PANCE Blueprint GI and Nutrition (9%)

Biliary Disorders (PEARLS + ReelDx)

The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint covers three topics associated with the gallbladder

Acute and chronic cholecystitis Inflammation of the gallbladder; usually associated with gallstones


  • 5 Fs: Female, Fat, Forty, Fertile, Fair
  • (+) Murphy's sign (RUQ pain with GB palpation on inspiration)
  • RUQ pain after a high-fat meal
  • Low-grade fever, leukocytosis, jaundice


  • Ultrasound is the preferred initial imaging - gallbladder wall >3 mm, pericholecystic fluid, gallstones
  • HIDA is the best test (Gold Standard) - when ultrasound is inconclusive
  • CT scan - alternative, more sensitive for perforation, abscess, pancreatitis
  • Labs: ↑ Alk-P and ↑ GGT, ↑ conjugated bilirubin
  • Porcelain gallbladder = chronic cholecystitis
  • Choledocholithiasis = stones in common bile duct - diagnosed with ERCP (gold standard)

Treatment: Cholecystectomy (first 24-48 hours)

Cholangitis Infection of biliary tract secondary to obstruction, which leads to biliary stasis and bacterial overgrowth

  • Characterized by pain in the upper-right quadrant of the abdomen, fever, and jaundice
  • Choledocholithiasis accounts for 60% of cases
  • Other causes include pancreatic and biliary neoplasm, postoperative strictures, invasive procedures such as ERCP or PTC, and choledochal cysts
  • Organisms: E. coli, Enterococcus, Klebsiella, Enterobacter


  • Charcot’s triad: RUQ tenderness, jaundice, fever
  • Reynold’s pentad: Charcot’s triad + altered mental status and hypotension

Diagnostic studies:

  • Initial imaging: Ultrasound
  • Best: ERCP

Treatment: Cholangitis is potentially life-threatening and requires emergency treatment

  • Aggressive care and emergent removal of stones, Cipro + metronidazole
  • Antibiotics, fluids, and analgesia.
  • ERCP to remove stones, insert a stent, repair the sphincter
  • Cholecystectomy (performed post-acute)

Primary sclerosing cholangitis

  • Jaundice and pruritus
  • Associated with IBD, cholangiocarcinoma, pancreatic cancer, colorectal cancer
Cholelithiasis REEL-DX-ENHANCED

41 y/p female with severe right upper quadrant pain

A precursor to cholecystitis, cholesterol stones account for > 85% of gallstones in the Western world

  • Stones in the gallbladder, pain secondary to contraction of gall against the obstructed cystic duct
  • Asymptomatic (most), symptoms only last few hours
  • Biliary colic—RUQ pain or epigastric
  • Pain after eating and at night
  • Boas sign—referred right subscapular pain
  • RUQ ultrasound - high sensitivity and specificity if  >2 mm. CT scan and MRI

TX: Asymptomatic—No treatment necessary

  • Elective cholecystectomy for recurrent bouts
GI/Nutrition Quick Cram Cards (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: Diseases of the Gallbladder and Liver
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