6. biliary & pancreatic duct

6. biliary & pancreatic duct

1. Gallbladder disease (Cholecystitis)

   • risk factors
     • nutrition habits,sedentary lifestyle, obesity, age, diabetes mellitus, Native Americans, Mexicans, rapid weight loss, longterm TPN, crowns, gastric bypass, sickle cell anemia, glucose intolerance
   • clinical manifestations
     • GI distress: dyspepsia, bloat, flatus, n/v
     • pain: bilary colic that radiates to shoulder or scapula
       • pain due to high fat or lg meal
         • give dilaudid or morphine
     • fever, tachycardia d/t infection
     • jaundice, pruritis, dark urine, steatorrhea, impaired absorption of fat soluble vitamins
   • surgical management
     • laproscopic cholecystectomy
       • advantages of MIS
         • complications rare, low death rate, quick recovery, minimal post op,
       • choledochocopy
         • iv antibiotics
         • 4 sm incisions around umbilicus
         • allows for exploration of bile duct and removal of stones
         • abdominal cavity inflated with 3-4 L o2
         • postop care
           • pain mgmt for shoulder or scapular pain d/t o2 movement
           • early ambulation to remove o2
           • monitor skin integrity
           • deep breathing
     • open cholecystectomy
       • drains (JP 24-48)
       • greater complication risk
       • t tube (keep bag below GB)
     • ercp
       • combines X-ray with endoscope
         • complications perforation, infection, bleeding, pancreatittis
   • medications
     • anticholinergics (bentyl)
       • decreases peristalsis
         • causes dry mouth
           • should not be given to older adults
     • cholinergics
       • increase peristalsis
         • increases salvation
     • antisecretory agents
       • somatostatin and octreotide
         • are used to decrease pancreatic enzymes
   • complications of gallstones
     • obstruction of common bile duct
     • obstruction of pancreatic duct causing pancreatitis
       • ERCP is needed for visualization. gallstones can be removed at stents can be placed to open stictures allowing bile to flow

2. Pancreatitis

   • caused by premature activation of pancreatic enzymes increased production (lipase,trypsin,kallikrein)
     • enzymes destroy ductal tissue and pancreatic cells (cause vasodilation, increased vascular permeability, edema, necrosis, and hemorrhage
       • autodigestion results
         • clinical manifestations of pancreatitis
           • abdominal pain immediately following consumption of ETOH or high fat diets
             • can radiate to left shoulder or back
           • n/v
           • hypoactive or absent bowels if periodic ileum
           • culling sign (periumbilical discoloration)
           • turners sign (flank discoloration)
           • respiratory complications: dyspnea, tachycardia, hypoxia, diminished breath sounds
           • as pancreatitis worsens what may occur?
             • board like abdomen and ecchymosis
               • indicates hemorrhagic pancreatitis
           • ascities: increased permeability, third spacing, leakage of protein rich fluids
           • bacterial infection - pancreatic pseudocysts
           • jaundice may develop with bilary obstruction
         • complications of pancreatitis
           • respiratory: pleural effusion, atelectasis and pneumonia leading to ards
           • Sepsis and MOSF (leading cause of death)
           • hypovolemia, hemorrhage, shock
           • acute renal failure
           • DIC
           • diabetes mellitus
         • how to manage pancreatitis?
           • pain medication
             • PCA pump (dilaudid/morphine)
           • IV for hydration
           • NPO
             • to rest pancreatic enzyme secretion
               • after - CL diet - if pain returns back NPO
                 • sm freq meals increased carbs and protein
                   • low fat intake
                     • avoid caffeine, smoking, chocolate, etoh
           • provide comfort
           • medications
             • spasmolytics (papaverine: pavabid, cerespan)
               • to relax smooth muscle
             • anticholinergics (bentyl)
               • decrease vagal stimulation, motility, pancreatic flow
                 • contraindicated with paralytic ileum
             • PPI (prilosec)
               • decrease acid secretions
             • antisecretory (somatostatin & Octreotide)
               • decreases secretion of pancreatic enzymes
   • factors of pancreatitis
     • cholelithiasis
     • alcohol & drugs
       • pancreatic tumors/cysts
         • abdominal trauma, surgical manipulation
           • infection
   • diagnosing pancreatitis
     • amylase and lipase
       • amylase rises quickly within 12-24 hr
         • lipase rises within 5-7 days but remains increased for up to 2wks
           • other tests: CBC, ESR (inflammatory marker), BMP, Electrolytes, ultrasound, CT, CXR
             • electrolytes: hypocalcemia with fat necrosis

3. review pancreatic cancer in text