THE GALLBLADDER, CHOLESYSITIS AND

ACUTE PANCREATITISLINDSEY CALLIHAN, MS DIETETIC INTERN

CASE STUDY: CLUE #1

• 77 yo female admitted for acute abdominal pain

• Recently hospitalized for pneumonia

• 8-10 days out of hospital

• Has had poor PO intake recently

• Known gallstones

THE GALLBLADDER AND ITS BILE

THE GALLBLADDER: (1,2)

• Is located under liver

• Collects and stores bile made from the liver

• Is connected to the liver, the pancreas and the small intestine

• Squeezes bile into the small intestine during meals to help

digest fat

BILE:

• Consists of bile salts, electrolytes, bilirubin, cholesterol and fats

• Alkaline secretion

• Bile assists fat digestion in the small intestine by entering through the common bile duct.

• In the absence of the gallbladder, fats are less efficiently digested

Photo: Webmd.com

GALLSTONES AKA CHOLELITHIASIS

WHAT? (1,2)

• Usually formed by cholesterol and/or bile pigments

• Form hard, crystal like particles

• 80% of gallstones are primarily made of cholesterol

• Can travel through ducts to pancreas, small intestine or stay put

• Vary in size from grains of sand to golf ball size

• Can be many or be few

HOW?

• Underactive gallbladder – starvation, extreme diets

• Inadequate contraction

RISK FACTORS:

• Female

• Older age

• Diabetes

• Obesity

• Pregnant or taking birth control pills

• Native American decent

• Rapid wt loss or fasting

www.Ourwebdoctor.com

CASE STUDY: CLUE #2

• Wt hx: 5.1kg in 4 mos (12%)

• Jan 2014: 47.4kg

• March 2014: 45.6kg

• April 2014: 42.3kg

• Trying to gain wt after recent hospitalization

• Acute sx of pain in abd, sternum after eating a large meal of chicken wings, baked potato with sour cream/butter

• Denies alcohol abuse

CHOLELITHIASIS AND SURROUNDING IMPACT• HEPATIC DUCT: Blockage in the duct from liver to

small intestine blockage of bile = cholangitis

• Fever, jaundice, pain in abdomen

• CYSTIC DUCT: Blockage in the bile duct to small intestine backup of bile, inflammation = cholesystitis

• Pain in abdomen, back, nausea, vomiting esp following meal

• COMMON or PANCREATIC DUCT: blockage in pancreas build up of pancreatic juice, inflammation = pancreatitis

• Severe pain, nausea, vomiting

PANCREAS

• Secretes pancreatic juice to neutralize chyme from the stomach

• Secretes insulin and glucagon

• Secretes digestive enzymes including lipase, amylase, trypsin, chymotrypsin, CCK for the digestion of fat, protein and carbs.

Webmd.com

PANCREATITISCAUSES:

Gallstones or alcohol

SX:

dull epigastric pain, anorexia, nausea, vomiting, fever, tachycardia, hypotension

DX CRITERIA:

abdominal pain, radiographic evidence (CT, MRI, ultrasound) of gallbladder and pancreas, elevation of amylase or lipase 3x normal limit (4)

OTHER LABS:

hyperglycemia, hypocalcemia, leukocytosis, mild LFTs elevation

SEVERITY CRITERIA:

pseudocyst, necrosis, acute fluid collection

www.charlestongi.com

CASE STUDY: CLUE #3

Labs upon admit:

potassium

creatinine

calcium

BUN

LFTs

WBC

lipase – 10x normal limit

TREATMENT • NPO• IVF fluid tx• ERCP only, pre or post cholecystectomy

Mild: (4)• Ultrasound, CT or MRI stones• Lack of pseudocysts or excessive fluid around

pancreas• Ensure no current infection• Cholecystectomy after acute sx subside

Severe: (4)• Ultrasound, CT or MRI stones• Necrosis, infection, pseudocysts, organ failure• Possible fluid removal• Improvement of condition home?• EN if needed: J-tube• Possible cholecystectomy

Clevelandclinicmeded.com

CASE STUDY: DX AND INTERVENTION

ULTRASOUND:

• Innumerable gravel-like gallstones filling the gallbladder

• Normal appearing common bile duct, though later suggested

pt has common duct stone

• No pericholecystic fluid

DX: Acute gallstone pancreatitis

INTERVENTION:

• IVF @ 125/hr

• NPO

• Suggest cholecystectomy

• Potential for ERCP to identify and remove stones in ducts post-surgery

www.ultrasoundcases.info

COMPLICATIONS• ARF

• ARDS

• Ascites

• Pancreatic cysts or pseudocysts (infectious?)

• Pancreatic necrosis

• Heart failure

• Low BP (5)

• Mortality rates: 5-10%

• Determinants: infected necrosis, infected pseudocysts, organ failure (4)

• Reoccurrence of pancreatitis with ERCP only or cholecystectomy without ERCP (6)

www.physio-pedia.com

CASE STUDY: TREATMENT AND COMPLICATIONS

• Cholecystectomy at MGH – unsuccessful due to hypotensive reaction to anesthetic

• Transferred to St. Peter

• Confirmed to have MI angioplasty

• Pancreatitis sx resolved, passed stone

• Multiple hypotensive episodes, FTT, prognosis poor

RECENT LITERATURE & NUTRITIONAL THERAPY

• Severe Pancreatitis(5,7)

• Early Cholecystectomy increased risk <7days

• Delayed cholecystectomy 7-45 days

• Mild gallstone pancreatitis: cholecystectomy within 48hrs (8)

• No cholecystectomy: (2)

• Encourage healthy weight

• Discourage fasting and rapid weight loss

• Encourage exercise

• Encourage appropriate fat intake

• Post cholecystectomy:

• Limit fat intake for a few months

• If diarrhea, antidiarrheal medications or a high fiber diet can be used

• Avoid fasting and rapid weight loss diets

ENTERAL NUTRITION

• EN vs TPN: increased risk for systemic inflammation, multi organ failure, need for operative interventions and death in TPN pts (9)

• EN through jejunum (10)

• Standard formula + pancreatic enzyme replacement meds

• Elemental, low in fat with MCTs

• Home with J-PEG: nocturnal cycle, 1.5kcal/ml, 80-130ml/hr x 12 hrs, 1-1.5L/day free water

• Vomiting, abd pressure kcal, release pressure through G tube

• TPN: EN has failed, ascites, prolonged ileus, bowel perforation, fistula, severe pain during jejunal feeding

• Diet advancement when GI doc pancreatitis resolution

Stillmilestogo.com

QUESTIONS?

TWO POPULAR STIMULANT DRUGS

METHAMPHETAMINES AND BATH SALTS

METHAMPHETAMINES

• Stimulant – causes rush of good feelings and happiness agitated, euphoric, angry, fear, paranoia, insomnia

• Highly addictive

• White, crystalline

• Eaten, snorted, injected, smoked

• Physiological:

• Increases body temp

• Severe itching

• Dental decay and dry mouth

• Emotional problems

• Suppressed appetite

• Tremors, convulsions

• BP

• Arrhythmia

• Brain damage (11)

www.pbs.org www.pbs.org

BATH SALTS

• Stimulant, similar to amphetamines causes feelings of joy with increased sociability and sex drive

• 10 times stronger effect on brain dopamine than cocaine

• Hodgepodge of synthetic drugs, most always contain manmade cathinones

• Swallowed, inhaled, injected, snorted, injection

• Resemble Epsom salts in appearance

• Recent rise since 2010

• Side effects include:

• Paranoia

• Violent behavior

• Delusions

• Seizures

• Panic attacks

• Increased BP and HR

• Chest pain

• Nausea/Vomiting

• Kidney failure

• Muscle breakdown

• Death (12,13)

REFERENCES• Mahan, L. K., Escott-Stump, S., Raymond, J. L., & Krause, M. V. Krause's food & the nutrition care process (13th ed.). (2012). St. Louis, Mo.: Elsevier/Saunders.

• Escott-Stump, S. Nutrition and Diagnosis-Related Care. (6th ed.). (2008). Baltimore, MD.:Lippincott Williams and Wilkins.

• Gallstones and Bile Duct Stones. Digestive Disease Center. Website. http://www.ddc.musc.edu/public/symptomsDiseases/diseases/pancreas/gallstones.cfm. Updated April 10, 2014. Accessed May 7, 2014.

• Lee, P., Stevens, T. Acute Pancreatitis. Cleveland Clinic. Website. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/acute-pancreatitis/. Published February 2014. Accessed May 8, 2014.

• Shikata S, Noguchi Y, Fukui T. Early versus delayed cholecystectomy for acute cholecystitis: a meta-analysis of randomized controlled trials. Surg Today. 2005;35(7):553-60.

• Mustafa A, Begaj I, Deakin M, et al. Long-term effectiveness of cholecystectomy and endoscopic sphincterotomy in the management of gallstone pancreatitis. SurgEndosc. 2014;28(1):127-33.

• Nealon WH, Bawduniak J, Walser EM. Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections. Ann Surg. 2004;239(6):741-9.

• Aboulian A, Chan T, Yaghoubian A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. 2010;251(4):615-9.

• Al-omran M, Groof A, Wilke D. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev. 2003;(1):CD002837.

• Fessler, T. Nutrition Support in Severe Acute Pancreatitis. Today’s Dietitian.2010; 12(1):36

• Methamphetamine. Medline Plus. Website. http://www.nlm.nih.gov/medlineplus/methamphetamine.html. Update May 6, 2014. Accessed May 7, 2014.

• Bath Salts. AAPCC. Website. http://www.aapcc.org/alerts/bath-salts/. Accessed May 6, 2014.

• What are Bath Salts? NIDA for Teens. Website. http://teens.drugabuse.gov/drug-facts/bath-salts. Updated May 5, 2014. Accessed May 6, 2014.