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What treatment steps are appropriate for patients with cholecystitis or cholangitis?
1. For cholecystitis or cholangitis, start broad-spectrum IV antibiotics to cover gram-negative enterics, gram-positives (Clostridium, enterococcus) and anaerobes (Bacteroides).

2. Volume resuscitate as needed.

3. Patients with cholecystitis may respond to antibiotics alone and warrant elective cholecystectomy
What to look for on a physical exam to indicate cholecystitis or cholangitis?
For both cholecystitis and cholangitis:

1. Fever
2. Tachycardia
3. Hypotension
4. RUQ pain
5. Guarding

Peritoneal signs are usually absent.

Jaundice is a feature of cholangitis, but is absent in cholecystitis.

50% of patients with cholecystitis have a palpably enlarged gallbladder
What are the complications of cholecystitis?
# Empyema (pus in the gallbladder)
# Peritonitis (inflammation of the lining of the abdomen)
# Gangrene (tissue death) of the gallbladder
# Injury to the bile ducts draining the liver
The classic exam finding for cholecystitis is Murphy's sign. How do you elicit it?
Palpate the liver edge deeply at the midclavicular line and ask the patient to inhale. When the inflamed gallbadder meets the hand, the patient abruptly stops breathing in.
How does cystic duct occlusion (cholecystitis) present?
Cystic duct occlusion occurs as postprandial right upper quadrant pain, worse with fatty food ingestion, as much as 3-4 hours after eating. It commonly occurs at night between 10pm and 2am. It can be intermittent or progressive.

If blockage persists, pain becomes steady, often radiating to the right shoulder. High fever is rare.
What are the risk factors for gallstones (cholecystitis)?
The classic patients with gallstones is "fat, fertile, forty and female", a derogatory but accurate characterization of the risk factors.
Progressive parenchymal fibrosis, associated w/ alchoholism/cholecystitis, can have calcifications & pseudocysts
Chronic pancreatitis
What is a priority for a pt admitted w/cholecystitis & cholelithiasis Sympts.acute RUQ pain that radiates to her back, N/V.
Medication for N/V due to cholecystitis ?
Compazine, Meclazine, and Tigan
Findings in acute cholecystitis
Sonographic murphy's (most specific)
Visualized gallstones
GB wall thickening > 3mm
Pericholecystic fluid
What are S&S of cholecystitis?
Pain in RUQ (radiating to shoulder or scapula), anorexia, N, V, dyspepsia, flatulence, eructations (burping), abdominal fullness, fever, jaundice & steatorrhea, rebound tenderness with peritonitis.
What are diagnostic tests for cholecystitis?
Liver function studies, CBC (inc. WBC), serum & urine amylase (inc. amylase with pancreatic involvement), abdominal ultrasound (most common), cholangiography (IV contrast injected, xrays taken over 1-2 hr. period)
What is the clinical management of cholecystitis?
Diet (small, frequent meals), decrease fat & volume of food, analgesics (demoral), morphine is avoided d/t cauases spasms, antiemetics, bile acids and fat soluable vitamin replacement (ADEK) with gallstones.
What are the causes of pancreatitis?
gallstone obstruction, excessive alcohol ingestion, trauma, tumors, metabolic, renal or GI complications, viral infection, drug toxicity, abdominal surgery or invasive procedure.
What is acute pancreatitis?
inflammation of the pancrease due to premature activation of pancreatic enzymes that destroy the pancrease (autodigestion
What are complications of acute pancreatitis?
paralytic ileus, pleural effusion (collection of fluid in plural space), multisystem failure (NHP)
How is acute pancreatitis diagnosed?
Inc. serum/urine amylase and serum lipase, inc. liver function tests if liver involvement, inc. wbc and glucose d/t inflammation, dec. ca and mg, abdominal ct scan and ultrasound.
What are the S&S of Acute pancreatitis?
Abdominal pain (sudden, mid-epigastric or LLQ), weight loss, N, V, jaundice, discoloration of abdomen & flank(pancreatic enzyme leakage), dec. or absent bowel sound, W&W of peritonitis, behavioral changes, impending shock (d/t pancreatic hemorrhage)
What diet is recommended for chronic pancreatitis?
inc. carbs, proteins, dec. fat, TPN or TEN, supplements., IV fluids, F&E,
What are S&S of chronic pancreatitis?
Intense abdominal pain, ascities, LUQ mass (if cyst), respiratory symptoms (if fluid buildup), loss of exocrine function (steatorrhea, clay colored stools, frequent defecation), wt. loss, jaundice, dark urine, signs of diabetes,
What is done for management of acute pancreatitis?
Pin (demoral), NPO, IV fluids, NG tube, antacids, histamine receptor antagonists, anticholinergics, comfort measures, surgery with complications
What is an indicator of pancreatitis?
serum amylase and lipase in the blood
what are some causes of acute pancreatitis?
gallstone obstrucion
excessive alcohol
trama, tumors
metabolic, renal , gi complications
viral , drug toxicity, penetrating duoddenal ulcer, infection
Features of Chronic pancreatitis
Pain after eating and radiates to back (worse when supine), malabsorption, jaundice, DM
What are three conditions that can cause acute pancreatitis?
1)obstruction of main pancreatic duct, frequently by gallstones with reflux of bile
2)injection of bile or other chemicals into the pancreatic duct
3)mechanical disruption of the pancreatic acinar cells (seatbelt trauma)
What is the pathology of acute hemorrhagic pancreatitis?
-massive edema, hemorrhage, and necrosis of tissue
peritoneal irritation or chemical peritonitis occurs due to leakage of enzymes
-serum levels of lipase and amylase are high
Complications of cholelithiasis
Biliary colic,common bile duct obstruction,ascending cholangitis, cholecystitis,acute pancreatitis, gallstone ileus,mucocele,malignancy
Which sx would be most consistent with a dx of cholelithiasis?
ultrasound shows stones in the common bile duct
Symptoms of cholelithiasis include what?
nausea, vomiting, right upper quadrant tenderness, jaundice, abdominal distress
Diagnosis of hernia are confirmed by________, ________, and _____.
Barium Swallow
What are 4 types of hernias?
Inguinal, Femoral, Umbilical, Incisional.
where is a Inguinal hernia
Hernia in the groin, where abdomial folds of meet the thighs
What is an inguinal hernia?
When a portion of the bowel herniates into the inguinal canal. In males, herniation can be seen in the scrotum
This hernia occures in obese or pregnant woman
femoral hernia involves enlarged femoral ring which invites herniation
very susceptible to incarceration
_________ hernia occurs when the upper stomach and the gastroesophagel junction (GEJ) are displaced upward and slide in and out of the thorax.
Who usually get an indirect hernia and why?
infants, because of the failure of processus vaginalis to close
Diaphragmatic Hernia Diagnosis & Tests
The pregnant mother may have shown signs of polyhydramnios (excessive amounts of amniotic fluid). Fetal ultrasound may show abdominal contents in the chest cavity.
Examination of the infant shows:
* chest movements asymmetric with breathing
* breath sounds absent on the affected side
* bowel sounds heard in the chest
* concave abdomen
Who usually gets a direct hernia?
older men
Interventions for hernia
modify diet to include smaller, more frequent meals, eliminate spicy foods, avoid coffee/caffeine, sleep in reverse Trendelenburg position,
How are peptic ulcers treated?
antisecretory agents
What are the 3 main causes of peptic ulcers?
1. helicobacter pyloric infections
2. use of certain anti-inflammatory medications
3. disorders that cause excessive gastric acid secretion
Common surgical procedures involved with peptic ulcers disease are?
management for pt with peptic ulcers include what labs?
i and o, hct, hgb, cbc
What pain is associated with peptic ulcers?
1. Duodenal: food brings relief, there is often nocturnal pain, there are remissions and exacerbations.
2. Gastric: food brings releif, noctural pain, chronic pain without remissions & exacerbations.
3. Stress: usually asymptomatic until hemmorhage occurs or perforation
Gastric Ulcer Symptoms & Signs Include ?
* Abdominal pain
o May wake you at night
o May be relieved by antacids or milk
o May occur 2 to 3 hours after a meal
o May be worse if you don't eat
* Nausea
* Abdominal indigestion
* Vomiting, especially vomiting blood
* Blood in stools or black, tarry stools
* Weight loss
* Fatigue
Gastric Ulcer Diagnosis & Tests include?
* EGD (esophagogastroduodenoscopy) and biopsy showing a benign gastric ulcer
* Upper GI series showing a gastric ulcer
Gastric Ulcer Prognosis (Expectations)
Most ulcers heal with medication in 6 to 8 weeks. Recurrence is common but is less likely if H. pylori infection is treated and acid-blocking medications are continued.
Gastric Ulcer Complications
* Bleeding from the ulcer
* Perforation (hole) in the stomach
* Obstruction of the passage of stomach contents
Complications are often corrected by medication, through an endoscope, or (in rare instances) with surgery.
How is hepatitis transmitted?
A: fecal-oral, parenteral, sexual
B: parenteral, sexual
C: perenteral
what is diagnostics for suspected hepatitis
alt ast
IgM anti HAV
Anti HCV
possibly anti hep b core antigen to check for window period
How does cirrhosis manifest?
Chronic alcohol abuse is the most common cause. Other causes: some infections, prolonged obstruction or diseases of the bile ducts, severe heart disease, severe reactions to medications, and exposure to toxic chemicals.
3 manifestations seen in alcoholic cirrhosis
esoph. Varices, hemorrhoids, caput medusae "Gut, butt and caput"
Reasons why patients with cirrhosis and ascitis have Spontaneous bacterial peritonitis?
1. Poor removal of bacteria by liver
2. low levels of complement in ascitis
3. Poor function of neutrophils in advanced liver disease.
Name 9 causes of liver cirrhosis.
hepatitis (B,C,D,TTV)
Wilson's dis
secondary cirrhosis
secondary to any CAH
cystic fibrosis
What are the manifestations of cirrhosis?
chronic indigestion
weight loss
spider telangiectasis
varices-d/t portal hypertension
decrease in albumin
vitamin deficiency
caput medusae-enlarged vessels ATC belly button
It is given to treat bleeding of the esophagus that may result from cirrhosis of the liver.
Terlipressin, somatostatin
What lab value is elevated in the end stage of cirrhosis of the liver?
Tests can reveal liver problems including
# Anemia (detected on a CBC)
# Coagulation abnormalities
# Elevated liver enzymes
# Elevated bilirubin
# Serum albumin low
Treatment for managing the complications of cirrhosis
* Offending medications and alcohol are stopped.
* Bleeding varices are treated by upper endoscopy with banding or sclerosis.
* Ascites (excess abdominal fluid) is treated with diuretics, fluid and salt restriction, and removal of fluid (paracentesis).
* Coagulopathy may be treated with blood products or vitamin K.
* Encephalopathy is treated with the medication lactulose; sometimes antibiotics are used and patients should avoid a diet high in protein.
* Infections are treated with antibiotics.
* If cirrhosis progresses and becomes life-threatening, a liver transplant should be considered.
Cirrhosis Complications include?
* Bleeding esophageal varices
* Portal hypertension
* Hepatic encephalopathy
* Mental confusion
* Coma
* Abdominal fluid retention (ascites) and infection of the fluid (bacterial peritonitis)
* Sepsis
* Liver cancer (hepatocellular carcinoma)
* Kidney failure (hepatorenal syndrome)
What are Bleeding Esophageal Varices ?
result from dilated veins in the walls of the lower part of the esophagus and sometimes the upper part of the stomach.
What is Hepatic Encephalopathy
Hepatic encephalopathy is brain and nervous system damage that occurs as a complication of liver disorders. It is characterized by various neurologic symptoms including changes in reflexes, changes in consciousness, and behavior changes that can range from mild to severe
Nasogastric Tube (NG tube)
Short tube - goes from nose to stomach - includes types such as Levin & Salem Sump. Removes gas & fluid from upper GI. Sometimes used for meds or feedings.
Levin Tube
Single lumen, 14-18fr.
Salem Sump
Double lumen, plastic 12-18fr. Smaller inner tube vents larger suction/drainage tube to atmosphere.
Nasoenteric Tubes
Go from nose to intestine - can be medium or long in length (placed in either duodenim or jejunum)
DobHoff Tube
small-bore nasoenteric feeding tube. Weighted at bottom. Placement must be verified by xray.
Miller-Abbott Tube
Long nasoenteric tube. Goes into small intestine. Used for aspiration. Weighted with mercury, water, or saline.
Harris Tube
Long nasoenteric tube - used for suction & irrigation. Is weighted by mercury.
Documenting Tube (what to note)
Tube type & size; Drainage - amt color & consistency; irrigation type & amt; suction type/level (eg: low intermittent); feeding: type & amt; pt tolerance; pt education & response.
NG suction
Keep btwn 20-80 mm/Hg. Continuous suction> 25mm/Hg can cause damage to gastric mucosa.
Changing NG tubing
For feeding: Must change q24h. For suction change tubing q48h. Cannister changed prn, but must be emptied & output documented on I&O qShift.

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