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NURS 642 Exam 2. Maryville University.
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NURS 642 Exam 2. Maryville University.Cholelithiasis (Quick) (what is it? what does it look like? what imaging? Tx?) - ANS o Stone formation in
the gallbladder.
o Colicky (comes and goes) RUQ pain - worse with fatty foods.
o Dx: RUQ US.
o Tx: elective cholecystectomy.
Cholelithiasis (in depth) - ANS • Is the creation/presence of gallstones (calculi) in the gallbladder. Not
usually with any complications.
• High risk: Female >male, Increasing age, family Hx, Pregnancy, DM, Dyslipidemia (>HDL), Obesity,
Rapid weight loss, Cirrhosis, Crohn disease, & Hyperbilirubinemia. Medication use: Fibrates, Ceftriaxone,
Somatostatin analogues, Hormone replacement, Oral contraceptives.
• Physical activity, statins, vitamin C, coffee, vegetable protein, nuts, and mono/poly saturated fats may
all help prevent gallstone formation.
• Evaluated via Ultrasound of abdomen.
• Most gallstones do not have complications and do not require intervention.
o S/SX: Majority are asymptomatic.
o Expectant management = no TX needed.
o Cholecystectomy is not recommended for these patients as possible complications from surgery >
non-symptomatic gallstones.
Patients at risk for gallbladder cancer may choose to have preventative cholecystectomy. High risk:
Patients with gallbladder adenomas, with porcelain gallbladder, large gallstones (>3 cm), or if pancreatic
duct is draining into their common bile duct.
o Educate on symptoms of gallstone disease / biliary colic / acute cholecystitis.
o May consider gallstone dissolution trial with Ursodiol. Typical trial is 3 months, may need >/= 2 years
of this to dissolve gallstones.
• Can cause pain attacks with no complications; that is referred to as biliary colic.
,o TX: is pain control: NSAIDS (ex: Ketorolac, Diclofenac, Tenoxicam, Flubiprofen, Ketoprofen), then
opioids if needed or if NSAIDS are contraindicated.
o Report to ED after 4 hours if pain is uncontrolled; potential to advance to a complication such as acute
cholecystitis.
o May have elective cholecystectomy to prevent further pain flairs (lap prefered over open).
o Final Tx: cholecystectomy. Can do elective to prevent future reocurr
Cholecystitis (Quick) (what is it? what does it look like? what imaging? Tx?) - ANS o Cystic duct
obstruction (inflammation).
o + Murphy sign.
o Constant RUQ pain.
o Fever, leukocytosis.
o Dx: RUQ US, HIDA scan.
o TX: cholecystectomy.
Cholecystitis (in depth) - ANS • Is a complication from outlet obstruction (usually from gallstones)
resulting in gallbladder inflammation.
• Acute cholecystitis is a primary diagnostic consideration in patients presenting with RUQ pain.
• Primarily a result of gallbladder outlet obstruction
• Gallstones cause the majority of acute cholecystitis cases.
• Gangrene and perforation can result if inflammation is not treated
• Colicky pain in the RUQ - severe - usually with radiation to the flank and occasionally to the right
shoulder. Accompanied by nausea and vomiting.
• Ultrasound (for diagnosis) will demonstrate the presence of stones or calculi, gallbladder wall
thickening (greater than 4 to 5 mm), pericholecystic fluid, and, on occasion, sonographic Murphy sign.
• WBC elevated
• Elevated liver enzymes: AST, ALT, ALP. (Most common in chronic).
• Mild elevation in serum aminotrANSferase, amylase, and hyperbilirubinemia can occur.
,• Usually have fever.
• A positive Murphy's sign on physical examination supports the diagnosis. (elicited by firmly placing a
hand at the costal margin in the right upper abdominal quadrant and asking the patient to breathe
deeply; if the patient abruptly ceases inhaling due to pain.)
• Cholecystectomy is the mainstay of treatment for acute calculous cholecystitis. Lap chole > open.
• Poor surgical candidates may benefit from initial nonoperative management with antibiotics and a
gallbladder drainage procedure.
• Acute calculous cholecystitis should be admitted to the hospital and provided with supportive care:
o Intravenous hydration.
o Correction of any electrolyte abnormalities.
o Pain control - (NSAIDs) or opioids.
o Intravenous antibiotics.
o Patients should be kept fasting, and although uncommonly needed, those who are vomiting should
have placement of a nasogastric tube.
• Can escalate to gallbladder perforat
Choledocolithiasis (Quick)(what is it? what does it look like? what imaging? Tx?) - ANS o Common bile
duct obstruction.
o Proximal inflammation.
o Obstructive Jaundice.
o Dilated hepatic bile ducts.
o Tx: ERCP.
Choledocolithiasis (in depth) - ANS is the presence of a gallstone in the common bile duct.
o Labs: Elevated bilirubin (>4 very strong, 1.8 - 4 strong), and alkaline phosphatase (late). Elevated AST
and ALT (early).
o High risk: >55 y/o
, o S/SX: biliary-type pain (right upper quadrant or epigastric pain/tenderness), nausea, and vomiting.
Patients may also appear jaundiced. Courvoisier's sign (a palpable gallbladder on physical examination)
may be seen when gallbladder dilation develops because of an obstruction of the common bile duct.
Occasionally are asymptomatic.
o Pain from choledocholithiasis resolves when the stone either passes spontaneously or is removed.
symptom resolution suggests that a patient with choledocholithiasis has spontaneously passed the
gallstone.
o Uncomplicated choledocholithiasis are typically afebrile and have a normal complete blood count and
pancreatic enzyme levels.
o Imaging for diagnosis: trANSabdominal ultrasound. (Dialated common bile duct >6mm, +common bile
duct stone).
high risk proceed to ERCP w/ stone removal, followed by elective cholecystectomy.
intermediate risk either undergo preoperative EUS or MRCP, or they proceed to laparoscopic
cholecystectomy w/ intraoperative cholangiography or ultrasonography. If a stone is found
preoperatively, patients should proceed to ERCP with stone removal, followed by elective
cholecystectomy, provided gallstones or sludge were seen on preoperative imaging.
Patients at low risk can proceed directly to cholecystectomy without additional testing, provided
gallstones or sludge were seen on preoperative imaging.
o Long-standing biliary obstruction from various causes, including common bile duct stones, may result
in liver disease that may progress to cirrhosis, a phenomenon referred to as secondary biliary cirrhosis.
o Complications of choledocholithiasis include acute pancreati
Cholangitis (what is it? what does it look like? what imaging? Tx?) - ANS o Choledocolithiasis + Infection
(leukocytosis).
o Charcot's triad: Fever, RUQ pain, Jaundice.
o Raynold's Pentad: Hypotension, AMS
o Dx: RUQ US.
o Tx: Emergent ERCP.
Cholangitis (in depth) - ANS • is an inflammation of the bile duct system that develops as a result of
stasis and infection in the biliary tract.
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