Acute Cholecystitis Flashcards
What is acute cholecystitis?
acute gallbladder inflammation, and one of the major complications of cholelithiasis or gallstones
What are the risk factors for acute cholecystitis?
- Gallstones
- Previous episode of biliary pain
- Severe illness
- Physical inactivity
- Ceftriaxone
- Ciclosporin
- Risk factors for acalculous cholecystitis
What sort of people are at high risk of gallstones?
- Patients (with a gallbladder in situ) who have undergone bariatric surgery and are experiencing rapid weight loss
- Those receiving parenteral nutrition
- Those using somatostatin long-term
What are the gastro symptoms of acute cholecystitis?
- Pain in upper right quadrant (constant, long lasting, may radiate to back)
- Tenderness in the right upper quadrant
- Palpable mass
- Murphy’s positive
What are the general symptoms of acute cholecystitis?
- Signs and symptoms of inflammation: fever, high WBC, CRP, erythrocyte sedimentation rate
- Fever/chills
- Nausea
- Right shoulder pain
- Anorexia
What are the differential diagnosis of acute cholecystitis?
- Acute cholangitis
- Chronic cholecystitis
- Peptic ulcer disease
- Acute pancreatitis
- Sickle cell crises
- Appendicitis
- Right lower lobe pneumonia
- Acute coronary syndrome
- GORD
What imaging is used in acute cholecystitis?
- CT or MRI
2. US
What would the findings be on a CT or MRI for acute cholecystitis?
- Irregular thickening of the gallbladder wall
- Poor contrast enhancement of the gallbladder wall (interrupted rim sign)
- Increased density of fatty tissue around the gallbladder
- Gas in the gallbladder lumen or wall
- Membranous structures within the lumen (intraluminal flap or intraluminal membrane)
- Peri‐gallbladder abscess
What would the findings be on an abdominal US for acute cholcystitis?
- Pericholecystic fluid
- Distended gallbladder
- Thickened gallbladder wall (>3 mm)
- Gallstones
- Positive sonographic Murphy’s sign (may be absent in gangrenous cholecystitis)
What bloods do you order for acute cholecystitis?
- FBC
- CRP
- Bilirubin
- LFT
- Serum Lipase or amylase
- Blood culture and/or bile cultures
What would the fbc show is acute cholecystitis?
WCC increased
What would the CRP be like in acute cholecystitis?
increased
What would the bilirubin be like in acute cholecystitis?
increased
What would LFTs be like in acute cholecystitis?
may be elevated
Why do you measure serum lipase and amylase in acute cholecystitis?
result >3 times the upper limit of the normal range confirms the diagnosis of acute pancreatitis in a patient with acute upper abdominal pain
Why would you do a blood culture or bile cultures in acute cholecystitis?
confirm infective organism, if present
What is the sonographic criteria for acute cholecystitis?
- Pericholecystic fluid
- Distended gallbladder
- Thickened gallbladder wall (>3 mm)
- Gallstones
- Positive sonographic Murphy ‘s sign
What grading is used in acute cholecystitis?
TG18/TG13 severity
What is the initial management of acute cholecystitis?
- Manage sepsis
- organ failure
- fluid resus
- antibiotics
What is the first line treatment of acute cholecystitis with associated organ dysfunction (severe; Tokyo guideline grade III)?
intensive care admission
What other treatment is used in acute cholecystitis with associated organ dysfunction (severe; Tokyo guideline grade III)?
Plus: 1. Analgesia Consider: 1. Fluid resus 2. Antibiotic therapy 3. Percutaneous cholecystomy 4. Delayed cholecystectomy 5. Post op management
What is the first line treatment for acute cholecystitis with no associated organ dysfunction (mild or moderate; Tokyo guideline grade I or grade II)?
analgesia
What other treatment is used for acute cholecystitis with no associated organ dysfunction (mild or moderate; Tokyo guideline grade I or grade II)?
Consider: 1. Fluid resus 2. Antibiotic therapy Plus: 1. Early laparoscopic cholecystectomy or percutaneous 2. Post op management
What are the possible complications of acute cholecystitis?
- Suppurative cholecystitis
- Bile duct injury due to surgery
- Gallstone ileus
- Cholecystoenteric fistulas
What is prognosis of acute cholecystitis like?
- Removing the gallbladder and the contained gallstones when biliary pain starts will prevent further biliary attacks and reduce the risk of developing cholecystitis
- If the gallbladder perforates, mortality is 30%.
- Untreated acute acalculous cholecystitis is life-threatening and is associated with up to 50% mortality
What is the intial management for acute cholecystitis?
Clear fluids only and analgesics, fluid resus, broad IV Abx if infection.
What is the definitive treatment for acute cholceystitis?
- Early lap chole within a week of onset.
- Otherwise, delayed to let inflammation settle
What are other complications of acute cholecystitis?
- Gallbladder empyema
- porcelain gallbladder
- risk of GB cancer
- gallstone ileus
What should be done if symptoms fail to improve despite medical management?
- symptoms fail to improve with medical management, a local abscess/empyema should be suspected
- can be confirmed with a CT scan. In this event, a percutaneous cholecystostomy is performed and a pigtail catheter inserted to drain the abscess
