Acute calculous cholecystitis: Difference between revisions
 
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==Background==
==Background==
[[File:Gallstones 2.jpg |thumb|Acute cholecystitis on gross pathology of removed gallbladder containing multiple stones.]]
{{Gallbladder disease types}}
{{Gallbladder disease types}}
{{Gallbladder background}}
{{Gallbladder background}}
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*Murphy Sign
*Murphy Sign
**Highest positive LR (2.8) of any clinical finding or lab value<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
**Highest positive LR (2.8) of any clinical finding or lab value<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
*Boas sign: hyperaesthesia below the right scapula from referred pain<ref>Iyer HV. Boas' sign revisited. Ir J Med Sci. 2011;180(1):301. doi:10.1007/s11845-010-0640-x</ref>


===Systemic signs===
===Systemic signs===
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==Evaluation==
==Evaluation==
[[File:Ultrasonography of sludge and gallstones, annotated.jpg|thumb|Abdominal ultrasound showing biliary sludge and gallstones]]
[[File:Cholecystitis_Neck_Stone_Bowra.gif|thumbnail|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
[[File:Gallstones.png|thumb|Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.]]
[[File:GB_Thickening_Fluid_Bowra.gif|thumbnail|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
===Workup===
===Workup===
====Laboratory Findings====
====Laboratory Findings====
*Common findings:
*Common findings:
**Leukocytosis
**[[Leukocytosis]]
**LFT abnormalities (obstructive picture)
**[[LFTs|LFT]] abnormalities (obstructive picture)
*Meta-analysis shows there is no history, physical exam, or lab test or combination thereof that allows rule-out or rule-in without imaging.<ref>Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6.</ref>
*Meta-analysis shows there is no history, physical exam, or lab test or combination thereof that allows rule-out or rule-in without imaging.<ref>Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6.</ref>


====Imaging====
====Imaging====
[[File:Cholecystitis_Neck_Stone_Bowra.gif|thumbnail|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
[[File:GB_Thickening_Fluid_Bowra.gif|thumbnail|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
[[File:Acute cholecystitis.png|thumb|Acute cholecystitis]]
*[[Biliary ultrasound]] (preferred test<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>; sensitivity 84%; specificity 99%)<ref>Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;154:2573–81.</ref>
*[[Biliary ultrasound]] (preferred test<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>; sensitivity 84%; specificity 99%)<ref>Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;154:2573–81.</ref>
**Gallstones
**Gallstones
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==Complications==
==Complications==
*Gangrene
===[[Gangrene]]===
**Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
*Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
**Consider if patient presents with sepsis in addition to cholecystitis
*Consider if patient presents with sepsis in addition to cholecystitis
*Perforation
 
**Occurs in 2% after development of gangrene   
===Perforation===
**Usually localized, leading to pericholecystic abscess
*Occurs in 2% after development of gangrene   
*Gallstone [[Ileus]]
*Usually localized, leading to pericholecystic abscess
**Due to cholecystoenteric fistula
 
**Bowel obstruction due to impaction of gallstone at terminal ileum
===Gallstone [[Ileus]]===
***Gallstone enters small bowel through biliary-duodenal fistula
*Due to cholecystoenteric fistula
**Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone
*[[Bowel obstruction]] due to impaction of gallstone at terminal ileum
*Emphysematous cholecystitis
**Gallstone enters small bowel through biliary-duodenal fistula
**Due to secondary infection of GB by gas-forming organisms (C. perfringens)
*Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone
**Presents like cholecystitis but often progresses to sepsis and gangrene
 
**IV antibiotic and cholecystectomy are essential
===Emphysematous cholecystitis===
**Ultrasound report may mistake GB wall gas for bowel gas  
*Due to secondary infection of GB by gas-forming organisms (C. perfringens)
**Mortality as high as 15% due to gangrene or perforation
*Presents like cholecystitis but often progresses to sepsis and gangrene
*Mirizzi Syndrome
*IV antibiotic and cholecystectomy are essential
**Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
*Ultrasound report may mistake GB wall gas for bowel gas  
**Symptoms of acute cholecystitis + dilated intrahepatic ducts + jaundice
*Mortality as high as 15% due to gangrene or perforation
**Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
 
***US and CT can usually delineate the fistula
===Mirizzi Syndrome===
**Treatment = open cholecystectomy
*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


==See Also==
==See Also==
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[[Category:GI]]
[[Category:GI]]
[[Category:ID]]
[[Category:ID]]
[[Category:Surgery]]

Latest revision as of 19:23, 24 December 2020

Background

Acute cholecystitis on gross pathology of removed gallbladder containing multiple stones.

Gallbladder disease types

Gallbladder anatomy (overview).
Gallbladder anatomy

Anatomy & Pathophysiology

  • Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
  • These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
  • Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.

Clinical Features

Local Signs

  • RUQ pain
  • Murphy Sign
    • Highest positive LR (2.8) of any clinical finding or lab value[1]
  • Boas sign: hyperaesthesia below the right scapula from referred pain[2]

Systemic signs

Differential Diagnosis

RUQ Pain

Evaluation

Abdominal ultrasound showing biliary sludge and gallstones
Gallstone impacted in neck of gallbladder[3]
Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.
Gallbladder wall thickening with pericholecystic fluid[4]

Workup

Laboratory Findings

  • Common findings:
  • Meta-analysis shows there is no history, physical exam, or lab test or combination thereof that allows rule-out or rule-in without imaging.[5]

Imaging

  • Biliary ultrasound (preferred test[1]; sensitivity 84%; specificity 99%)[6]
    • 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
  • HIDA scan
    • Gold standard when other imaging modalities are equivocal[1]
  • Other imaging
    • CT: there is a lack of evidence to support diagnostic accuracy[1]
    • MRI: Accuracy similar to ultrasound[1]

Diagnosis

  • "Combining clinical, laboratory and imaging investigations is recommended, although the best combination is not yet known"[1]

Management

Antibiotics

Most often isolated organisms are Escherichia coli, Klebsiella pneumonia, and anaerobes, especially Bacteroides fragilis

Uncomplicated

Pathogenicity of Enterococci remains unclear and specific coverage is not routinely suggested for community-acquired infections[1]

Complicated or Healthcare Associated

Examples of complication include severe sepsis or hemodynamic instability

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

Options:

Surgical consultation

  • Definitive treatment: surgical cholecystectomy[1]
    • More effective than antibiotics alone[1]

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
  • 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

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

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5
  2. ↑ Iyer HV. Boas' sign revisited. Ir J Med Sci. 2011;180(1):301. doi:10.1007/s11845-010-0640-x
  3. ↑ http://www.thepocusatlas.com/hepatobiliary/
  4. ↑ http://www.thepocusatlas.com/hepatobiliary/
  5. ↑ Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6.
  6. ↑ Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;154:2573–81.
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