NURS 642 Exam 2. Maryville University.
Questions And Well Elaborated Solutions
Cholecystitis (Quick) (what is it? what does it look like? what imaging? Tx?) - ANSWER 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) - ANSWER • 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?) - ANSWER o
Common bile duct obstruction.
o Proximal inflammation.
o Obstructive Jaundice.
o Dilated hepatic bile ducts.
o Tx: ERCP.
Choledocolithiasis (in depth) - ANSWER 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?) - ANSWER 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) - ANSWER • is an inflammation of the bile duct system that develops as
a result of stasis and infection in the biliary tract.
o Elevated liver enzymes: AST, ALT, ALP. (Most common in chronic)
o Charcot's triad (fever, right upper quadrant pain, and jaundice) and leukocytosis.
,o Patients with severe (suppurative) cholangitis may present with hypotension, and mental status
changes (Reynolds pentad).
o Patients have evidence of cholestasis on laboratory testing and biliary dilation on imaging. (In
contrast to patients with acute cholecystitis).
o Labs to obtain: hCG, Blood cultures, CBC, CMP, PT/INR.
o In patients with fever, abdominal pain, jaundice (Charcot's triad), and abnormal liver tests, we
proceed directly to endoscopic retrograde cholangiopancreatography (ERCP) to confirm the
diagnosis and provide biliary drainage.
o In all other patients with suspected acute cholangitis, we perform a transabdominal
ultrasonography to look for common bile duct dilatation or stones. An abdominal computed
tomography (CT) is performed in patients with abdominal pain and in patients with suspected
acute cholangitis who have a normal abdominal ultrasound.
o Diagnosis — A diagnosis of acute cholangitis is made if a patient has evidence of systemic
inflammation with one of the following:
Fever and/or shaking chills.
Laboratory evidence of an inflammatory response (abnormal white blood cell count, increased
serum C-reactive protein, or other changes suggestive of inflammation).
• and both of the following:
• Evidence of cholestasis: Bilirubin ≥2 mg/dL or abnormal liver chemistries (elevated alkaline
phosphatase, gamma-glutamyl transpeptidase, alanine aminotransferase, or aspartate
aminotransferase, to >1.5 times the upper limit of normal).
• Imaging with biliary dilation or evidence of the underlying etiology (eg, a stricture, stone, or
sten
Murphy sign (how to perform? when positive?) - ANSWER o Is elicited in patients with acute
cholecystitis by asking the patient to take in and hold a deep breath while palpating the right
subcostal area.
o If pain occurs when the inflamed gallbladder comes into contact with the examiner's hand,
Murphy's sign is positive.
Charcot's triad - ANSWER Fever, RUQ pain, & Jaundice
Raynold's Pentad - ANSWER Hypotension & AMS
Cholelithiasis (Quick) (what is it? what does it look like? what imaging? Tx?) - ANSWER 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) - ANSWER • 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
Acute Pancreatitis - ANSWER • Inflammation of the pancreas; sometimes associated with a
systemic inflammatory response.
• May settle spontaneously or may progress to necrosis of the pancreas or surrounding fatty
tissue.
• Most common cause: gallstones.
• S/sx: Sudden severe constant abdominal pain associated with vomiting, pain radiates to back
(thoracic area), epigastric tenderness, guarding,
• DDX: perforated peptic ulcer, myocardial infarction, and cholecystitis
• Note increases in serum amylase or lipase levels at least more than three times the upper limit
of normal. (alanine transaminase (ALT) level >150 U/L has a positive predictive value).
• International consensus is that acute pancreatitis is diagnosed when two of three criteria are
present: typical abdominal pain, raised enzyme levels, or appearances of pancreatitis on
computer tomography.
• All patients with acute pancreatitis should have liver function tests and abdominal
ultrasonography within 24 hours of admission to look for gallstones.
• If symptoms persist for more than seven days computed tomography is required to assess
pancreatic and peripancreatic necrosis.
• Initial management includes adequate fluid resuscitation, analgesia, and supplemental oxygen.
• If gallstones are found, definitive treatment (by cholecystectomy or sphincterotomy) should be
given within two weeks of resolution of symptoms.
Severe acute pancreatitis & Necrotizing pancreatitis - ANSWER Severe acute pancreatitis is
characterized by persistent (>48 hours) organ failure; these patients have a >30% mortality rate.
(Systemic inflammatory response is indicative of severe pancreatitis = temp >38 C, HR >90, RR
