GI Packet #2

Gallbladder anatomy

RUQ tucked under the liver

Size of gallbladder

3-4 inches

Function of gallbladder

A storage place for bile

Bile (place of production and function)

Produced by the liver and helps the body digest fat

What does the gallbladder do when you eat a fatty meal?

Contracts

How does bile flow out of the gallbladder?

Via common bile duct

Where does the bile go and what happens to it after flowing out of the gallbladder?

Goes into the small intestine for breakdown of fats

Medical term for gallstones

Cholelithiasis

What are gallstones?

Hardening of the bile

What are the 2 types of gallstones?

1. Cholesterol stones

2. Pigment stones

Most cases of gallstones are...____________.

Asymptomatic

How are asymptomatic gallstones typically found?

During a routine exam (Ex. Going in for a CT scan)

Cholecystitis

Inflammation of the gallbladder

Cholelithiasis

Stones in the gallbladder

Choledocholithiasis

Stones in the common bile duct or anywhere in the ductile system

Risk factors of gallstones are the classic 5 F's

1. Family Hx (Fair Complexion)

2. Female

3. Fat (Obesity/Overweight)

4. Forty (40)

5. Fertile

Signs vs. Symptoms

Signs: Found on examination, objective

Symptoms: What the Pt complains of, subjective

Signs of gallstones (3)

1. RUQ tenderness

2. Dehydration (if persistent vomiting)

3. Murphy's sign (positive)

RUQ tenderness on physical examination is found during which step?

Palpation

How would dehydration be found on P.E.?

Dry mouth or tenting

Positive Murphy's sign

Cessation of breathing; Pt can't complete a deep breath

Symptoms of gallstones (3)

1. Abdominal pain

2. Abdominal pain timing

3. Associated symptoms

Abdominal pain of gallstones can be found in what regions of the stomach?

RUQ or epigastric

Abdominal pain of gallstones can radiate to what other areas of the body?

Right shoulder or infrascapular region (below shoulder blade)

Abdominal pain with gallstones sets in how long after eating what specific type of meal?

30-60 minutes; a fatty meal

What other Sx can a Pt with gallstones experience?

1. Fever and chills (if infection)

2. Nausea/vomiting (N/V)

3. Diarrhea (D)

Differential Dx of gallstones (3)

1. Gallbladder

2. Liver

3. Right kidney

What kind of disease can be found in the liver as a differential Dx for gallstones?

Hepatitis (inflammation of the liver)

TRUE OR FALSE: The size of the gallstone(s) aligns with the amount of pain the Pt is experiencing.

False

Diagnostic testing of gallstones (6)

1. Labs-evaluated WBC count

2. Abdominal ultrasound

3. ERCP

4. Helical CT

5. Oral cholecystogram

6. HIDA

A WBC count can elevate if what is present in the body?

Infection

ERCP meaning

Endoscopic retrograde cholangiopancreatography

What is an ERCP?

Scope with light goes down into duodenum via mouth to show gallstones made visible via dye

How does a helical CT differentiate from a regular CT?

Images in cross-section rather than overlapping

Why would you NOT give a Pt contrast?

Allergic

What is an oral cholecystogram?

X-ray of the gallbladder after contrast tablets are taken the night before

HIDA meaning

Hepatobiliary Iminodiacetic Acid Scan

What is a HIDA?

Nuclear medicine scan; radioactive tracer injected and tracked by scan

Management of asymptomatic gallstones

Watchful waiting, eat low fat diet

Tx of asymptomatic gallstones

No Tx

Management of symptomatic gallstones

Watchful waiting, removal if persistent and recurrent Sx

What is the procedure for removal of the gallbladder called?

Cholecystectomy

TRUE OR FALSE: Most Pts have post-surgical Sx following a cholecystectomy.

False

What Sx might a Pt experience post-op cholecystectomy

Diarrhea; would have Sx when eating a fatty meal, switch to low fat diet

Where is the pancreas located?

Sits across the back of the abdomen behind or adjacent to the stomach

Anatomic parts of the pancreas (3)

1. Head

2. Body

3. Tail

Size of the pancreas

6 inches

What is the function(s) of the pancreas? (2)

1. Produce hormones essential for sugar regulation -> Insulin

2. Product digestive enzymes -> Amylase and Lipase

What 2 types of tissue make up the pancreas?

1. Exocrine tissue

2. Endocrine tissue

What does the exocrine tissue produce?

Digestive enzymes amylase and lipase

What does the endocrine tissue secrete?

Insulin and glucagon

Pancreatitis

Inflammation of the pancreas, occurs when digestive enzymes, usually contained within ducts in the pancreas, leak into the rest of the pancreas, and irritate it. It can be sudden (acute pancreatitis), or over many years (chronic pancreatitis).

If you do not document something during an appointment,...........

It didn't happen

Risk factors of pancreatitis (4)

1. Increase in triglycerides

2. Excessive, persistent alcohol use

3. Gallstones

4. Certain medications

Common signs of pancreatitis (2)

1. Decreased bowel sounds

2. Abdominal rigidity

Abdominal rigidity can lead to failure to complete......

Physical exam

Typical Sx of pancreatitis (7)

1. Upper abdominal pain often radiating to back (knife feeling)

2. 10/10 pain scale rating

3. Increased pain with eating

4. Sudden onset, worsens with time

5. Anorexia (lack of eating)

6. N/V (can be a side effect of pain)

7. Fever (present with infection)

Most common causes of pancreatitis (2)

1. Alcohol abuse

2. Gallstones

Diagnostic tools of pancreatitis (3)

1. Labs

2. CT of abdomen with contrast

3. Ultrasound of abdomen

What is the preferred diagnostic tool for pancreatitis?

CT of abdomen with contrast

What kinds of labs can be done for pancreatitis? (3)

1. Amylase and lipase levels (check for elevation)

2. WBC count with CBC (elevation shows infection)

3. Liver function

Management routine of pancreatitis (5)

1. Admit Pt

2. Manage pain (initial Tx)

3. IV hydration (from N/V, use saline solution via IV)

4. Bowel at rest (no amylase or lipase, nothing by mouth, all nutrients via IV)

5. Antibiotics if infection issue

What kind of Pts should you be aware of that have pancreatitis?

Diabetics

Bowel obstruction

Any condition that prevents the flow of chyme through the intestine

What percentage of bowel obstructions occur in the small bowel/intestine?

80%

Why do most bowel obstructions happen in the small bowel

Because the small intestine is 22 feet long and loops around itself and can stick to itself

Sx of a bowel obstruction depend on if it is....?

Partial or complete

Sx of bowel obstructions (5)

1. N/V

2. D/C

3. Cramps

4. Distension

5. Absence of BM's

What are the two categories of causes of a bowel obstruction?

Mechanical and functional

Mechanical cause of a bowel obstruction

Physical or anatomical blockage

Examples of a mechanical caused bowel obstruction (5)

1. Tumor or growth of any kind

2. Adhesions via volvulus

3. IBD

4. Intussusception

5. Hernia

Volvulus

Twists and turns of the bowel

IBD

Inflammatory bowel disease

Intussusception

Bowel invaginates or telescopes within itself

Functional cause of a bowel obstruction

Peristalsis is non-functioning

Examples of functional causes of a bowel obstruction (4)

1. Prior surgery with general anesthesia

2. Infection

3. Certain medications

4. Nerve or muscle disorders

Complications of bowel obstructions

Concerned about death of intestinal wall via obstructed blood supply

TRUE OR FALSE: There is still some liquid flowing through the bowels when there is a partial bowel obstruction.

True

Tx of a partial bowel obstruction

Put bowel at rest; change of diet (soft, clear liquids, nothing by mouth)

Tx of a complete bowel obstruction (3)

1. Surgical removal if the area has gone beyond a point of return

2. Nasogastric (NG) tube to get rid of everything

3. Bowel at rest via diet

What is an appendix?

Finger-shaped pouch that projects from the first part of the large intestine (cecum)

What is the size of the appendix?

Pinky finger

Location of appendix

RLQ

Causes of appendicitis (4)

1. Fecal obstruction

2. Infection

3. Excessive mucus secretion and retention

4. Tumors (any new growth)

What does appendicitis start with, alongside being the most common initial Sx?

Periumbilical or epigastric pain

What else might a Pt with appendicitis complain of? (3)

-Anorexia

-N/V

-Low grade fever

Where does the pain localize with appendicitis?

RLQ

What Sx is seen in pediatric Pts with appendicitis?

Diarrhea

What Sx may occur in later stages of appendicitis or if the appendix has burst?

Rigid (acute) abdomen

What does a rigid abdomen feel like during P.E.?

A washboard

Differential Dx of appendicitis (10)

1. Appendicitis

2. Right ovarian cyst

3. Right ureter issue

4. UTI

5. Diverticulitis

6. Testicular torsion

7. Muscle strain

8. Ectopic pregnancy

9. Tumor

10. Gastroenteritis (gastric infection)

Dx used during P.E. as supporting evidence for appendicitis (2)

1. Psoas (Iliopsoas) sign

2. Obturator sign

Psoas sign

Clinical indication of irritation to the iliopsoas (hip flexor) muscle group

Obturator sign

Refers to pain elicited during a P.E. maneuver involving the hip

Dx tools used for appendicitis (3)

1. Ultrasound

2. CT of abdomen

3. Lab work (CBC to identify any increase in WBC for possible infection)

Management of appendicitis (2)

1. Antibiotics

2. Appendectomy

What is the most common Tx of appendicitis?

Appendectomy with or without antibiotics

What kind of historical questions would you ask a Pt you suspect has appendicitis? (2)

1. Do you still have your appendix? (look for scar during P.E.)

2. Ask chronological order of vomiting and pain

Why does chronological order of vomiting and pain matter?

If vomiting precedes the pain, it is PROBABLY not appendicitis (an exception, not a rule)

McBurney's Point (where appendix lies)

2/3 of the way from the umbilicus (belly button) to the anterior superior iliac spine (pelvic bone)