Updated: 8/19/2020

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
  • 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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(M3.GI.16.35) 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? Tested Concept

QID: 103058
FIGURES:
1

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

25%

(1/4)

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IV fluid hydration, analgesics, NPO, Open cholecystectomy

0%

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IV fluid hydration, analgesics, NPO, Laparoscopic cholecystectomy

50%

(2/4)

4

IV fluid hydration, analgesics, NPO, Hida Scan

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5

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

25%

(1/4)

L 3 B

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(M2.GI.15.30) 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? Tested Concept

QID: 104821
FIGURES:
1

Cholelithiasis

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Cholangitis

8%

(2/24)

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Acute calculous cholecystitis

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Acute acalculous cholecystitis

88%

(21/24)

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Acute pancreatitis

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L 2 E

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