ch44 part 3: Pancreas, Gallbladder

  1. Acute pancreatitis - define and treat.
    • Define: Acute inflammation, varies from mild edema to severe hemorrhagic necrosis
    • Causes: 1) Gallbladder disease, gallstones, 2) chronic alcohol intake; less common include trauma, viral infections (mumps, coxsackievirus B, HIV), duodenal ulcer, cysts, abscess, cystic fibrosis, Kaposi sarcoma, drugs, metabolic disorders, vascular disease, idiopathic
    • What happens: Autodigestion of pancreas by pancreatic enzymes
    • How: Trypsinogen (inactive proteolytic enzyme produced by pancreas) + enterokinase = trypsin; this should occur in the intestines; if it occurs in pancreas, trypsin causes autodigestion and activates other proteolytic enzymes such as elastase and phospholipase A, which result in further pancreatic autodigestion
    • Clinical manifestations: LUQ to mid abdominal pain; sudden onset, severe, deep piercing, continuous or steady; aggravated by eating or recumbent position; not relieved by vomiting; may have flushing, cyanosis, dyspnea, nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, jaundice
    • Lab tests: Elevated serum amylase (24-72 hours), elevated lipase (elevates and stays elevated)
  2. Grey-Turner's sign.
    • Areas of ecchymosis, bluish flank discoloration
    • Takes 24-48 hours to appear
    • Can predict severe attack of acute pancreatitisImage Upload 1
  3. Cullen's sign.
    • Ecchymosis, bluish periumbilical discoloration
    • Takes 24-48 hours to appear
    • Can predict acute pancreatitisImage Upload 2
  4. Pancreatic pseudocyst.
    • Cavity continuous with or surrounding the outside of the pancreas
    • Fills with necrotic products and liquid secretions (plasma, pancreatic enzymes, inflammatory exudates)
    • Manifestations include abdominal pain, palpable epigastric mass, nausea, vomiting, anorexia
    • Elevated serum amylase
    • Usually resolves spontaneously within a few weeks, but may perforate, causing peritonitis, or rupture into stomach or duodenum
    • Treatment includes internal drainage procedure with anastomosis between pancreatic duct and jejunum
  5. Pancreatic abscess.
    • Large fluid-containing cavity within the pancreas
    • Results from extensive necrosis in the pancreas
    • Manifestations include upper abdominal pain, abdominal mass, high fever, leukocytosis
    • Requires prompt surgical drainage to prevent sepsis
    • Complications include pleural effusion, atelectasis, pneumonia, hypotension, and tetany (hypocalcemia)
  6. Pancreatitis - collaborative care.
    • Relief of pain
    • Prevention or alleviation of shock - IV fluids, volume expanders (dextran, albumin); vasoactive drugs (dopamine/Intropin) to reduce hypotension
    • Reduction of pancreatic secretions and stimulation - NPO, NG suction to reduce stomach acids
    • Control of fluid and electrolyte imbalances - Lactated Ringers, other electrolyte solutions
    • Prevention or treatment of infection
    • Removal of precipitating cause (if possible)
    • Aggressive rehydrationPain management - IV morphine, spasmolytics (nitroglycerine, papaverine)
    • Management of metabolic complications
  7. Chronic pancreatitis, obstructive and calcifying.
    • Continuous, prolonged, inflammatory and fibrosing process of the pancreas; pancreas becomes progressively destroyed and replaced by fibrotic tissue
    • Chronic obstructive pancreatitis: Associated with biliary disease, most commonly caused by inflammation of the sphincter of Oddi associated with cholelithiasis; other causes include cancer of ampulla of Vater, duodenum, or pancreas
    • Chronic calcifying pancreatitis: Inflammation and sclerosis mainly in the head of the pancreas and around pancreatic duct; also called alcohol-induced pancreatitis
  8. Cholelithiasis.
    • Gallstones (stones in the gallbladder), predominantly made from cholesterol
    • Develop r/t imbalance between cholesterol, bile salts, and calcium
    • Treatment includes sphincterotomy and mechanical removal, extracorporeal shock-wave lithotripsy (ESWL), and cholecystectomy (gallbladder removal)
  9. Cholecystitis.
    • Inflammation of the gallbladder
    • Usually associated with gallstones (cholelithiasis) or biliary sludge
    • Acalculous (without gallstones) cholecystitis can occur from prolonged immobility and fasting, prolonged parenteral nutrition, diabetes mellitus, bacteria (E. coli), or chemical irritant
    • Manifestations include RUQ to mid abdominal pain, nausea, vomiting, restlessness, diaphoresis, right shoulder blade pain
  10. Gallbladder cancer.
    • Primary cancer of gallbladder is uncommon
    • Majority are adenocarcinomas (cancer of epithelium that originates in glandular tissue)
    • Relationship between gallbladder cancer and chronic cholecystitis and cholelithiasis
    • Symptoms similar to cholecystitis
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ch44 part 3: Pancreas, Gallbladder
Chapter 44 Pancreas and Gallbladder