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Gall bladder
Thegallbladderis a small pear-shaped organ that stores and concentrates bile. The gallbladder is connected to theliver by the hepatic duct. It approximately 3 to 4 inches (7.6 to 10.2 cm) long and about 1 inch (2.5 cm) wide. function of the gallbladder is to store bile and concentrate
Pancreas
Exocrine secretion of pancreatic enzymes into the GIT through the pancreatic duct. Endocrine secretion of insulin, glucagon, and somatostatin into the blood stream
Exocrine Pancreas
Secretions are high in protein content and electrolyte rich fluid Alkaline Secretions include
Amylase
aids in the digestion of carbohydrates Trypsin digestion of proteins Lipase digestion of fats
Endocrine Pancreas
Islet of langerhans
Collection
of cells embedded in the pancreatic tissue Composed of alpha, beta, delta cells
Alpha cells
Secrete
Beta cells
Secrete
Delta cells
Secrete
Terminology
Cholecystitis inflammation of the gallbladder Cholelithiasis the presence of calculi in the gallbladder Cholecytectomy- removal of the gallbladder Cholecytostomy opening and drainage of the gall bladder Choledochotomy opening of the common duct Choledocholithiasis stones in the
Cholecystitis
defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct fromcholelithiasis
Manifestations
Pain, Rigidity, tenderness of the upper right abdomen Fever Nausea Vomiting Tachycardia (+) Murphys Sign
described
Causes
Calculous cholecystitis
Female sex Obesity or rapid weight loss Drugs (especially hormonal therapy in women) Pregnancy Increasing age
Acalculous cholecystitis
Critical illness Major surgery or severe trauma/burns Sepsis Long-term TPN Prolonged fasting
Other causes
Cardiac
events, including myocardial infarction Sickle cell disease Salmonellainfections Diabetes mellitus Patients with AIDS with cytomegalovirus, cryptosporidiosis, or microsporidiosis
Diagnostics
Increased Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels Amylase mildly elevated Ultrasonography Radiography
Medical Treatment
initial treatment includes bowel rest, intravenous hydration, analgesia, and intravenous antibiotics Emesis can be treated with antiemetics and nasogastric suction. Restoration of hemodynamic stability Daily stimulation of gallbladder contraction Laparoscopic cholecystectomy
is
Cholecystectomy or Cholecystotomy
usually
reserved for complicated cases in which the patient has gangrene or perforation.
Nursing Management
Encourage fluid input and output Monitor vital signs Assess pain and administer analgesics as ordered Provide diet a liquid or low-fat diet if surgery is not an option Administer antibiotics as ordered Assist with ambulation Encourage adequate nutrition Assess for complications
Cholelithiasis
Risk Factors
Obesity Women Multiple preganancies Frequent changes in weight Rapid weight loss Treatment of High dose estrogen Ileal resection or disease Cystic fibrosis Diabetes
Four Fs
Female Fat Forty Fertile
Pathophysiology
Biliary sludgeis often a precursor of gallstones. It consists of Ca bilirubinate (a polymer of bilirubin), cholesterol microcrystals, and mucin Sludge develops during gallbladder stasis as occurs during pregnancy or while receiving TPN.
Types:
Cholesterol stones
Bile
must be supersaturated with cholesterol The excess cholesterol must precipitate from solution as solid microcrystals microcrystals must aggregate and grow.
small, hard gallstones composed of Ca bilirubinate and inorganic Ca salts (eg, Ca carbonate, Ca phosphate) alcoholic liver disease, chronic hemolysis, and older age
soft and greasy, consisting of bilirubinate and fatty acids (Ca palmitate or stearate). They form during infection, inflammation, and parasitic infestation
Manifestations
distention Vague pain in the RUQ May follow ingestion of fried and fatty foods
or intermittent ache in the upper abdomen, usually under the right side of the rib cage.
Biliary
colic
pain
Jaundice
Occurs
in few patients
Diagnostics
radioactive dye is administered IV. The Biliary tree is then scanned iodide containing contrast agent is administered to the patient . And a xray is taken
Cholecystography
An
Surgical treatment
Endoscopic Retrograde Cholangiopancreatography (ERCP) is a test that combines the use of a flexible, lighted scope (endoscope) with X-ray pictures to examine the tubes that drain theliver,gallbladder, andpancreas
Purpose:
Check persistent abdominal pain orjaundice. Findgallstones or diseases of the liver, bile ducts, or pancreas. Remove gallstones from the common bile duct if they are causing a problem such as blockage (obstruction), inflammation or infection of the common bile duct (cholangitis), orpancreatitis. Open a narrowed bile duct or insert a drain.
radiologic technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken
Medical Management
Administration of IV fluids Nasogastric suction Adequate rest Antibiotic therapy Ursodeoxycholic acid (UDCA) Chenodeoxycholic acid
Has
Mono-octanoin or methyl tertiary butyl ether (MTBE) infusion Extracorporeal Shockwave Lithotripsy
Nursing Management
Monitor pain administer analgesics as ordered Assess vital signs Encourage hydration Administer a low fat diet Instruct to avoid gaseous foods Prepare the client for surgery
Pancreatitis
Acute Pancreatitis
is a suddeninflammationof thepancreas
Manifestation
Edema on the pancreas Inflammation Severe epigastric pain radiating to the back Nausea,vomiting,diarrheaandloss of appetite Fever/chills Hemodynamicinstability, includingshock
Grey-Turner's sign(hemorrhagic discoloration of the flanks) Cullen's sign(hemorrhagic discoloration of the umbilicus) Grnwald sign (appearance ofecchymosisaround the umbilicus due to local toxic lesion of the vessels.) Krte's sign (pain or resistance in the zone where the head of pancreas is located (inepigastrium, 6-7 cm above the umbilicus). Kamenchik's sign (pain with pressure under thexiphoid process) Mayo-Robson's sign (pain while pressing at the top of the angle lateral to theErector spinae musclesand below the left 12th rib (left costovertebral angle (CVA))
Cullens Sign
Age > 55 years WBC >16,00 mm3 Serum Glucose >200 mg/dL Serum LDH > .350 IU/L AST .250/mL
Causes
that travel down the commonbile ductand which subsequently get stuck in theAmpulla of Vatercan cause obstruction in the outflow of pancreatic juices from the pancreas into theduodenum. The backflow of these digestive juices causeslysis(dissolving) of pancreatic cells and subsequent pancreatitis.
E -ethanol(alcohol) T -trauma
(Epstein-Barr virus,Cytomegalovirus)
A -autoimmune diseas(Systemic lupus erythematosus) S -scorpion sting (e.g.Tityus trinitatis), and alsosnake bites H -hypercalcemia,hyperlipidemia/hypertriglyceri demiaandhypothermia E -ERCP(EndoscopicRetrogradeCholangioPancreatography - a procedure that combinesendoscopyandfluoroscopy) D -drugs
Diagnostics
Increased blood amylase level Increasedserum blood lipase level Increaseurine amylase level
Medical Treatment
Pain medicines Fluids given through a vein (IV) (NPO)Stopping food or fluid by mouth to limit the activity of the pancreas NGT to drain insertion Drain fluid that has collected in or around the pancreas (biliary drainage) Removegallstones (ERCP, ESWL) Relieve blockages of the pancreatic duct
Nursing Management
Monitor vital signs Administer pain medications Implement NPO status Complete bed rest Assess fluid and electrolyte balance (monitor input and output) Monitor NGT drainage Provide health teachings
Chronic Pancreatitis
is long-standing inflammation of the pancreas that results in irreversible deterioration of pancreatic structure and function
Causes
Manifestations
Back pain Abdominal pain Weight loss swollen and tender abdomen nausea vomiting fever rapid pulse Fatty stools (steatorrhea)
Diagnostics
Asecretinstimulation test
Is
considered thegold standard functional test for diagnosis of chronic pancreatitis but not often used clinically be elevated
ESR,IgG4,rheumatoid factor
May
Medical Treatment
Chemical dependency treatment is the most important step in treating alcohol-related pancreatitis. Pain relief drugs Endoscopic therapy by introducing stents to drain blocked pancreatic ducts Shock wave lithotripsy to pulverize pancreatic stones Surgery (laparoscopic and traditional) Islet cell transplantation may be offered if most or all of the pancreas is removed. Enzyme therapy for malabsorption helps restore normal digestion and reduces the amount of fat in the feces, leading to weight gain and improved well-being. Dietary changes such as eating smaller meals and limiting fats help reduce the need for digestive enzymes. Treatment of diabetes, if that develops
Nursing Management
Assess pain
Administer
analgesics as ordered
Monitor Input and output Monitor vital signs Assess hydration status (I & 0) Administer oxygen as ordered Insruct the patient to avoid alcohol and fatty foods Assess stools
Pancreatic cancer
amalignantneoplasmof thepancreas Sometimes called a "silent killer" because early pancreatic cancer often does not cause symptoms
Manifestations
Pain in the upper abdomen that typically radiates to the Loss of appetiteand/or nausea and vomiting Significantweight loss Painlessjaundice(yellow skin/eyes, dark urine) pale-colored stool andsteatorrhea Trousseau sign Diabetes mellitus, or elevated blood sugar levels.
Causes
Age (particularly over 60) Male Smoking Diets low in vegetables and fruits Diets high in red meat Diets high in sugar-sweetened drinks (soft drinks) Obesity
Diabetes mellitus
is
both risk factor for pancreatic cancer, and, as noted earlier, new onset diabetes can be an early sign of the disease.
Diagnostics
Computed tomography (CT) scans Magnetic resonance cholangiopancreatography (MRCP) Endoscopic ultrasound (EUS) Endoscopic retrograde cholangiopancreatography (ERCP) Upper GI series
Surgical treatment
Whipple procedure
the
most common surgical treatment for cancers involving the head of the pancreas procedure involves removing the pancreatic head and the curve of the duodenum together (pancreatoduodenectomy)
Distal Pancreatectomy
Medical Management
hundreds of small radiation beams of varying intensities to precisely target cancer cells, while sparing healthy tissue
Chemotherapy
Nursing Management
Assess pain
Administer
small low fat feedings Monitor weight Assess and monitor hydration
ulcers
Relieve discomforts
Relief