Acute Cholecystitis - Gastrointestinal

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 Post cholecystectomy syndrome occurs after a cholecystectomy presents with right upper quadrant pain increased AST/ALT and alkaline phosphatase management ultrasound endoscopic retrograde cholangiopancreatography (ERCP)