Chapter 50 = Biliary & Pancreas Worksheet
Cholecystitis
What is it? Inflammation of the gallbladder wall. Caused by gallstones (cholelithiasis) obstructing the cystic and/or
common bile ducts (biles flow from the gallbladder to the duodenum) causing bile to back up and the gallbladder
to become inflamed.
Cholecystitis (inflammation of the gallbladder which can be acute or chronic) causes pain, tenderness, and rigidity
of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with
nausea, vomiting, and the usual signs of an acute inflammation. An empyema of the gallbladder develops if the
gallbladder becomes filled with purulent fluid (pus).
Where is the pain located?
Sharp pain in the right upper quadrant, often radiating to the right shoulder.
Pain with deep respiration during right subcostal palpation (Murphy's Sign).
Intense pain (increased heart rate, pallor, diaphoresis) with nausea and vomiting after ingestion of high fat
food caused by biliary colic.
Rebound tenderness (Blumberg’s sign performed by the provider or advanced practiced nurse)
Dyspepsia, eructation (belcjing), and flatulence
Fever
Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis. In calculous cholecystitis, a
gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis
and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply.
Calculous cholecystitis vs. Acalculous cholecystitis
When does it occur? When a gallbladder stone obstructsafter major surgical procedures,
bile outflow orthopedic procedures, severe
trauma, or burns
Are stones present? Yes NO
Acalculous cholecystitis describes acute gallbladder inflammation in the absence of obstruction by gallstones.
Acalculous cholecystitis occurs after major surgical procedures, orthopedic procedures, severe trauma, or burns.
Other factors associated with this type of cholecystitis include torsion, cystic duct obstruction, primary bacterial
infections of the gallbladder, and multiple blood transfusions. It is speculated that acalculous cholecystitis is caused
by alterations in fluids and electrolytes and alterations in regional blood flow in the visceral circulation. Bile stasis
(lack of gallbladder contraction) and increased viscosity of the bile are also thought to play a role. The occurrence
of acalculous cholecystitis with major surgical procedures or trauma makes its diagnosis difficult
Cholelithiasis
Definition: Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile;
they vary greatly in size, shape, and composition.
Two major types of gallstones: those composed predominantly of pigment and those composed
primarily of cholesterol.
, Pigment stones- Pigment stones probably form when unconjugated pigments in the bile precipitate
to form stones; these stones account for about 10% to 25% of cases in the United States. The risk of
developing such stones is increased in patients with cirrhosis, hemolysis, and infections of the
biliary tract. Pigment stones cannot be dissolved and must be removed surgically.
Composed primarily of: Pigment
Who is at risk to develop? patients with cirrhosis, hemolysis, and infections of the biliary tract.
Pigment stones cannot be dissolved and must be removed surgically
Cholesterol stones- Cholesterol stones account for most of the remaining 75% of cases of gallbladder
disease in the United States. Cholesterol, which is a normal constituent of bile, is insoluble in water.
Its solubility depends on bile acids and lecithin (phospholipids) in bile (Hall, 2015). In gallstone-
prone patients, there is decreased bile acid synthesis and increased cholesterol synthesis in the
liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form
stones (Hall, 2015; Kumar et al., 2014). The cholesterol-saturated bile predisposes to the formation
of gallstones and acts as an irritant that produces inflammatory changes in the mucosa of the
gallbladder
Which type of stones is seen more often? Cholesterol stones
List some risk factors for the development of stones: (chart 50-1)
Chart 50-1 RISK FACTORS
Cholelithiasis
Cystic fibrosis
Diabetes
Frequent changes in weight
Ileal resection or disease
Low-dose estrogen therapy—carries a small increase in the risk of gallstones
Obesity
Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease)
Treatment with high-dose estrogen (e.g., in prostate cancer)
Women, especially those who have had multiple pregnancies or who are of Native American or U.S.
southwestern Hispanic ethnicity
Clinical Manifestations- Gallstones may be silent, producing no pain and only mild GI symptoms. Such stones
may be detected incidentally during surgery or evaluation for unrelated problems.
The patient with gallbladder disease resulting from gallstones may develop two types of symptoms: those due to
disease of the gallbladder itself and those due to obstruction of the bile passages by a gallstone. The symptoms may
be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper
quadrant of the abdomen, may occur. This distress may follow a meal rich in fried or fatty foods.
If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute
cholecystitis). The patient develops a fever and may have a palpable abdominal mass. The patient may have biliary
colic with excruciating upper right abdominal pain that radiates to the back or right shoulder. Biliary colic is usually
associated with nausea and vomiting, and it is noticeable several hours after a heavy meal. The patient moves about
restlessly, unable to find a comfortable position. In some patients, the pain is constant rather than colicky
Fever
Palpable abdominal mass (does this happen in every case?) Sometimes
Biliary colic- describe pain location and intensity: excruciating upper right abdominal pain that radiates to the back
or right shoulder
Cholecystitis
What is it? Inflammation of the gallbladder wall. Caused by gallstones (cholelithiasis) obstructing the cystic and/or
common bile ducts (biles flow from the gallbladder to the duodenum) causing bile to back up and the gallbladder
to become inflamed.
Cholecystitis (inflammation of the gallbladder which can be acute or chronic) causes pain, tenderness, and rigidity
of the upper right abdomen that may radiate to the midsternal area or right shoulder and is associated with
nausea, vomiting, and the usual signs of an acute inflammation. An empyema of the gallbladder develops if the
gallbladder becomes filled with purulent fluid (pus).
Where is the pain located?
Sharp pain in the right upper quadrant, often radiating to the right shoulder.
Pain with deep respiration during right subcostal palpation (Murphy's Sign).
Intense pain (increased heart rate, pallor, diaphoresis) with nausea and vomiting after ingestion of high fat
food caused by biliary colic.
Rebound tenderness (Blumberg’s sign performed by the provider or advanced practiced nurse)
Dyspepsia, eructation (belcjing), and flatulence
Fever
Calculous cholecystitis is the cause of more than 90% of cases of acute cholecystitis. In calculous cholecystitis, a
gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder initiates a chemical reaction; autolysis
and edema occur; and the blood vessels in the gallbladder are compressed, compromising its vascular supply.
Calculous cholecystitis vs. Acalculous cholecystitis
When does it occur? When a gallbladder stone obstructsafter major surgical procedures,
bile outflow orthopedic procedures, severe
trauma, or burns
Are stones present? Yes NO
Acalculous cholecystitis describes acute gallbladder inflammation in the absence of obstruction by gallstones.
Acalculous cholecystitis occurs after major surgical procedures, orthopedic procedures, severe trauma, or burns.
Other factors associated with this type of cholecystitis include torsion, cystic duct obstruction, primary bacterial
infections of the gallbladder, and multiple blood transfusions. It is speculated that acalculous cholecystitis is caused
by alterations in fluids and electrolytes and alterations in regional blood flow in the visceral circulation. Bile stasis
(lack of gallbladder contraction) and increased viscosity of the bile are also thought to play a role. The occurrence
of acalculous cholecystitis with major surgical procedures or trauma makes its diagnosis difficult
Cholelithiasis
Definition: Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile;
they vary greatly in size, shape, and composition.
Two major types of gallstones: those composed predominantly of pigment and those composed
primarily of cholesterol.
, Pigment stones- Pigment stones probably form when unconjugated pigments in the bile precipitate
to form stones; these stones account for about 10% to 25% of cases in the United States. The risk of
developing such stones is increased in patients with cirrhosis, hemolysis, and infections of the
biliary tract. Pigment stones cannot be dissolved and must be removed surgically.
Composed primarily of: Pigment
Who is at risk to develop? patients with cirrhosis, hemolysis, and infections of the biliary tract.
Pigment stones cannot be dissolved and must be removed surgically
Cholesterol stones- Cholesterol stones account for most of the remaining 75% of cases of gallbladder
disease in the United States. Cholesterol, which is a normal constituent of bile, is insoluble in water.
Its solubility depends on bile acids and lecithin (phospholipids) in bile (Hall, 2015). In gallstone-
prone patients, there is decreased bile acid synthesis and increased cholesterol synthesis in the
liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form
stones (Hall, 2015; Kumar et al., 2014). The cholesterol-saturated bile predisposes to the formation
of gallstones and acts as an irritant that produces inflammatory changes in the mucosa of the
gallbladder
Which type of stones is seen more often? Cholesterol stones
List some risk factors for the development of stones: (chart 50-1)
Chart 50-1 RISK FACTORS
Cholelithiasis
Cystic fibrosis
Diabetes
Frequent changes in weight
Ileal resection or disease
Low-dose estrogen therapy—carries a small increase in the risk of gallstones
Obesity
Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease)
Treatment with high-dose estrogen (e.g., in prostate cancer)
Women, especially those who have had multiple pregnancies or who are of Native American or U.S.
southwestern Hispanic ethnicity
Clinical Manifestations- Gallstones may be silent, producing no pain and only mild GI symptoms. Such stones
may be detected incidentally during surgery or evaluation for unrelated problems.
The patient with gallbladder disease resulting from gallstones may develop two types of symptoms: those due to
disease of the gallbladder itself and those due to obstruction of the bile passages by a gallstone. The symptoms may
be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper
quadrant of the abdomen, may occur. This distress may follow a meal rich in fried or fatty foods.
If a gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed, and eventually infected (acute
cholecystitis). The patient develops a fever and may have a palpable abdominal mass. The patient may have biliary
colic with excruciating upper right abdominal pain that radiates to the back or right shoulder. Biliary colic is usually
associated with nausea and vomiting, and it is noticeable several hours after a heavy meal. The patient moves about
restlessly, unable to find a comfortable position. In some patients, the pain is constant rather than colicky
Fever
Palpable abdominal mass (does this happen in every case?) Sometimes
Biliary colic- describe pain location and intensity: excruciating upper right abdominal pain that radiates to the back
or right shoulder
