1
Q
- inflammation of the gallbladder which can be __ or __
A
Cholecystitis
acute or chronic.
2
Q
___ is the cause of more than 90% of cases of ____
A
Calculous cholecystitis (gall stones)
acute cholecystitis.
3
Q
___ describes acute gallbladder inflammation in the absence of obstruction by _____.
A
- Acalculous cholecystitis
gallstones
4
Q
- _____ of the gallbladder develops if the gallbladder becomes filled with purulent fluid.
A
empyema
5
Q
CALCULOUS CHOLECYSTITIS
- a gallbladder stone ___ bile outflow.
- ___ of bile occurs in approximately 50% of cases.
- The organisms involved are generally enteric and include ,,_
A
obstructs
Secondary infection
Escherichia coli, Klebsiella species, and
Streptococcus.
6
Q
- acute gallbladder inflammation in the absence of obstruction by gallstones.
A
ACALCULOUS CHOLECYSTITIS
7
Q
- hard deposits (gallstones, calculi) that may form in the gallbladder.
- gallstones usually form from the solid constituents of bile.
A
CHOLELITHIASIS
8
Q
(____ in color)
- Caused by conditions that produces __
- The risk is increased in patients with cirrhosis, hemolysis, and infections of the biliary tract.
- cannot be dissolved and must be removed ___.
A
- Pigment stones
dark brown or black
too much bilirubin
surgically
9
Q
(_____ in color)
– caused by ___. (decreased bile acid synthesis and increased cholesterol synthesis in the liver
- resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form stones.
A
- Cholesterol stones
yellow-green
imbalances bile composition
10
Q
RISK FACTORS OF CHOLELITHIASIS:
- ____ (leads to rapid development of gallstones and high risk of symptomatic disease)
- Treatment with high-dose estrogen (eg, in prostate cancer)
- ___ – a small increase in the risk of gallstones
- Ileal resection or disease
- Cystic fibrosis
- Diabetes mellitus
A
Rapid weight loss
Low-dose estrogen therapy
11
Q
Clinical Manifestations
- Pain and Biliary Colic
- excruciating ___ pain that radiates to the ___ or ___
- usually associated with nausea and vomiting.
- noticeable several hours after a heavy meal.
- In some patients, the pain is ___ rather than colicky - ____
- frequently accompanied by marked pruritus of the skin. - Changes in Urine and Stool Color
– ______ urine (bile excretion by the kidney) and
- _____ feces (absence of bile) - Vitamin Deficiency
- vitamins _____ deficiency. No absorption.
A
RUQ
back or right shoulder.
constant
Jaundice
dark-colored urine
grayish or clay-colored feces
A, D, E, and K
12
Q
- the diagnostic procedure of choice because it is rapid and accurate with 90% accuracy.
- most accurate if the patient fasts overnight so that the gallbladder is distended
A
Ultrasonography
13
Q
____
- used successfully in the diagnosis of acute cholecystitis or blockage of a bile duct.
a radioactive agent is administered IV which is taken up by the ___ and excreted rapidly through the biliary tract.
- The biliary tract is then scanned, and images of the gallbladder and biliary tract are obtained.
- often used when ultrasonography is not conclusive, such as in ____.
A
Radionuclide Imaging or Cholescintigraphy
hepatocytes
acalculous cholecystitis
14
Q
- used if ultrasound equipment is not available or if the ultrasound results are inconclusive.
- an iodine-containing contrast agent that is excreted by the liver and concentrated in the gallbladder is given 10 to 12 hours before the x-ray study.
- If gallstones are present, they appear as ___ on the x-ray image.
A
Oral Cholecystography
shadows
15
Q
– permits direct visualization of structures.
- examines the hepatobiliary system via a side-viewing flexible fiberoptic endoscope inserted through the esophagus to the descending duodenum.
- __ & ___ are used during ERCP to evaluate the presence and location of ductal stones.
- The patient is ___ for several hours before the procedure.
- Moderate is used.
- During ERCP, the nurse monitors ___, administers medications, and positions the patient.
- After the procedure, the nurse monitors the patient’s condition, observing vital signs and assessing for signs of ____
A
Endoscopic Retrograde Cholangiopancreatography
Fluoroscopy and multiple x-rays
NPO
Sedation
IV fluids
perforation or infection.
16
Q
- involves the injection of dye directly into the biliary tract.
- reserved for patients whom an _____ due to previous surgery.
- The fluoroscopy table is tilted and the patient is repositioned to allow x-rays to be taken in multiple projections.
- It is useful for:
1. distinguishing jaundice caused by liver disease (____) from that caused by
biliary obstruction,
2. investigating the GI symptoms of a patient whose gallbladder has been removed,
3. locating stones within the bile ducts, and
4. diagnosing cancer involving the biliary system.
A
Percutaneous Transhepatic Cholangiography (PTC)
ERCP may be unsafe
hepatocellular jaundice
17
Q
Pharmacologic Therapy
- acts by inhibiting the synthesis and secretion of cholesterol.
- can reduce the size of existing stones, dissolve small stones, and prevent new stones from forming.
- ____ of therapy is required in many patients to dissolve stones.
A
- Ursodeoxycholic acid (ursodiol) and chenodeoxycholic acid (chenodiol)
Six to 12 months
18
Q
Nonsurgical Removal of Gallstones
- infusion of a __ into the gallbladder.
- used for patients who may not be candidates for __
A
Dissolving Gallstones
solvent (mono-octanoin or methyl tertiary butyl ether [MTBE])
laparoscopic cholecystectomy.
19
Q
____
- a catheter and instrument with a basket attached are threaded through the T-tube tract or fistula formed at the time of T-tube insertion.
- the __ is used to retrieve and remove the stones lodged in the common bile duct.
A
Stone Removal by Instrumentation
basket
20
Q
___
- Stones are fragmented by means of laser pulse technology.
- A ___ is directed under fluoroscopic guidance with the use of devices that can distinguish between stones and tissue.
- The laser pulse produces rapid expansion and disintegration of plasma on the stone surface, resulting in a __
- used percutaneously with a basket or balloon catheter system or by direct visualization through an ___.
A
Intracorporeal Lithotripsy
laser pulse
mechanical shock wave.
endoscope
21
Q
Surgical Management
a. Preoperative Measures
- __ may be given if the prothrombin level is low.
- Provide IV glucose with protein supplements to __
A
Vitamin K
aid wound healing.
22
Q
- __ nonsurgical fragmentation of gallstones.
- uses repeated shock waves directed at the gallstones in the gallbladder or common bile duct to fragment the stones.
- The waves are transmitted to the body through a fluid-filled bag or by immersing the patient in a water bath.
A
Extracorporeal Shock Wave Lithotripsy (lithotripsy or ESWL)
23
Q
- __ is the standard of therapy for symptomatic gallstones.
A
Laparoscopic Cholecystectomy
24
Q
-___ the gallbladder is removed through an abdominal incision.
- performed for __ & __ .
- In some patients, a drain is placed close to the gallbladder bed and brought out through a puncture wound if there is a bile leak.
- only a small amount of __ drains in the initial 24 hours after surgery; afterward, the drain is removed.
- The drain is maintained if there is excess oozing or bile leakage.
A
Cholecystectomy
acute and chronic cholecystitis
serosanguinous fluid
25
- a surgical procedure in which the gallbladder is removed through a small abdominal incision.
- Drains may or may not be used.
Small-Incision Cholecystectomy
26
-__ reserved for the patient with acute cholecystitis who may be too ill to undergo a surgical procedure.
- Involves making an incision in the __
- a tube is usually inserted into the duct for drainage of bile until edema subsides.
- A __ is planned for a future date after acute inflammation has resolved.
Choledochostomy
common duct.
laparoscopic cholecystectomy
27
- performed when the patient’s condition precludes more extensive surgery or when an acute inflammatory reaction is severe.
Cholecystostomy
28
-__ The gallbladder is surgically opened, stones and the bile or the purulent drainage are removed, and a drainage tube is secured with a purse-string suture.
- __ Under local anesthesia, a fine needle is inserted through the abdominal wall and liver edge into the gallbladder under the guidance of ultrasound or computed tomography (CT).
Surgical
Percutaneous
29
Acute pain and discomfort related to surgical incision - NI
Relieving Pain
30
* sudden inflammation of the pancreas.
* There are two main types:
(1)mild (_)
(2)severe (_)
ACUTE PANCREATITIS
interstitial edematous pancreatitis
acute hemorrhagic pancreatitis
31
- affects the majority of patients.
- Characterized by a lack of pancreatic or peripancreatic parenchymal necrosis with diffuse enlargement of the gland due to inflammatory edema.
- The edema and inflammation is confined to the pancreas itself.
- return to normal function usually occurs within __.
Interstitial pancreatitis
6 months
32
- presence of tissue necrosis in either the pancreatic parenchyma or in the tissue surrounding the gland.
- Enzymes damage the local blood vessels, and bleeding and thrombosis can occur.
- Local complications include __ or __ and acute fluid collections in or near the pancreas.
- Also, patients who develop systemic complications with organ failure, such as pulmonary insufficiency with hypoxia, shock, kidney disease, and GI bleeding are categorized as ___.
acute hemorrhagic pancreatitis
pancreatic cysts or abscesses
severe
33
- by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis.
Self-digestion of the pancreas
34
Pain is frequently acute in onset, occurring ____ (unrelieved by __)
24 to 48 hours after a very heavy meal or alcohol ingestion
antacids
35
ASSESSMENT AND DIAGNOSTIC FINDINGS
* __'& __ (elevated within 24 hours of the onset of the symptoms).
Serum amylase and lipase levels
36
- to establish pancreatic drainage; or to resect or débride an infected, necrotic pancreas.
Diagnostic laparotomy
37
Postacute Management
- oral feedings that are low in __ and ___
- __ and ___ are eliminated from the diet.
- Follow-up may include __, __, __ to determine whether the pancreatitis
is resolving
fat and protein
Caffeine and alcohol
ultrasound, x-ray studies, or ERCP
38
6 MEDICAL MANAGEMENT OF PANCREATITIS
1. Pain Management
2. Intensive Care
3. Respiratory Care
4. Biliary Drainage
5. Surgical Intervention
6. Postacute Management
39
* an inflammatory disorder characterized by progressive destruction of the pancreas.
* cells are replaced by fibrous tissue with repeated attacks of pancreatitis
* Increased pressure within the pancreas causes obstruction of the pancreatic and common bile ducts and the duodenum.
* Also, there is ___ of the epithelium of the ducts, inflammation, and destruction of the secreting cells of the pancreas.
Chronic Pancreatitis
atrophy
40
- __ and __ are the major causes of chronic pancreatitis.
* Long-term alcohol consumption causes hypersecretion of ___ in pancreatic secretions,
resulting in protein plugs and calculi within the pancreatic ducts.
* Alcohol consumption and malnutrition
protein
41
most useful study in the diagnosis of chronic pancreatitis
ERCP
42
- evaluates pancreatic islet cell function.
Glucose tolerance test
43
- ___collections of fluid walled off by fibrous tissue (___)
- result of the local necrosis that occurs because of ___
PANCREATIC CYSTS
pancreatic pseudocysts
acute pancreatitis
44
- are amylase-rich fluid collections that occur within 4 to 6 weeks after an episode of acute pancreatitis.
- ___ into the GI tract or through the skin and abdominal wall may be established.
- Pseudocysts
Drainage
45
CLINICAL MANIFESTATIONS of PANCREATIC CYSTS
* Same as _____
acute pancreatitis
46
* Diagnosis of pancreatic cysts and pseudocysts is made by
ultrasound, CT scan, and ERCP
47
overproduction of insulin by the pancreatic islets.
The findings at the time of surgery or at autopsy may indicate ___
All of the symptoms that accompany spontaneous hypoglycemia are relieved by the __ or __
Surgical removal of the __ or __ from the pancreas is the only successful method
of treatment
HYPERINSULINISM
hyperplasia of the islets of Langerhans.
oral or parenteral administration of glucose.
hyperplastic or neoplastic tissue
48
- performed through a small incision or puncture made through the abdominal wall at the umbilicus
- __ attached to the laparoscope permits the surgeon to view the intra abdominal field on a television monitor
- The __ is dissected free and clipped.
- The abdominal cavity is insufflated with carbon dioxide (___).
- The __ is separated from the hepatic bed and removed from the abdominal cavity after bile and small stones are aspirated.
- With the laparoscopic procedure, the patient does not experience __.
- The patient is often discharged from the hospital on the same day of surgery or within 1 or 2 days.
Laparoscopic cholecystectomy
Camera
cystic artery
(pneumoperitoneum)
fiberoptic
paralytic ileus
49
- The most serious complication after laparoscopic cholecystectomy is a
bile duct injury
50
Impaired gas exchange related to the high abdominal
surgical incision- ni
Improving Respiratory Status
51
Impaired skin integrity related to altered biliary
drainage after surgical intervention -
Maintaining Skin Integrity And Promoting Biliary Drainage
52
Imbalanced nutrition, less than body requirements,
related to inadequate bile secretion -
Improving Nutritional Status
53
Monitoring And Managing Potential Complications
Ni
(Bleeding, Gi Symptoms, Infection)
54
- enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice.
gallstones
55
- from the common bile duct into the pancreatic duct activates the powerful enzymes within the pancreas
Reflux of bile
56
can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage.
- Activation of the enzymes
