Gallstones for the NP Exam
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Gallstones (Cholelithiasis) for the Nurse Practitioner Licensing Exam
Overview
- Gallstones are solid formations within the gallbladder, classified as:
- Cholesterol stones: The most common type, formed due to cholesterol supersaturation.
- Pigment stones: Composed of bilirubin, typically found in patients with chronic hemolytic disorders or biliary infections.
Pathophysiology
Cholesterol Stones
- Cholesterol stones develop from supersaturated bile combined with gallbladder stasis.
- Risk factors include:
- Obesity, rapid weight loss, and pregnancy.
- Estrogen therapy and oral contraceptives increase cholesterol saturation.
- Metabolic syndrome and insulin resistance contribute to stone formation.
Pigment Stones
- Pigment stones are associated with elevated bilirubin levels in bile, often due to:
- Chronic hemolytic disorders (e.g., sickle cell anemia).
- Cirrhosis or biliary tract infections.
Clinical Presentation
- Asymptomatic: Many gallstones are found incidentally.
- Biliary colic: Characterized by episodic RUQ or epigastric pain lasting 30 minutes to several hours, often triggered by fatty meals. Associated symptoms include nausea and vomiting.
- Acute cholecystitis: Inflammation caused by cystic duct obstruction, leading to persistent RUQ pain, fever, and Murphy’s sign (pain with inspiration during palpation).
Complications
Acute Cholecystitis
- Persistent cystic duct obstruction leading to gallbladder inflammation.
- Managed with antibiotics and laparoscopic cholecystectomy.
Choledocholithiasis and Cholangitis
- Choledocholithiasis: Gallstones obstructing the common bile duct, causing jaundice and elevated bilirubin.
- Cholangitis: Infection of the bile duct, presenting with fever, jaundice, and RUQ pain (Charcot’s triad).
- Treated with urgent ERCP to remove the obstructing stone.
Diagnosis
- Ultrasound: First-line imaging for detecting gallstones.
- Liver function tests (LFTs): Elevated bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT) indicate biliary obstruction.
Management
- Asymptomatic gallstones: Managed conservatively unless symptoms develop.
- Laparoscopic cholecystectomy: The definitive treatment for symptomatic gallstones and complications like acute cholecystitis.
- ERCP: Used for diagnosis and treatment of choledocholithiasis and cholangitis.
Key Points
- Cholesterol stones are the most common type of gallstone, linked to obesity, rapid weight loss, and estrogen exposure.
- Biliary colic presents with episodic RUQ pain after fatty meals and resolves spontaneously.
- Acute cholecystitis involves persistent RUQ pain, fever, and requires cholecystectomy.
- Choledocholithiasis can lead to cholangitis, a life-threatening condition treated with ERCP.
- Ultrasound is the preferred diagnostic test for detecting gallstones.