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Updated: Dec 14 2021

Acute Cholecystitis

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https://upload.medbullets.com/topic/120163/images/gallbladder_u.jpg
https://upload.medbullets.com/topic/120163/images/pacutecholecystitits.jpg
https://upload.medbullets.com/topic/120163/images/abscess_gallbladder2..jpg
  • 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
  • ETIOLOGY
    • 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
  • 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
    • Diagnostic testing
      • studies
        • ↑ or normal alkaline phosphatase
        • ↑ or normal bilirubin
        • ↑ or normal white blood cell count
  • Differential
    • Acute pancreatitis
      • distinguishing factor
        • usually has elevated lipase and epigastric tenderness
        • may be associated with gallstones
  • DIAGNOSIS
    • Diagnostic criteria
      • local inflammation
        • Murphy sign
        • right upper quadrant tenderness
      • systemic inflammation
        • fever
        • ↑ white blood cell count
      • imaging
        • cholecystitis
  • 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)
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