Acute cholecystitis

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Background

Gallbladder disease types

Anatomy & Pathophysiology

Gallbladder anatomy
  • 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 of any clinical finding or lab value

Systemic signs

Differential Diagnosis

RUQ Pain

Evaluation

  • Meta-analysis of 17 studies which evaluated role of history, physical, and lab tests in working up cholecystitis showed all likelihood ratios cross or almost cross 1.0. There is no history, physical exam, or lab test that would comfortably allow you to rule-out or rule-in cholecystitis.[1]

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

  1. Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6.