Gallbladder Basics for the Physician Assistant Exam

Gallbladder surgery is one of the most common types of surgery medical professionals are exposed to during their training. For the Physician Assistant Exam (PANCE), make sure you review common indications for surgery: gallbladder inflammation and gallstones.

Gallbladder inflammation

Anyone who has experienced gallbladder pain knows it can be debilitating. Presenting symptoms can include abdominal pain with eating. Recall that the risk factors for gallbladder inflammation are the five f’s: female, fat, fertile, fair, and forty. Classic gallbladder pain often radiates to the right upper quadrant (RUQ), although midepigastric pain can be present. Pain can also radiate to the right shoulder.

On physical examination, in addition to midepigastric tenderness, you may find tenderness to palpation in the right upper quadrant. Specifically, a positive Murphy’s sign indicates that cholecystitis may be present.

Various laboratory and imaging studies can be helpful in diagnosing cholecystitis. On a CBC, a leukocytosis may be present, with or without an accompanying left shift. You may also see elevation in the hepatic function tests, particularly the alkaline phosphatase and bilirubin levels. Amylase can be elevated but is relatively nonspecific.

Ultrasonography is the imaging study of choice for further evaluating right upper-quadrant pain. Common findings can include gallbladder dilatation, thickening of the gallbladder wall, gallbladder sludge, and/or pericholecystic fluid. A CT scan with contrast may be ordered, but it’s less sensitive to issues concerning the right upper quadrant.

You can order a hepatobiliary iminodiacetic acid (HIDA) scan to see how well the gallbladder is functioning. Just as an echocardiogram can show the ejection fraction of the heart, the HIDA scan can show the ejection fraction of the gallbladder. If other imaging studies of the gallbladder are normal and you want to find out how well the gallbladder is working, this scan is the one to order.

When the patient is admitted to the hospital, he or she is initially made NPO, with intravenous fluids and antibiotics being administered.

Surgeons previously used an open surgical approach to treat the inflamed gallbladder, but because of laparoscopic techniques, the number of post-operative days patients spend in the hospital has decreased.

Gallbladder stones

Gallstones are a common cause of cholecystitis, but they can also cause nonspecific pain, such as biliary colic. Gallstones actually come in two types:

  • Cholesterol stones: Cholesterol stones are the most common kind. They contain a lot of cholesterol and a little bit of calcium.

  • Pigment stones: You can find pigment stones in states of chronic hemolysis, including sickle-cell disease.

Gallstones can be present and completely asymptomatic, in which case the treatment is watching and reducing risk factors that contribute to their formation. The treatment includes diet modification, specifically avoiding fatty foods, and minimizing the use of medications that increase the risk of gallstones, including hormonal therapy that’s estrogen-based. One medication that’s been used to try to reduce the risk of gallstones is ursodeoxycholic acid (ursodiol).

A life-threatening complication of gallstones is gallstone pancreatitis.

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