Cholecystitis and Pancreatitis

Cholelithiasis

stone formation in gallbladder

Cholecystitis

inflammatino of the gallbladderusually associated with stones

• helps with digestion

• breaks down fat

Functions of bile:

Stores excess bile . When we eat, gallbladder contracts and bile comes out to digest food.

function of gallbladder

hepatic duct

duct that comes right out of liver

Cystic duct

duct that comes out of gallbladder

Common duct

Where hepatic and cystic duct both meet.

nothing is going anyhere. can back up into gallbladder and liver.

What happens if there is a stone in the common duct>

liver can pass but gallbladder cannot do anything

What happens if there is a stone in the cystic duct

can rupture or burst. bile will be expelled into periotoneal cavity, causing periotonitis

What happens if gallbladder is inflammed or infected?

When balance between bilesalts/calcium and cholesterol changes. Substances preciitate to form little stones. Supersaturated bile with cholesterol and more common

when do gallstones develop

They never cause an issue. Not obstructing anything. May become symptomatic if the stone moves or increases in numbers

Why do 80% of peopel with gallstones not nkow they have them?

if stones are moving or causing obstruction

gallstone pain depends on:

biliary colic

As the stones in the gallbladder move, causes spastic pain.

3-6 hours after eating. Pain will subside but will have residual tenderness or pain on palpation

When will people with gallstones typically experience the most pain?

­Abdominal distension

­RUQ pain radiating to shoulder 

­Severe pain up to an hour, then residual tenderness RUQ

­Tachycardia, diaphoresis, weakness

­Spasms – ‘biliary colic’

S+S of gallstones [5]

Cholecystisis: painful response when right subcostal region Is palpated. Get them to take a big deep breath, keep hand there, and palpate. When they breathe in, may ump from pain.

Positive murphy’s sign:

 Pain & tenderness RUQ

 Indigestion

 N&V

 Restlessness

 Diaphoresis

 ↑WBC^′ s & Fever

 Positive Murphy’s Sign

S+S of acute cholecystitis: [7]

 Fat intolerance

 Dyspepsia

 Heartburn

 Flatulence

S+S of chronic cholecystitis [4]

• §Risk of bleeding – ↓vit. K,  ↓prothrombin

  §Clay coloured stools – blockage of flow of bile salts

  §Dark amber urine – bilirubin in urine

  §Intolerance of fatty foods (nausea, fullness, anorexia) - no bile in small intestine for fat digestion

  §Obstructive jaundice – no bile flow in duodenum

  §Pruritis – bile salts in skin

  §Steatorrhea (fatty stools) – no bile salts, preventing fat emulsion and digestion. Bulky fat in stool

Clinical manifestationt of obstructed bile flow [7]

1. fatty diet

2. smoking

3. sedentary lifestyle

4. obesity

5. men over age 40

Risk for gallbladder issues: [5]

gallbladder

cystic duct

common hepatic duct

common bile duct

ERCP looks at what with endoscope? [4]

pancreatitis. pressure and mechanical disruption can cause inflammaiton of the pancreas as a post op complication

Complicatino of ERCP

1. amylase

2. lipase

(enzymes)

increased levels indicate issues with pancreas [2]

1. increased liver enzymes

2. increased WBC

3. increased Bilirubin

4. increased amylase, lipase

Labs support cholecystitis diagnosis:

ultrasound

Diagnostic test to visualize gallstones

Conservative therapy. watch and wait, body can pass on its own

Management of uncomplicated gallstone

Bile acids

oral pills taken for 6-12 months to dissolve gallstones. most patients are symptom free after a month

to investigate and rest the gallbladder

Why might patients with cholecystitis be kept NPO?

1. analgesics

2. anticholinergic (antispasm)

3. antibiotics (possible infection)

med management for cholecystitis: [3]

low continuous suction got gastric decompression if severe N+V

Why might patients with cholecystisis get NG tube?

laparoscopic cholecystectomy

surgeon uses small punctures to dissect gallbladder under guidance

1. less invasive

2. shorter healin

3. pt goes home quicker

benefits of laparoscopic cholecystectomy [3]

T-tube

small tube put into common bile duct, exits, attach t dainage bag. Kee it in patient when healing, after a few weeks take it out

Transhepatic biliary catheter

Catheter creates an opening for bile to flow freely into drainage bag to enhance comfort. Done when bile can’t drain and cause cannot be fixed. Done for palliation

surgeon puts air into the cavity for a better view. Educate patients to move to expell the gas (could rise to shoulders)

why might patients have a lot of gas post lap chole?

1. bowel sounds

2. vitals

3. iv fluids

4. sips to clear fluids to full fluids

5. Soft diet

6. splint incision

7. ambulate ASAP

8. dressing and drain care (bile can be damaging to skin)

9. Deep breathe and cough q1h

post-op nursing care for cholecystectomy [9]

1. bleeding

2. periotonitis (infection)

3. pneumonia

4. jaundice (onstrction of bile)

post-op cholecystectomy complications:

when bowel sounds return

when can patient move to soft diet

1. analgesic

2. anticholinergic

3. fat soluble vitamins

4. bile salts

5. cholestyramine (for itching)

med therapy post-op cholecystectomy

Lots of weight over short time: gallstones can occur (supersaturation with cholesterol)

loss of a lot of weight over a short time can cause:

Avoid gas-forming foods, may be more uncomfortable if you eat these:

-Carbonated drinks

-Beans

-Cabbage

instruct patients to avoid these gas forming foods post op

Removed gallbladder, pt has loose stools originally from continuous dumping of bile

Over time, the ducts will actually dilate a bit and can hold bile temporarily

. Takes a few weeks for body to compensate

how can people live without a gallbladder [3]

after 4-6 weeks

when can patient heavy lift after cholecystectomy?

1. jaundice

2. puritis

3. dark urine, clay stool

4. intense pain

5. n/v

6. abdominal distension

educate patient to report these findings after cholecystectomy:[6]

perforation (or periotonitis)

abdominal distention post op can indicate what:

1. exocrine: helps digestion

2. Endocrine: regulates blood sugar

function of the pancreas [2]

pancreas still releases what it normally will. Digestive enzymes will auto-digest, causing significant burning pain

what happens when pancreatic duct is blocked?

§Gallbladder disease

§ ETOH

§ Trauma

§ Infections

§ Medications

§ Post-op complication

§ Post-ERCP pancreatitis

common causes of pancreatitis [7]

can be mild (edema) to severe necrotizing pancreatitis leading to permanent gland dysfunciton, organ failre, and sepsis.

Range of acute pancreatitis:

may feel better to lean forward

position that is more comfortable in pancreatitis

Aggrevated by eating and not releaved by vomiing

how is pancreatitis pain made worse?

with so much inflammaiton, chemicals can get secreted int the blood stream and cause pulmonary edema. Acute pulmonary distress syndrome

why might someone with pancreatitis have crackles in the lungs?

Ecchymosis

Bruising, discoloration

1. severe abdominal pain

2. decreased or absent bowel sounds

3. abd dstention

4. hypotension

5. tachycardia

6. jaundice

7. crackles

8. n/v

9. low grade fever

10. ecchymosis

11. shock

clinical manifestations of pancreatitis [11]

cullens sign

bruising around umbilicus indicates pancreatic hemorrhage

turners sign

bruising around the flank area indicating pancreatic hemorrhage

pseudocyst

accumulation of fluid, pancreatic enzymes, tissue debris and inflam. exudate that is not enclosed

abscess

results from infected pseudocyst. usually has pus and can rupture

leukocytosis

increased WBC

due to digestive nature of the condition

why is every organ affected with pancreatitis

CT with contrast and MCRP (done under MRI with dye)

test to detect complications from pancreatitis, no endoscope.

1. physical exam

2. increased amylase

3. increase lipase

4. increased iver enzymes, triglycerides, glucose

5. abdominal exray

6. ct with contrast

7. MRCP

diagnosis of pancreatitis: [7]

1. opioids

2. antispasmodic agents

3. spasmolytics

pain management for pancreatitis: [3]

­↓ stimulation of pancreas

­NPO

­NG to LCS

­Parenteral nutrition (if needed)

how to reduce pancreatic enzyme secretion [4]

Ringers lactate

fluid that has anti inflammatory and electrolytes:

Gallstones

if someone has acute pancreatitis and gallstones, which is treated first?

1. insulin

2. pancreatin, pancrelipase

medication therapy for chronic pancreatitis: [2]

1. fat necrosis

2. tetany

3. paresthesia

4. muscle spasms

5. numbness around the mouth

signs of hypocalcemia

hypocalcemia

pancreatitis increases risk of which electrolyte imbalance?

Fibrotic

with chronic inflammation, pancreas can become:

1. alcohol use disorder

2. following acute

3. idiopathic

common causes of chronic pancreatitis:

biliary disease or cancer

obstructive chronic pancreatitis is associated with:

1. inflammation

2. sclerosis

   (caused most commonly by alcohol)

nonobstructive chronic pancreatitis is associated with:

1. prevent attacks

2. pain relief

3. control pancreatic exocrine and endocrine insufficiency

4. bland and low fat fiet with small frequent meals

focus of treatment for chronic pancreatitis:

1. bile salts

2. pancreatic enxyme products

3. acid-neutralizing and acid-inhibiting drgs to decrease HCL

pancreatic enzyme replacement: [3]