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Hepatobilliary Adult
Hepatobilliary
| Question | Answer |
|---|---|
| Gallbladder | Stores and expels bile. Hormones of digestion |
| What are gallstones made up of | Cholesterol, Bilirubin, calcium salts and unconjugated bilirubin |
| Cholecystitis | Inflammation of the gallbladder |
| Cholelithiasis | Gallstones in the gallbladder |
| Choledocholithiasis | Stones in the common duct |
| Cholangitis | Inflammation in the common duct |
| Acute cholecystitis | diffuse inflammation of the gallbladder due to obstruction caused by gallstones . Removal of gallstones is a treatment |
| What happens in the quiescent phase of acute cholecystitis | The stones are in place and are not causing any obstruction |
| Chronic cholecystitis | Repeated episodes of acute and the symptoms may vary. Removal of gallbladder is a treatment |
| Treatment of Acute cholecystitis | Removal of gallstones |
| Treatment of Chronic cholecystitis | Removal of gallbladder |
| Risk factors of Cholecystitis | Women over 40 more than men Age Pregnancy Obesity |
| Underlying cause of Cholecystitis | No stones vs. Stones |
| Cholecystitis Diagnostics | Xray Ultrasonography MRCP ERCP Cholecystogram, Cholangiogram Laparoscopy |
| MRCP: Magnetic resonance cholangiopancreatography | Visualize the biliary tree and detect biliary tract obstruction |
| ERCP: Endocsopic retrograde cholangiopancreatography | Visualize the biliary structures and pancreas via endoscopy |
| Cholecystogram, Cholangiogram | visualize gallbladder and bile duct |
| Laparoscopy | Visualize anterior surface of liver, gallbladder and mesentery through trocar |
| Meds for Cholecystitis | Analgesia Antibiotics Ursodeoxycholic acid (UDCA) & chenodeoxycholic acid (chenodiol or CDCA) Used to reduce size of stones, dissolve small stone & prevent new stone formation |
| Medical Management for Cholecystitis: ESWL | Extracorporeal Shock Wave Lithotripsy (ESWL) Shock waves used to break up stones Fragments removed by being passed, removed w/ endoscopy or dissolved |
| Medical Management for Cholecystitis: Diet | usually low-fat liquids |
| Food to eat in cholecystitis | cooked fruits, rice, lean meats, mashed potatoes, non-gas forming vegetables, bread, coffee or tea |
| Foods to avoid in cholecystitis | eggs, cream/cheese, fried food, gas-forming vegetables, ETOH |
| Medical Management for Cholecystitis: Surgery | Cholecystectomy: Open or Laparoscopic |
| Medical Management for Cholecystitis: Collaboration | Rest GI Rest IVF NG Suction |
| Exocrine functions of the pancreas | Produces digestive enzymes Secretes enzymes into the small intestine |
| Endocrine functions of the pancreas | Releases hormones into the blood Beta cells → Insulin Alpha cells → Glucagon |
| Pancreatitis patho | In normal pancreas, enzymes such as trypsin, amylase and lipase are released into the duodenum but in pancreatitis, enzymes accumulate in the injured acing cells of the pancreas causing inflammation, scarring and pain |
| Pancreatic enzymes: Trypsin | breakdown of proteins and activation of other pancreatic enzymes |
| Pancreatic enzymes: Amylase | breakdown of carbohydrates |
| Pancreatic enzymes: Lipase | breakdown of fats |
| Risk Factors of Acute pancreatitis | Gallstones ETOH abuse Biliary tract disease Bacterial or viral infection Trauma Drug toxicities Smoking |
| Clinical Manifestations | Abdominal Pain: sudden onset and may be severe, deep, piercing *N/V Fever *Hypotension Tachycardia Jaundice Abdominal tenderness with muscle guarding Bowel sounds may be decreased or absent Cullen's sign Turner Sign |
| Cullen's sign | a bluish periumbilical discoloration |
| Grey Turner sign | Bluish discoloration on the side of stomach |
| Diagnostics for acute pancreatitis: imaging | X-rays:Abdominal and Chest CT Scans ERCP Ultrasound |
| Diagnostics for acute pancreatitis: Labs | Serum amylase ↑ Serum lipase ↑ Blood glucose↑ WBC ↑ Serum bilirubin ↑ Serum Ca+ ↓ |
| Medical Management for acute pancreatitis: *Pain management | Positioning – Side lying with knees flexed to alleviate pressure |
| Medical Management for acute pancreatitis: *IVF/ Electrolytes | Correction of fluid & electrolyte imbalances Prevention or alleviation of shock |
| Medical Management for acute pancreatitis: Reduction of pancreatic secretions | Monitor infected/necrotic drainage |
| Medical Management for acute pancreatitis: Antibiotics | Prevention or treatment of infection |
| Medical Management for acute pancreatitis: | identify etiology and consider early CT scan |
| Medical Management for acute pancreatitis: Oral Feeding | As soon as tolerated Preference for Enteral vs. Parenteral nutrition |
| Chronic Pancreatitis Patho | Digestive problems because of inability to deliver enzymes to the duodenum |
| Chronic Pancreatitis Patho | Glucose control problems because of damage to the islets of Langerhans |
| Chronic Pancreatitis Patho | Signs of biliary obstruction because of underlying bile tract disorders or duct compression by tumors |
| Medical management Chronic Pancreatitis: Medication | Non-opioid analgesic Insulin therapy |
| Medical management Chronic Pancreatitis: Pancreatic Enzyme Replacement | Pancrelipase (Pancrease, Viokase) Improve nutritional status & reduce amount of fatty stools |
| Side effects of Pancrelipase | abdominal cramps/ pain, nausea, diarrhea |
| What does Pancrelipase (Pancrease, Viokase) do | Pancrelipase (Pancrease, Viokase) Improve nutritional status & reduce amount of fatty stools |
| Medical management Chronic Pancreatitis: Nutritional Therapy | 4-8 Small, bland, frequent meals |
| Medical management Chronic Pancreatitis: Lifestyle | No ETOH No smoking |
| Medical management Chronic Pancreatitis: Surgery | This is done to divert the bile flow to relieve ductal obstruction Endoscopic Choledochojejunostomy Roux-en-Y procedure |
| ERCP with Sphincterotomy | Relieve ductal obstruction may include stent placement at the site of the obstruction May require follow to remove or exchange stent |
| Choledochojejunostomy | Diverts bile around the ampulla of Vater Common bile duct is anastomosed into the jejunum |
| Roux-en-Y Pancreatojejunostomy | Pancreatic duct is opened and an anastomosis is made with the jejunum |
| Blood supply for hepatic artery | 300ml/min |
| Blood supply for portal vein | 1050 m;/min → from GI tract, pancreas and spleen |
| Total blood flow for portal circulation | ~ 1.5 L of blood exit the liver/ minute |
| Normal blood flow for portal circulation | Portal Vein → Liver → Hepatic Vein → Empties into the vena cava → Right ventricle |
| Function of Liver | Metabolism of Drugs |
| Function of Liver | Production of Bile Salts & Removal of Bile Bile salts are reabsorbed and recycled by the liver Bile salts enter the GI tract → emulsify fat → allows them to be broken down and enter the lymphatic system |
| Function of Liver | Metabolism of Steroid Hormones |
| Function of Liver | Storage of Filtration Minerals and Vitamins 1. Vitamins A, D, and K |
| Function of Liver | Filtration of Blood, Removal of bacteria, Elimination of bilirubin |
| Function of Liver | Carbohydrate Metabolism Storage of glucose as glycogen Synthesis of glucose |
| Function of Liver | Fat Metabolism Formation of lipoproteins Cholesterol production, storage and elimination Formation of ketones |
| Function of Liver | Formation of urea from ammonia Synthesis of plasma proteins (albumin) Synthesis of clotting factors |
| Fate of Bilirubin step 1 | 1. Break down of old RBCs |
| Fate of Bilirubin step 3 | 3. The liver links unconjugated bilirubin together creating |
| Fate of Bilirubin step 4 | 4. Conjugated bilirubin _ Excreted with bile |
| Fate of Bilirubin step 5 | 5. Removed through feces from the body _ gives stool its normal color |
| Jaundice | Excess unconjugated bilirubin in the blood → not being excreted → bilirubemia → Jaundice → yellow tint of skin & eyes |
| Hepatitis | Inflammation of the liver through toxins, bacterial, viral Hep A B C D E |
| Hep A | Spread through water/food through fecal oral route of transmission. there is a vaccine and diarrhea is a s&s |
| Hep B | Spread through blood/body fluids through Unprotected Sex, needles/ syringes, birth and razors. there is a vaccine and when severe antivirals or interferon is given |
| Hep C | spread through blood/body fluids through needles/ syringes or other equipment to inject drugs, there is no vaccine and when severe antivirals or interferon is given |
| Fate of Bilirubin step 2 |
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