Acute cholecystitis

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Background

Gallbladder anatomy

Clinical Features

Local Signs

  • RUQ pain
  • Murphy Sign
    • Highest positive LR of any clinical finding or lab value

Systemic signs

Differential Diagnosis

RUQ Pain

Evaluation

Laboratory Findings

  • Leukocytosis
  • LFT abnormalities (obstructive picture)

Imaging

Gallstone impacted in the neck of the gallbladder with gall bladder wall thickening.
Gallbladder wall thickening
Acute cholecystitis
  • Biliary ultrasound
    • Gallstones
      • Distinguish by characteristic "shadowing"
      • Better seen with patient in left lateral decub
    • GB wall thickening (>3mm)
    • Pericholecystic fluid
    • Sonographic Murphy's Sign (PPV 92%)
      • May be absent in patients with DM, gangrenous cholecystitis
  • CT

Management

Antibiotics

Coverage is targeted at E. coli, Enterococcus, Bacteroides, and Clostridium (anerobic)

Uncomplicated Cholecystitis

Complicated

Complicated disease such as severe sepsis or hemodynamic instability

  • Vancomycin 15-20mg/kg PLUS any of the following options

Options:

Surgical consultation

  • Definitive treatment involves surgical removal or decompression

Disposition

  • Admit

Complications

  • Gangrene
    • Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
    • Consider if patient presents with sepsis in addition to cholecystitis
  • Perforation
    • Occurs in 2% after development of gangrene
    • Usually localized, leading to pericholecystic abscess
  • Gallstone Ileus
    • Due to cholecystoenteric fistula
  • Emphysematous cholecystitis
    • Due to secondary infection of GB by gas-forming organisms (C. perfringens)
    • Presents like cholecystitis but often progresses to sepsis and gangrene
    • IV antibiotic and cholecystectomy are essential
    • Ultrasound report may mistake GB wall gas for bowel gas
    • Mortality as high as 15% due to gangrene or perforation
  • Mirizzi Syndrome
    • Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
    • Symptoms of acute cholecystitis + dilated intrahepatic ducts + jaundice
    • Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
      • US and CT can usually delineate the fistula
    • Treatment = open cholecystectomy
  • Gallstone Ileus
    • Bowel obstruction due to impaction of gallstone at terminal ileum
      • Gallstone enters small bowel through biliary-duodenal fistula
    • Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone

See Also

References