NURS 642 Exam 2. Maryville University questions
with correct answers
Cholelithiasis (Quick) (what is it? what does it look like? what imaging?
Tx?) Correct 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) Correct 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
Cholecystitis (Quick) (what is it? what does it look like? what imaging?
Tx?) Correct 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) Correct 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?) Correct Answer-o Common bile duct obstruction.
o Proximal inflammation.
o Obstructive Jaundice.
o Dilated hepatic bile ducts.
o Tx: ERCP.
Choledocolithiasis (in depth) Correct 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
