Liver and Biliary Key Points and Learning Map

What is cholecystitis and what causes it?

• Cholecystitis is inflammation of the gallbladder, often due to abnormal cholesterol/bile salt metabolism.

• Trapped bile is reabsorbed, acting as a chemical irritant to the gallbladder wall

What is the difference between acalculous cholecystitis and calculous cholecystitis?

• Calculous cholecystitis:

  • Most common type.

  • Caused by gallstones blocking the cystic duct or bile duct.

  • Leads to obstruction, bile stasis, inflammation, possible infection.

• Acalculous cholecystitis:

  • No gallstones.

  • Often occurs in critically ill patients (trauma, sepsis, TPN, major surgery).

  • Caused by bile stasis, ischemia, or infection → inflammation without stones.

What are the classic "5 Fs" risk factors for gallbladder disease?

• Fat

• Female

• Fertile

• Forty

• Fatty foods

What assessment findings are common with cholecystitis?

• RUQ pain (steady, may radiate to right shoulder)

• Pain after high-fat meal

• Nausea, vomiting, dyspepsia, eructation, flatulence

• Fullness, anorexia

• Rebound tenderness (Blumberg’s sign)

• Fever, jaundice, clay-colored stools, dark urine

• Steatorrhea (chronic cases)

Which assessment cues suggest a complication of cholecystitis?

• Fever

• Tachycardia

• Hypotension

• Sudden severe pain

• All → may indicate biliary colic or sepsis

What should the nurse do if a patient with cholecystitis develops pallor, diaphoresis, tachycardia, and hypotension?

Suspect shock from biliary colic.

• Notify HCP/RRT immediately

• Keep patient supine

• Stay with patient

What labs and tests confirm cholecystitis?

• CBC: WBC ≥ 10,000 (infection/inflammation) (Left-shift w/ bands)

• LFTs: ↑ AST, LDH, bilirubin

• X-ray: gallstone calcification

• HIDA scan: gallbladder visualization/patency

• ERCP: assess biliary system (check contrast allergy, pacemaker)

What nonsurgical interventions are used for acute cholecystitis?

• NPO

• IV fluids (NS, LR, D5W)

• Analgesia: opioids, ketorolac (monitor for GI bleed)

• Monitor labs & vitals

What are pre-op nursing responsibilities before cholecystectomy?

• Verify consent (surgeon responsibility to explain)

• Assess drug history (anticoags, antihypertensives, insulin, etc.)

• Maintain NPO

• IV access (18–20G)

• Skin prep as ordered

• Administer prophylactic antibiotics

What are key post-op interventions after cholecystectomy?

• Monitor airway & O2

• Keep NPO until awake & gag reflex returns

• Advance diet slowly (clear → solids as peristalsis returns)

• Pain/nausea control

• Splint incision for coughing/deep breathing

• Encourage early ambulation (decreases chance of clots and increases perstalsis)

• Avoid NSAIDs/aspirin ×10 days

What discharge teaching is important after cholecystectomy?

• Low-fat diet (to prevent post-cholecystectomy syndrome: pain/diarrhea)

• Ambulate frequently (relieves gas pain)

• Ice/oral opioids for incisional pain

• Resume normal activity in 1–2 weeks

What is the first priority of care for acute pancreatitis patients?

Acute pain relief

What labs are most important to monitor in pancreatitis?

Amylase and lipase (both elevated)

What complication are biliary/pancreatic patients at high risk for?

Biliary obstruction – serious and painful

What is the effect of estrogen on cholecystitis?

Estrogen increases the risk of cholecystitis because it raises cholesterol levels in bile and slows gallbladder emptying. This promotes gallstone formation, which can block ducts and trigger gallbladder inflammation.

👉 That’s why women (especially those pregnant, on oral contraceptives, or on hormone therapy) are at higher risk.

What referral should be made for patients with end-stage pancreatic cancer?

Refer to palliative and hospice care.

What referral should be made for patients with pancreatitis who use alcohol?

Refer to community resources such as Alcoholics Anonymous.

Who is most at risk for gallbladder disease?

Obese, middle-aged women.

What lifestyle advice helps prevent gallbladder disease?

Avoid rapid weight loss and maintain a healthy weight.

What teaching helps prevent alcohol-induced acute pancreatitis?

Avoid alcohol consumption.

What should patients with chronic pancreatitis be instructed on?

Ways to prevent exacerbations.

What referrals help pancreatic cancer patients cope?

Support services such as spiritual leaders and counselors.

How should nurses support families of pancreatic cancer patients?

Help prepare them for the death and dying process.

What causes severe pain in acute pancreatitis?

Autodigestion of the pancreas.

What labs should be monitored in pancreatitis?

Amylase and lipase (both elevated).

What are common symptoms of cholecystitis?

Abdominal pain and intolerance to fatty foods.

What is a priority intervention for acute pancreatitis?

Provide pain management, including opioids.

What is the first priority of care in acute pancreatitis?

Acute pain relief.

What serious complication are patients with biliary/pancreatic disorders at risk for?

Biliary obstruction.

What health teaching should be documented for patients with pancreatic enzyme therapy?

Enzyme replacement therapy education.

What symptoms suggest pancreatic cancer?

Jaundice and abdominal pain.

What must nurses monitor closely after a Whipple procedure?

Life-threatening complications (e.g., bleeding, infection, leakage).

Why do Ozempic (semaglutide) and other rapid weight loss drugs put patients at risk for gallbladder attacks?

Rapid weight loss causes increased cholesterol secretion into bile, making it more saturated. This slows gallbladder emptying and promotes gallstone formation, which can trigger cholecystitis or gallbladder attacks.

A 38-year-old female presents with vague upper abdominal pain radiating to the right shoulder after eating pizza, nausea, and dyspepsia. What condition should the nurse suspect?

Cholecystitis (likely acute, triggered by fatty meal)

How should the nurse explain the disease process of cholecystitis?

The gallbladder becomes inflamed, usually because gallstones block bile flow. This causes pain, nausea, and digestive upset, especially after eating fatty foods.

What additional questions should the nurse ask a client with suspected cholecystitis?

• Onset, duration, and severity of pain

• Dietary triggers (fatty, greasy foods)

• History of gallstones or similar episodes

• Associated symptoms: fever, jaundice, changes in stool/urine

• Family history of gallbladder disease

• On any meds? (Weight-loss, statins, birth-control (OC))

What assessment findings should the nurse anticipate in a patient with cholecystitis?

• RUQ abdominal pain (may radiate to right shoulder)

• Murphy’s sign (pain with deep inspiration during RUQ palpation)

• Nausea, vomiting, dyspepsia, flatulence

• Fever, leukocytosis

• Jaundice (if bile duct obstruction)

• Clay-colored stools, dark urine

What are the priority nursing actions when a patient with suspected gallbladder/biliary complication becomes unstable (e.g., pallor, diaphoresis, exhaustion, low BP)?

1. First assess the patient – stay at bedside, evaluate symptoms.

2. Lay the patient flat – promotes perfusion during hypotension/shock.

3. Apply oxygen – support tissue oxygenation.

4. Obtain vital signs – determine hemodynamic status.

5. Notify provider immediately – patient may be progressing to shock or perforation.

👉 Basically: Assess → Position flat → Oxygen → VS → Call provider.

While reviewing orders, the nurse sees the client suddenly becomes pale, diaphoretic, exhausted, and in severe pain. Vitals: BP 88/58, HR 106, RR 24, T 101.2°F, O2 sat 90% RA. What complication is this?

• Low BP (88/58): From exhaustion, vasodilation, or dehydration related to severe pain.

• High HR (106): Tachycardia from pain, stress, and fever.

• Fast RR (24): Pain, anxiety, and ↑ work of breathing.

• Fever (101.2 °F): Inflammatory response (possible cholecystitis developing).

• Low O₂ sat (90% RA): Poor oxygenation from tachypnea, fatigue, and increased metabolic demand.

👉 Together: These vitals reflect the systemic effects of severe biliary colic — intense pain, stress response, and possible early infection.

👉 Why not shock?

• In shock, hypotension is sustained and associated with end-organ hypoperfusion (confusion, cold clammy skin, ↓urine output).

• This patient is alert and showing pain + early infection response, not full circulatory failure.

What is the priority nursing action for a cholecystitis patient showing shock symptoms?

Call Rapid Response/STAY WITH PT/ notify provider, apply O2, establish IV access with fluids, and prepare for emergency interventions.

The patient asks: “Are they going to perform any tests to confirm what I have?” How should the nurse respond?

“Yes, the provider will likely order blood tests (liver function, WBCs, amylase/lipase, CRP) and imaging such as an ultrasound or HIDA scan to confirm the diagnosis.”

• If pt needs antibiotics, give AFTER blood cultures

• Endoscopic Retrograde Cholangiopancreatography

What patient problems should the nurse hypothesize for this client with cholecystitis?

• Acute pain

• Risk for infection

• Imbalanced nutrition (due to nausea, fatty food intolerance) (Lab: albumin)

• Risk for Fluid Volume Deficit (check electrolytes, BUN/Creatinine)

• Risk for impaired skin integrity (jaundice, pruritus)

• Risk for hypovolemic shock (if gallbladder ruptures)

What evidence in the patient’s chart would support these hypotheses?

• Reports of severe RUQ pain

• Nausea and vomiting after fatty meals

• Lab values: ↑ WBC, ↑ bilirubin, abnormal LFTs, decreased albumin, ↑ BUN/Creatinine (not enough blood flow to kidneys bc dehydration), ↑ Urine specific gravity (dehydration)

• Imaging: gallstones, gallbladder wall thickening

• Vitals: fever, tachycardia, hypotension (shock signs)

What orders should the nurse expect for a patient with acute cholecystitis?

• NPO status

• IV fluids and electrolyte replacement

• Pain control (opioids or ketorolac — monitor for GI bleeding)

• Antiemetics

• IV antibiotics if infection suspected

• Prepare for possible cholecystectomy

Why should you avoid palpating the gallbladder aggressively in suspected cholecystitis?

It can cause extreme pain and risk gallbladder rupture, leading to bile peritonitis (life-threatening).

What is acalculous cholecystitis, and how does it cause problems?

• Definition: Inflammation of the gallbladder without gallstones.

• Causes/Risk factors: Often seen in critically ill patients (trauma, burns, sepsis, prolonged fasting, TPN, major surgery).

• Pathophysiology:

  • Gallbladder stasis (not contracting normally) → bile sits too long.

  • Thickened, stagnant bile + infection/inflammation → gallbladder wall swelling.

  • This blocks bile flow even though no stone is present, leading to biliary obstruction.

  • Bile backs up into the liver → jaundice, elevated bilirubin, dark urine, clay-colored stools.

• Complications: Can progress quickly to gangrene, perforation, or sepsis if untreated.

Why do rapid weight loss drugs (like Ozempic) increase the risk of gallbladder attack?

Rapid weight loss → cholesterol supersaturation of bile + gallbladder stasis → increased risk of gallstone formation → gallbladder attack.

In a patient with cholecystitis, what could dizziness, pallor, diaphoresis, tachycardia, and hypotension indicate?

• Possible Signs of Complication:

  • Sepsis / Septic shock – infection spreading from the gallbladder to the bloodstream.

  • Peritonitis – due to gallbladder rupture or bile leakage.

  • Hypovolemic shock – internal bleeding or fluid shifts.

• Why it happens:

  • Infection or inflammation triggers systemic inflammatory response (SIRS) → vasodilation, ↓ BP, poor perfusion.

  • Gallbladder rupture causes bile/peritoneal irritation → fluid shift, shock.

• Nursing priority: Recognize as early shock → lay patient flat for perfusion, stay with them, start IV fluids, oxygen, notify provider.

What is biliary colic and what causes it?

• Definition: Sudden, intense pain in the right upper quadrant (RUQ) or epigastric area caused by temporary obstruction of the cystic duct (usually from a gallstone).

• Mechanism: Gallbladder contracts against the stone → ↑ pressure inside gallbladder → visceral pain.

• Pain characteristics:

  • Sudden onset, steady, severe (not cramping, despite the name “colic”)

  • May radiate to right shoulder or back

  • Triggered by fatty meals (stimulate bile release)

  • Lasts 30 min to several hours, then subsides when the stone shifts.

• Associated symptoms: Nausea, vomiting, indigestion, bloating.

• Difference from cholecystitis:

  • Biliary colic = transient obstruction → no infection, pain eventually goes away.

  • Cholecystitis = persistent obstruction + inflammation/infection.

👉 Think of it this way: biliary colic = gallbladder “attack” pain from a stone temporarily blocking flow; if it doesn’t clear → progresses to cholecystitis.

What is the nursing significance of biliary colic and how should it be managed?

• Clinical Presentation:

  • Sudden, severe RUQ/epigastric pain radiating to the right shoulder or back

  • Often follows a fatty meal

  • May cause tachycardia, diaphoresis, pallor, exhaustion, and restlessness

• Key Risks:

  • Pain reflects transient obstruction of bile flow → can reduce circulatory perfusion if severe

  • If unrelieved, may progress to cholecystitis or even shock

• Nursing Actions:

  • Do NOT leave the bedside – stay with the patient to monitor for deterioration

  • Call the provider immediately

  • Place the head of bed flat to improve cerebral perfusion if patient is hypotensive or feeling faint

  • Monitor vital signs and O₂ sat continuously

  • Prepare to give NSAIDs first-line for pain (opioids if uncontrolled)

  • Provide reassurance and anticipate further orders (labs, imaging, IV fluids)

• Exam Tip:

  • Biliary colic = red flag pain episode from gallstone blockage → stay, call, and keep perfusion stable.

What is the purpose of ursodeoxycholic acid (ursodiol) in gallstone management?

• A: Reduces cholesterol content of bile → gradually dissolves cholesterol gallstones.

• Indication: Used in patients who are not surgical candidates or have small cholesterol stones.

• Limitations:

  • Takes months–years to work

  • Stones often recur after stopping

  • Only effective for cholesterol stones, not pigment or calcified stones

👉 Basically: Ursodiol = “stone dissolver” for nonsurgical gallbladder patients.

Why are NSAIDs (like ketorolac) preferred over opioids initially for biliary colic/cholecystitis pain management, and why is bleeding risk considered acceptable?

• NSAIDs are first choice because:

  • They reduce gallbladder inflammation (anti-inflammatory effect), not just mask pain.

  • They decrease prostaglandins, which lowers biliary pressure and pain.

  • Opioids (especially morphine) can cause spasm of the sphincter of Oddi, which may actually worsen biliary pain.

  • NSAIDs often control pain effectively enough to avoid or delay stronger meds.

• Why bleeding risk is acceptable:

  • GI bleeding is a known risk, but patients are usually only on short-term NSAID therapy during the acute phase.

  • Nurses monitor closely for signs of GI bleed (black stools, coffee-ground emesis, abdominal pain).

  • If the patient has a high bleeding risk (ulcers, anticoagulants, varices, etc.), opioids may be used instead.

👉 Key takeaway: NSAIDs treat both pain and inflammation without worsening biliary spasm, but close monitoring for GI bleeding is essential.

• Usually only get 1-2 doses of ketorolac so not too much risk w/ NSAIDS and this is b4 surgery

What are the key points to know about a T-tube after gallbladder surgery?

• Drain placement: Always kept below the level of the incision so bile and drainage flow by gravity.

• Expected drainage:

  • First 24 hrs: Serosanguineous (pinkish) fluid expected. Amount should be 200–500 mL total.

    • ⚠ Bright red blood is NOT normal.

  • After 24 hrs: Drainage should shift to green-brown bile.

  • After post-op day 2: Drainage should decrease to <400 mL/day.

• Critical values:

  1,000 mL in first 24 hrs → report immediately.

  • 510 mL in first 24 hrs → okay (within normal range).

  • 750 mL in first 24 hrs → too much, abnormal, report.

• Monitoring:

  • Check amount, color, and character of drainage.

  • Clamp tube during meals if ordered (to aid digestion and allow bile into duodenum).

  • Watch for sudden decrease in drainage → possible obstruction or displacement.

👉 Exam tip: They love to test whether you can distinguish expected drainage vs critical values — remember the “200–500 mL first day, <400 mL after day 2, >1,000 mL bad anytime” rule.

Why is a T-tube sometimes clamped?

• Purpose of T-tube: Allows bile to drain externally after gallbladder surgery while the common bile duct heals.

• Why clamp it:

  • CLAMP DURING MEALS

  • Promotes natural digestion – clamping lets bile flow into the small intestine instead of draining out, helping digest dietary fat.

  • Tests bile duct function – ensures the duct is open and working properly.

  • Doctor’s order: Often clamped during meals so bile aids digestion, then unclamped afterward to allow excess drainage and prevent buildup.

• Nursing considerations:

  • Only clamp when ordered.

  • Monitor for pain, nausea, or jaundice → may indicate obstruction.

  • Document patient tolerance.

  👉 Think of it this way: Clamp = bile goes to intestine → digestion + duct testing; Unclamp = external drainage → prevents pressure buildup.

What bedside test can an advanced care provider (NOT the nurse) use to assess for acute cholecystitis?

• Murphy’s sign → Provider palpates the RUQ while patient inhales.

  • Positive sign: Sudden pain & halted inspiration when gallbladder is inflamed.

  • Indicates acute cholecystitis.

• Nursing note: Nurses should NOT attempt Murphy’s sign or deeply palpate the RUQ.

  • Risk: Can cause gallbladder rupture → bile leak → peritonitis.

What discharge instructions should be given to a patient after T-tube placement?

A:

• Diet:

  • Advance diet slowly once bowel sounds return: clear liquids → soft foods → regular diet.

  • Start with carbohydrate-rich foods (e.g., rice, toast, potatoes) because they are easier to digest.

  • Avoid large amounts of fat at first; reintroduce gradually as tolerated.

  • Eat small, frequent meals instead of large portions.

• Hydration: Maintain adequate fluid intake.

• Tube care:

  • Keep drainage bag below incision (gravity drainage).

  • Expect serosanguineous drainage for first 24 hrs (200–500 mL).

  • Report: >400 mL/day after day 2 or >1000 mL/day anytime.

  • Report: Sangeonius (bright-red drainage) and Purulent drainage

• Clamping: Tube may be clamped during meals (per provider order) to allow bile flow into intestine for digestion.

• Activity: Avoid heavy lifting until cleared by provider.

• Follow-up: Keep appointments for tube checks/removal.