Pancreatitis Flashcards
Gallbladder
Several disorders affect the normal drainage of bile into the duodenum.
- inflammation (cholecystitis) of the biliary system
- carcinoma that obstructs the biliary tree.
- Gallstones (cholilithiasis)
Risk Factors
- Incidence increases with age
- Obesity
- Frequent changes in weight
- Rapid weight loss (leads to development of gallstones)
- Women – over 40, multiple pregnancies (multiparous), * * * Native American or Hispanic ethnicity
- Four times more women than men
- Treatment with high dose estrogen (prostate cancer)
Low-dose estrogen therapy – oral contraceptives increase biliary cholesterol saturation - Cystic fibrosis
Symptoms
- Gallstones may be silent, producing no pain and only mild gastrointestinal symptoms. Such * Stones may be detected incidentally during surgery or evaluation for unrelated problems
- With gallbladder disease from gallstones may develop two types of symptoms:
-Those due to disease of the gall bladder itself
-Those due to obstruction of the bile passages by a gallstone.
Symptoms may be acute or chronic:
Pain (Gallbladder)
- The patient develops a fever and may have a palpable abdominal mass.
- Biliary colic is caused by contraction of the gallbladder, which cannot release bile because of obstruction by the stone. When distended, the fundus of the gallbladder comes in contact with the abdominal wall in the region of the right ninth and tenth costal cartilages. This produces marked tenderness in the right upper quadrant on deep inspiration and prevents full inspiratory excursion.
- May have biliary colic with excruciating upper right abdominal quadrant pain
- Epigastric distress such as fullness, abdominal distention and vague pain.
- Some pain is constant rather than colicky that radiates to the midsternal areas, back or right shoulder, usually associated with nausea and vomiting and is noticeable several hours after a heavy meal.
- This pain may follow a meal rich in fried or fatty foods
- Pain of acute cholecystitis may be so severe that analgesics are required – morphine is thought to increase spasm of the sphincter of Oddi and may be avoided in many cases in favor of meperidine
- If the gallstone is dislodged and no longer obstructs the cystic duct, the gall bladder drains and the inflammatory process subsides after a relatively short time. If the gallstone continues to obstruct the duct, abscess, necrosis, empyema and perforation of the gallbladder with generalized peritonitis may result.
Jaundice
- Occurs in a few patients with gallbladder disease and usually occurs with obstruction of the common bile duct
- The bile, which no longer carried to the duodenum, is absorbed by the blood and gives the skin and mucous membranes a yellow color.
- This is frequently accompanied by marked itching of the skin
- The excretion of bile pigments by the kidney gives the urine a very dark color (because the bile is absorbed by the blood and not drained into the intestine)
- The feces, no longer colored with bile pigments are greyish, like putty, and usually described as clay-colored
Vitamin deficiency
Obstruction of the bile flow also interferes with absorption of the fat soluble vitamins –if the obstruction has been prolonged
A
D
E
K – may experience bleeding due to deficiency. Preoperatively administer Vit K if the prothrombin level is low
Diagnosis
- Abdominal x-ray – only 15% to 20% of gallstones are calcified sufficiently to be visible on x-rays
- Utrasonography
- Procedure of choice
- No ionizing radiation
- Most accurate if fast overnight so that the -gallbladder is distended
- Based on reflected sound waves
- Can detect calculi in the gallbladder or a dilated common bile duct
- Detects gallstones with 95% accuracy
Goals
- To reduce the incidence of acute episodes of gallbladder pain and cholecystitis by supportive and dietary management
- To remove the cause of cholecystitis by pharmacologic therapy, endoscopic procedures, or surgical intervention
Non surgical approaches
Nonsurgical approaches:
- eliminate risks associated with surgery but are associated with persistent symptoms or recurrent stone formation.
- Approximately 80% of the patients with acute gallbladder inflammation achieve remission with rest, IV fluids, nasogastric suction, analgesia, and antibiotic agents.
- Diet: Fatty foods may bring on a episode
- Diet immediately after an episode is usually limited to low fat liquids.
- Avoid eggs, cream, pork, fried foods, cheese and rich dressings, gas-forming vegetables, and alcohol.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Endoscopic Retrograde Cholangiopancreatography (ERCP) with Sphincterotomy
* If the common bile duct is thought to be obstructed by a gallstone, an ERCP with sphincterotomy may be performed to explore the duct before laparoscopy
* permits direct visualization of structures
* Examination of the hepatobiliary system via a side viewing flexible fiberoptic endoscope inserted into the esophagus to the duodenum.
* Insertion of a catheter through the endoscope into the common bile duct (sphincterotomy- division of the muscles of the biliary sphincter) for gallstone extraction
* Multiple position changes are required during the procedure, beginning in the left semi prone position to pass the endoscope
* Fluoroscopy and multiple x-rays are used during ERCP to evaluate the presence and location of ductal stones
Pre test:
- NPO several hours,
During test:
- mild sedation
- Observe for respiratory and CNS depression, hypotension, over sedation and vomiting (if glucagon is given)
Post test:
- Monitor for signs of perforation or infection
- Assess return of gag reflex and cough reflex after the use of local anesthetics
Extracorporeal Shock-Wave Lithotripsy (ESWL) and Intracorporeal Lithotripsy
- Extracorporeal Shock-Wave Lithotripsy (ESWL) Repeated shock waves, through fluid filled bags or submerged in water, to remove fragments of the stones in the gallbladder and CBD. The fragmented stones pass from the gallbladder or CBD spontaneously. Laparscopic cholecystectomy has reduced the use of this procedure.
- Intracorporeal Lithotripsy –stones are fragmented by the use of laser pulse technology. Can distinguish between stones and tissue. This allows time for improvement in the patient’s clinical condition until gallstones are cleared endoscopically, percutaneously, or surgically.
Surgical management
Surgical intervention is delayed until the acute symptoms subside and a complete evaluation can be carried out- unless the patient’s condition deteriorates.
- laparoscopic or open cholecystectomy
Types :
Removal of the gallbladder (cholecystectomy)
Laparoscopic cholecystectomy
Percutaneous Cholecystostomy
(cholecystectomy)
Removal of the gallbladder (cholecystectomy) – the gallbladder is removed through an abdominal incision (usually right subcostal) after the cystic duct and artery are ligated.
- A drain may be inserted in the incisional area if there is leakage of bile- a small leak should close spontaneously in a few days with the drain preventing accumulation of bile.
- Usually only a small amount of serosanguinous fluid will drain in the initial 24 hours after surgery, then the drain will be removed
- Use of a T-tube into the CBD is Uncommon –it is used only in the setting of a complication (i.e. retained common bile duct stone)
- Bile duct injury is a serous complication of this procedure
- This procedure has largely been replaced by laparoscopic cholecystectomy
Laparoscopic cholecystectomy
Laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus).
* The abdominal cavity is insufflated with carbon dioxide (pneumoperitoneum) to assist in inserting the laparoscope and to visualize the abdominal organs. Post op pain may occur in the right shoulder of scapular area (from migration of the CO2 used to insufflate the abdominal cavity during the procedure) – heating pad for 15-20 minutes hourly, walking, and sitting up when in bed/chair may ease discomfort until CO2 is absorbed
* The most serious complication after laparoscopic cholecystectomy is a bile duct injury
Post op nursing care:
- Drive a care after 3-4 days
- Avoid lifting objects exceeding 5 pounds after surgery for 1 week
- Allow special adhesive strips on the puncture site to fall off – DO NOT pull them off
- Gradually add fat back into diet in small increments
Percutaneous Cholecystostomy
Percutaneous Cholecystostomy
- Used in treatment and diagnosis of acute cholecytitis in patients who are poor risks for any surgical procedure
- A fine needle/catheter is inserted through the abdominal wall into the gallbladder to decompress the biliary tract.
- Antibiotics are administered before, during and after the procedure
