B.

CLIENT BASED NON-MODIFIABLE FACTORS *Age Increase in age = increase in prevalence of gallstones (bile becomes more lithogenic) Women = more estrogen than men(Stimulates hepatic cholesterol secretion into bile) Increased progesterone (Decreased gallbladder motility) Increased estrogen( Stimulates hepatic cholesterol secretion into bile) Gallbladder volume is doubled(bile stasis) Accelerates nucleation with unconjugated bilirubin(st)

*Gender

*Pregnancy

Stimulates mucin secretion Biliary sludge Made up of hydrophobic regions that can bind to cholesterol, phospholipid and bilirubin

Acetyl CoA cholesterol transferase(A CAT) Low ACAT enlarged

Produces cholesterol as fatty acid ester Stored in the liver Cholesterol ester pool Stimulates hepatic secretion into bile

BILE Primary acid: chenodeoxycholate and cholate Secondary acid: deoxycholate and lithocholate Tertiary acid: ursodeoxycholate

Secreted by ATP-binding cassettes superfamily from hepatocytes into ABCG5 with ABCG8 trasports cholesterol Correlates with arachidonic acid Precursor of prostaglandin ABCB4 transports phospholipids If mutated(st) ABCB11 transports bile acids Secretion of bile salts

Gallbladder Acidifies bile Increase solubility of calcium salts Precipitation less favorable Stimulates mucin secretion Biliary sludge

Made up of hydrophobic regions that can bind to cholesterol, phospholipid and bilirubin Accelerates nucleation with unconjugated bilirubin

STONE

CHOLESTEROL STONE-undissolved cholesterol

Stone formation (cholelithiasis)** Stasis of bile within the gallbladder lumen Stone becomes impacted in the gastric duct Damage of gallbladder mucosa (mucosal trauma) Chronic obstruction Releases phosholipase A Converts lecithin to lysotecithin Activation of inflammatory mediators Inflamed gallbladder nocireceptors which are located in the liver, GI tract responds to noxious stimuli

Increased prostaglandin production due to arachidonic acid from damaged cells

Bilirubin is converted to urobilinogen through bacterial metabolization The bileare that allows the bilirubin to Some duct Some are drain from the liver to intestine is blocked excreted reabsorbed and through feces reprocessed Urobilinogen in systemic circulation

Transduction along nocireceptor fibers of spinal exchange of sodium and potassium ions at cord to brain stem the cell membranes activates nocireceptors Neurotransmitters such (ATP, bradykinin , glutamate,etc.)are released so that pain impulses will be transmitted through the synaptic cleft

Foreign body sensed by the mechano- and chemoreceptors in the stomach, jejunum and ileum Chemoreceptor trigger zone (CTZ) Vomiting center located in the medulla Contraction of the abdominal and chest wall Descent of the diaphragm Opening of the gastric cardia

Connects to thalamus, cortex and higher levels of the brain somatosensory cortex

Rapid and forceful evacuation of stomach contents

JAUNDICE

NAUSEA AND VOMITING (vomiting reflex)

PAIN