow

Question 18

During an acute attack of cholecystitis:

Answer 18

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

Question 19

Clinical Manifestations of Cholecystitis (4)

Answer 19

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)

Question 20

Positive Murphys Sign

Answer 20

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

Question 21

Lab findings in Cholecystitis (6)

Answer 21

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

Question 22

Clinical Manifestations: Chronic Cholecystitis

Answer 22

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

Question 23

Clinical Manifestations: Biliary Colic (4)

Answer 23

• 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

Question 24

Clinical Manifestations caused by obstructive bile flow (7)

Answer 24

• 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)

Question 25

Subphrenic Abscess

Answer 25

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

Question 25

Complications of Cholecystitis (7)

Answer 25

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

Question 26

Cholangitis

Answer 26

inflammation of the bile ducts

Question 27

Biliary cirrhosis

Answer 27

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

Question 28

Fistula

Answer 28

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

Question 29

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

Answer 29

- gangrenous cholecystitis - bile peritonitis

Question 30

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

Answer 30

Abdominal Ultrasound

Question 31

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

Answer 31

- LFTs elevated (ALT, AST) - Elevated ilpase and WBC - Indirect and direct serum bilirubin could be increased

Question 32

Conservative Therapy Cholecystitis (2)

Answer 32

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

Question 33

ERCP

Answer 33

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.

Question 34

ESWL

Answer 34

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

Question 35

Dissolution Therapy

Answer 35

Ursodeoxycholic acid

Question 36

Drug Therapy (4)

Answer 36

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

Question 37

Nutrition (3)

Answer 37

- 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

Question 38

Surgical Therapy

Answer 38

- laparoscopic cholecystectomy - incisional cholecystectomy

Question 39

Transhepatic Biliary Catheter

Answer 39

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

Question 40

Cholecystitis: Acute episodes focus on: (3)

Answer 40

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

Question 41

Cholecystitis: treatment supportive and symptomatic

Answer 41

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

Question 42

Cholelithiasis treatment

Answer 42

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