Updated: 6/10/2019

Acute Cholecystitis

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Snapshot
  • A 40-year-old obese woman presents to the emergency room for pain in her right upper quadrant of her abdomen. She reports that she has had similar pain on and off for the past few weeks, but this time the pain has persisted for over an hour. She also reports nausea, vomiting, and loss of appetite. On physical exam, she has right upper quadrant pain and inspiratory arrest with deep palpation of the area. An ultrasound of that area reveals distended gallbladder with thickened gallbladder wall and gallstones. She is admitted for further management and the general surgery team is consulted for possible surgery within the next 72 hours.  
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
    • 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
Studies
  • Diagnostic testing
    • 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 but clinical suspicion is strong
        • findings
          • lack of gallbladder visualization = obstruction
      • computed tomography of abdomen and pelvis
        • indication
          • to rule out other abdominal pathologies
        • findings
          • gallbladder distention
          • thickened gall bladder wall
          • pericholecystic fat stranding
          • abscesses
    • 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
 

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Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.GI.35) A 48-year-old female presents to the emergency department with fevers, and worsening abdominal pain for 24 hours. Exam demonstrates an overweight female in distress. Abdominal exam is notable for tenderness to palpation in the right upper quadrant and a positive ultrasonic (US) murphy's sign. Right upper quadrant ultrasound is shown in Figure A. Vital signs are as follows: T 102.1 F HR 84 BP 135/92 RR 14 O2 Sat 97%. Lab studies demonstrate leukocytosis. What's the next best step in management? Review Topic

QID: 103058
FIGURES:
1

IV fluid hydration, analgesics, NPO, Interval cholecystectomy after 7 days antibiotic therapy

25%

(1/4)

2

IV fluid hydration, analgesics, NPO, Open cholecystectomy

0%

(0/4)

3

IV fluid hydration, analgesics, NPO, Laparoscopic cholecystectomy

50%

(2/4)

4

IV fluid hydration, analgesics, NPO, Hida Scan

0%

(0/4)

5

IV fluid hydration, analgesics, NPO, Endoscopic retrograde cholangiopancreatography (ERCP)

25%

(1/4)

M2

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SUBMIT RESPONSE 3

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(M2.GI.30) A 70-year-old male presents to the emergency department with fever and productive cough that has progressed rapidly over the past day. On exam, he is very ill appearing and his vitals demonstrate T: 39 deg C, HR: 95 bpm, BP: 80/40 mmHg, RR: 15, SaO2: 93%. A CBC is obtained which demonstrates a white blood cell count (WBC) of 14,000. A chest radiograph is obtained which is demonstrated in Figure A. The patient is subsequently diagnosed with severe sepsis secondary to pneumonia and is transferred to the ICU after intubation, appropriate antibiotic therapy, and resuscitation measures are initiated. The patient improves steadily over the subsequent days in the ICU with improving vitals and decreasing WBC. However, on hospital day 4 he develops a fever to 41 deg C, and his WBC elevates to 16,000. On exam, he appears to withdraw in pain when his abdomen is palpated. Liver function tests and amylase/lipase are ordered and shown to be within normal limits. An abdominal ultrasound is obtained which is demonstrated in Figure B. What is the most likely cause of this patient's current presentation? Review Topic

QID: 104821
FIGURES:
1

Cholelithiasis

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2

Cholangitis

8%

(2/24)

3

Acute calculous cholecystitis

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4

Acute acalculous cholecystitis

88%

(21/24)

5

Acute pancreatitis

0%

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M2

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SUBMIT RESPONSE 4
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