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A 32 year old female who recently delivered twins presents with colicky type pain, URQ pain radiating to the shoulder. After workup, she is diagnosis with cholecystitis.
What is the role of the gallbladder?
The gallbladder is a small, saclike organ located on the undersurface of the liver, and it serves as the reservoir for bile. While the gallbladder stores the bile, it concentrates it by removing water and electrolytes, leaving the bile salts, pigments, and cholesterol. The small intestines will then signal the gallbladder to contract and release the bile into another duct system. The gallbladder will also contract when the hormone cholecystokinin is produced in the small intestine due to the presence of fat. After surgical removal of the gallbladder, bile will flow directly from the liver to the small intestine (Dlugasch & Story, 2021).
Would you expect her to have nausea and vomiting? Defend your answer.
Yes because when the intermittent increase of the pressure in the gallbladder activates the visceral sensory neurons associated symptoms such as nausea and vomiting can be expected. Episodes of this may happen two hours after a meal for some (not always) due to the impact of the stone, microlithiasis, or sludge in the cystic duct or the ampulla of Vater. When this happens the distension of the gallbladder and the billary tract will then cause associated symptoms such as nausea and vomiting (Portincasa et al., 2019).
Why does the patient have referred pain?
Referred pain can be located in the right upper quadrant, or epigastric area then radiate to the back or right shoulder. Referred pain occurs it can last from 30 minutes to 6 hours and can bring on nausea, vomiting, bloating, belching, diaphoresis, chest pain, and pain that can be dull to intense depending on the individual.
When I had acute cholecystitis, I did not have the textbook referred pain. When my pain occurred, I would have instant nausea and vomiting, and my pain would be in my lower right quadrant. I would have a friend or myself push down on the pain site and feel relief and instant pain once the pressure was removed. I was sent to have a HIDA scan and was told that my gallbladder needs to be removed just when my scan started, and there was no need to finish the exam. I am one of those patients where my symptoms do not match the disease process.
How do gallstones form?
Gallstones, also known as cholelithiasis, is a common condition affecting 10-20% of people in the United States (Dlugasch & Story, 2021). A stone (calculi) are hardened deposits of digestive fluid that can range from all sizes and shapes and form inside the gallbladder. There are two types of gallstones; cholesterol and pigment or bilirubinate. Cholesterol stones are formed due to the altered hepatocellular and gallbladder function. Pigment stones are either brown or black. Brown stones are formed from calcium bilirubinate and are usually associated with a biliary infection. Brown stones are generally found in the bile ducts and gallbladder. Black pigment stones are hard bilirubin polymers found in the gallbladder (Portincasa et al., 2019). The presence of stones can cause inflammation and infection in the biliary system (cholecystitis).
References
Dlugasch, L., & Story, L. (2021). Applied Pathophysiology For The Advanced Practice Nurse (1st ed.). Jones & Bartlett Learning.
Housset, C. (2018). Gallstone disease, towards a better understanding and clinical practice. Current Opinion in Gastroenterology, 34(2), 5758. https://doi.org/10.1097/mog.0000000000000425
Portincasa, P., Molina-Molina, E., Garruti, G., & Wang, D. Q.-H. (2019). Critical care aspects of gallstone disease. The Journal of Critical Care Medicine, 5(1), 618. https://doi.org/10.2478/jccm-2019-0003
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