Acute Cholecystitis

Snapshot

• A 45-year-old obese woman presents to the emergency room with steady, severe, aching pain in the upper right quadrant that radiates to the right scapula. The onset was acute and occurred 30 minutes after lunch. She also reports nausea with vomiting. On physical exam, it is noted that she stops breathing on deep palpation of the right quadrant. Laboratory studies show an absolute neutrophillic leukocytosis with a left shift.

Introduction

• Clinical definition
  • acute inflammation of the gallbladder, often in the setting of gallstones or biliary sludge
    • acalculous cholecystitis 
      • etiology
        • gallbladder stasis
        • hypoperfusion
        • infection
      • often seen in very ill patients 
        • associated with high mortality
    • calculous cholecystitis
      • etiology
        • gallstone impaction resulting in inflammation
      • more common
• Epidemiology
  • demographics
    • female > male
    • adults
  • risk factors 
    • gallstones
    • F’s
      • Fat
      • Female
      • Forty
      • Flatulent
      • Fertile
    • hormone replacement therapy
    • obesity
    • hypertriglyceridemia
  • etiology
    • EEEK bugs
      • E. coli
      • Enterobacter
      • Enterococcus
      • Klebsiella
• Pathogenesis   
• blockage of cystic duct by gallstones can lead to distention of gallbladder, inflammation, and infection

Presentation

• Symptoms
  • systemic symptoms
    • fevers
    • chills
  • nausea and vomiting
  • anorexia
  • right upper quadrant pain
    • may radiate to shoulder
• Physical exam
  • inspection
    • jaundice typically not seen
    • Charcot triad may indicate progression of disease to ascending cholangitis 
      • jaundice
      • right upper quadrant pain
      • fever
  • palpation
    • right upper quadrant tenderness to palpation
    • peritoneal signs may indicate perforation
    • gallbladder may be palpable
  • tests
    • Murphy sign
      • arrest of inspiration with palpation of right upper quadrant
    • Boas sign
• hyperesthesia to light touch in right upper quadrant or infrascapular area

Imaging

• Right upper quadrant ultrasound
  • best initial imaging
  • findings
    • stones
    • biliary sludge
    • thickened gallbladder wall
    • ultrasonic Murphy sign
• Cholescintigraphy (HIDA scan)
  • indication
    • ultrasound findings are equivocal
  • findings
    • lack of gallbladder visualization
• Computed tomography (CT) of abdomen and pelvis
  • indication
    • to rule out other abdominal pathologies
  • findings
    • gallbladder distention
    • thickened gallbladder wall
    • pericholecystic fat stranding
• abscesses

Studies

• Studies
  • ↑ or normal alkaline phosphatase
  • ↑ or normal bilirubin
  • ↑ or normal white blood cell count
• Diagnostic criteria
  • local inflammation
    • Murphy sign
    • right upper quadrant tenderness
  • systemic inflammation
    • fever
    • ↑ white blood cell count
  • imaging
• cholecystitis

Differential

• Acute pancreatitis
  • distinguishing factor
    • usually has elevated lipase and epigastric tenderness
• may be associated with gallstones

Treatment

• First-line
  • supportive care
    • intravenous fluids
    • electrolyte repletion
    • analgesia
  • intravenous antibiotics
  • non-emergent cholecystectomy 
    • indication
      • usually done within 72 hours
  • emergent cholecystectomy
    • indication
      • generalized peritonitis
      • perforated cholecystitis or gangrenous cholecystitis
• Second-line
  • percutaneous drainage
    • indication
• medically unstable for cholecystectomy

Complications

• Ascending cholangitis
• Gallbladder perforation