The liver makes bile; the gallbladder stores and concentrates it and contracts after a fatty meal (stimulated by cholecystokinin), sending bile through the cystic and common bile duct into the duodenum. Bile emulsifies fat and carries bilirubin out of the body. When the flow is blocked, pain, infection, and jaundice follow.

Risk factors for gallstones: female sex, pregnancy and estrogen therapy, age over 40, obesity, rapid weight loss (including after bariatric surgery), family history, diabetes, prolonged parenteral nutrition, hemolytic disease.

Risk factors for gallbladder cancer: long-standing gallstones, gallbladder polyps 1 cm or larger (especially with stones), porcelain (calcified) gallbladder, PSC.

Biliary colic / cholecystitis

• RUQ or epigastric pain, often after a fatty meal, radiating to the right shoulder or scapula
• Nausea, vomiting, belching, bloating, fat intolerance
• Cholecystitis: fever, pain lasting more than about 6 hours, positive Murphy sign (inspiration stops on deep RUQ palpation), leukocytosis

Bile-duct obstruction

• Jaundice, scleral icterus, pruritus (bile salts in the skin)
• Dark (tea- or cola-colored) urine — conjugated bilirubin excreted by the kidneys
• Clay-colored (pale) stools — no bile reaches the intestine
• Steatorrhea and vitamin K deficiency (bleeding, prolonged INR)

Acute cholangitis

• Charcot triad: fever with chills, jaundice, RUQ pain
• Reynolds pentad: triad plus hypotension and confusion = septic shock

Asymptomatic gallstones — usually observed.

Biliary colic and acute cholecystitis

• NPO, IV fluids, antiemetics, NG decompression if vomiting persists
• Analgesia: NSAIDs (e.g., ketorolac) are effective for biliary colic — monitor for GI bleeding and kidney injury, avoid in kidney disease, and limit ketorolac to no more than 5 days; opioids for severe pain. Morphine is not contraindicated; the old concern about sphincter of Oddi spasm has little clinical importance
• IV antibiotics for cholecystitis
• Laparoscopic cholecystectomy — early, ideally during the same admission (ideally within 72 hours of symptom onset; still preferred within the first week)
• High-risk surgical clients: percutaneous cholecystostomy (drain through the skin into the gallbladder)
• Ursodiol dissolves small cholesterol stones slowly (months); stones often recur; diarrhea

Choledocholithiasis — ERCP with sphincterotomy and stone extraction, before or during cholecystectomy.

Acute cholangitis

• Sepsis care: blood cultures, broad-spectrum IV antibiotics promptly, fluids, vasopressors if needed
• Biliary drainage — ERCP — urgent, as soon as the client is stabilized, for severe cholangitis; early (within 24–48 hours) for moderate cases — or percutaneous transhepatic biliary drainage (PTBD) if ERCP fails

ERCP risks: post-ERCP pancreatitis (the most common), bleeding (especially after sphincterotomy), perforation, cholangitis.

Malignant obstruction — surgery if resectable; biliary stents (plastic or metal) or PTBD for palliation; chemotherapy.

PSC — no drug proven to change its course; manage itching, fat-soluble vitamin deficiency, strictures (endoscopic dilation); liver transplant is the only definitive treatment; regular surveillance for cholangiocarcinoma, gallbladder cancer, and (with colitis) colorectal cancer.

Pruritus — cholestyramine (binds other drugs; separate by 1 hour before or 4–6 hours after), antihistamines for sleep.

Listed in priority order.

1. Sepsis and shock — in cholangitis or suspected gallbladder perforation, monitor vital signs, mental status, urine output, and lactate; obtain cultures before antibiotics; give antibiotics without delay; report hypotension or confusion immediately. Gallbladder perforation with bile peritonitis is the most direct route to shock
2. Pain and comfort — analgesics on time; position of comfort (semi-Fowler's); NPO and NG care as ordered
3. Fluid and electrolytes — IV fluids, intake and output, electrolytes with vomiting or NG suction
4. Bleeding precautions — check INR before procedures; vitamin K as ordered
5. Post-ERCP — keep NPO until gag reflex returns and as ordered; monitor for severe epigastric pain radiating to the back (pancreatitis), fever, bleeding, rigid abdomen (perforation)
6. After laparoscopic cholecystectomy
   • Shoulder pain from CO₂ gas irritating the diaphragm is common — early ambulation and heat per protocol help
   • Deep breathing and incentive spirometry; early oral intake; most clients go home the same day or next day
   • Report fever, increasing abdominal pain, jaundice, or bile-colored drainage (bile leak or retained stone)
7. Drain care (PTBD, T-tube, cholecystostomy)
   • Keep the collection bag below the insertion site; avoid kinks; secure the catheter to prevent dislodgement
   • Record color and amount of bile every shift; report sudden decrease or stop (obstruction, dislodgement), blood in the drainage, cloudy or foul drainage, or leakage around the site
   • Flush only as ordered; protect skin from bile
   • A T-tube after open common bile duct exploration drains bile until the duct heals; output is commonly several hundred mL (about 300–500 mL) in the first 24 hours and should fall over the following days as bile flows into the duodenum; report output that stays above about 500 mL/day or suddenly rises. Clamping trials follow the surgeon's order — report pain, nausea, or leakage during clamping
   • Stools returning to brown and urine lightening indicate bile flow to the intestine
8. Skin (pruritus) — cool baths, unscented emollients, short nails, loose cotton clothing

• Before surgery: a lower-fat diet may reduce attacks; avoid large, heavy meals
• After cholecystectomy: most people return to a normal diet; if loose stools occur after fatty meals, reduce fat temporarily and add soluble fiber
• Post-cholecystectomy syndrome: persistent or recurrent RUQ pain, bloating, and indigestion after surgery (retained stone, sphincter dysfunction, bile-acid diarrhea) — report for evaluation
• Laparoscopic surgery: avoid heavy lifting as instructed (commonly about 1–2 weeks); shower as advised; watch incisions for redness or drainage
• Biliary stent: report fever, chills, jaundice, dark urine, or pale stools (stent blockage or cholangitis); keep scheduled stent exchange appointments. Do not massage or press on the abdomen to "adjust" a stent
• PTBD at home: secure the catheter, keep the bag below the waist, change dressings as taught, record output daily
• Weight loss should be gradual — rapid loss promotes gallstones
• After ERCP: report severe abdominal or back pain, vomiting, fever, black stools, or vomiting blood in the first days
• Pruritus from obstruction usually improves once bile flow is restored; avoid hot showers and scratching
• Ursodiol (if prescribed): take long term as directed; stones may recur when it is stopped; follow-up ultrasound checks the response

• Classic gallstone pain: RUQ after a fatty meal, radiating to the right shoulder
• Murphy sign = acute cholecystitis; ultrasound is the first imaging test
• Obstructive jaundice: dark urine, clay-colored stools, pruritus, raised direct bilirubin and ALP
• Charcot triad (fever, jaundice, RUQ pain) = cholangitis; add hypotension and confusion = Reynolds pentad
• Cholangitis: blood cultures before antibiotics, then urgent biliary drainage (ERCP)
• ERCP with sphincterotomy removes duct stones; watch for post-ERCP pancreatitis
• Acute cholecystitis: NPO, IV fluids, antibiotics, early laparoscopic cholecystectomy
• Laparoscopic shoulder pain = CO₂ — ambulate
• Drains: bag below the site; report sudden drop in output or blood
• PSC: associated with ulcerative colitis; liver transplant is the only cure
• Gallbladder polyp ≥ 1 cm with gallstones raises cancer risk