Acute Cholecystitis

Question 1

After …, acute cholecystitis is the second most common complication of gallstones (cholelithiasis) affecting an estimated 0.3-0.4% of patients with asymptomatic gallstones each year. Relatively rarely acute cholecystitis occurs in the absence of gallstones (acalculous cholecystitis).

Answer 1

After biliary colic, acute cholecystitis is the second most common complication of gallstones (cholelithiasis) affecting an estimated 0.3-0.4% of patients with asymptomatic gallstones each year. Relatively rarely acute cholecystitis occurs in the absence of gallstones (acalculous cholecystitis).

Question 2

… are by far the most common cause of acute cholecystitis.

Answer 2

Cholelithiasis (gallstones) are by far the most common cause of acute cholecystitis.

Question 3

Gallstones affect up to ….% of the population.

Answer 3

Gallstones affect up to 20% of the population.

Question 4

Cholelithiasis (gallstones) - There are a number of risk factors are associated with the development of cholelithiasis: (10)

Answer 4

Age
Female sex
Genetic predisposition
Obesity
Rapid weight loss / prolonged fasting
Diabetes
Medications (e.g. oestrogen replacement therapy, ceftriaxone, octreotide)
Crohn's disease
Diet (high in triglycerides, refined carbohydrates)
Haemolytic anaemia

Question 5

Acute calculous cholecystitis

Answer 5

Inflammation and infection occur when a stone becomes impacted in the cystic duct (see Cholelithiasis notes to review the basic anatomy).

The exact pathogenesis is still not understood and it is thought the presence of additional mediators is required for cholecystitis to occur. An impacted stone leads to impaired drainage of gallbladder contents and the release of inflammatory mediators.

Though patients with acute cholecystitis are always treated with antibiotics some have posited that a significant proportion of patients have a sterile inflammation.

Question 6

Acute acalculous cholecystitis refers to gallbladder inflammation in the absence of ….

Answer 6

Acute acalculous cholecystitis refers to gallbladder inflammation in the absence of gallstones.

Question 7

Acalculous cholecystitis is far less common than calculous cholecystitis and is normally seen in patients with significant systemic upset or following major surgery. Risk factors include:

Answer 7

Diabetes
Age
Recent major surgery (e.g. cardiac surgery)
Myocardial infarction
Sepsis
Major burn
Major trauma
Cancer
Immunocompromised patients
Vasculitis
CKD

Question 8

Acute cholecystitis presents with … pain, tenderness and signs of …

Answer 8

Acute cholecystitis presents with abdominal pain, tenderness and signs of infection.

Question 9

Symptoms of acute cholecystitis (3)

Answer 9

RUQ / epigastric pain
Nausea / vomiting
Fevers

Question 10

Signs in acute cholecystitis (5)

Answer 10

RUQ / epigastric tenderness
RUQ / epigastric guarding
Pyrexia
Tachycardia
Hypotension (severe cases)

Question 11

… sign is indicative of cholecystitis. As the patient breathes out, place your hand below the right costal margin. As the patient breathes in the inflamed gallbladder moves inferiorly to the hand causing the patient to catch their breath. To be considered positive, it should be absent on the left side.

Answer 11

Murphy’s sign is indicative of cholecystitis. As the patient breathes out, place your hand below the right costal margin. As the patient breathes in the inflamed gallbladder moves inferiorly to the hand causing the patient to catch their breath. To be considered positive, it should be absent on the left side.

Question 12

Murphy’s sign is indicative of cholecystitis. As the patient breathes out, place your hand below the right costal margin. As the patient breathes in the inflamed gallbladder moves inferiorly to the hand causing the patient to catch their breath. To be considered positive, it should be absent on the … side.

Answer 12

Murphy’s sign is indicative of cholecystitis. As the patient breathes out, place your hand below the right costal margin. As the patient breathes in the inflamed gallbladder moves inferiorly to the hand causing the patient to catch their breath. To be considered positive, it should be absent on the left side.

Question 13

Murphy’s sign is indicative of …. As the patient breathes out, place your hand below the right costal margin. As the patient breathes in the inflamed gallbladder moves inferiorly to the hand causing the patient to catch their breath. To be considered positive, it should be absent on the left side.

Answer 13

Murphy’s sign is indicative of cholecystitis. As the patient breathes out, place your hand below the right costal margin. As the patient breathes in the inflamed gallbladder moves inferiorly to the hand causing the patient to catch their breath. To be considered positive, it should be absent on the left side.

Question 14

These are signs and symptoms of what condition?

Answer 14

Acute cholecystitis

Question 15

Acute cholecystitis is most commonly confirmed on … or CT abdomen/pelvis.

Answer 15

Acute cholecystitis is most commonly confirmed on USS or CT abdomen/pelvis.

Question 16

Bedside OBS in acute cholecystitis

Answer 16

Bedside

Observations
BM
Urine dip
Pregnancy test (any woman of child-bearing age)

Question 17

Bloods in acute cholecystitis

Answer 17

Bloods

Full blood count
Urea & electrolytes
CRP
Liver function tests
Amylase

Question 18

Imaging in acute cholecystitis

Answer 18

Ultrasound: in acute cholecystitis gallstones and a ‘radiological’ Murphy’s sign may be seen. Suggestive findings include a thickened gallbladder and pericholecystic fluid. It also allows for the assessment of the CBD.

Computed tomography: may be used to demonstrate cholecystitis and exclude alternative causes of symptoms. Again a thickened gallbladder and pericholecystic fluid may be seen. It has a poor sensitivity (around 60-70%) for picking up simple gallstones, only clearly demonstrating stones that are calcified.

MRCP: magnetic resonance cholangiopancreatography offers excellent visualisation of the biliary tree. Arranged if there is suspicion of stones in the biliary tree.

Question 19

Acute cholecystitis is managed how?

Answer 19

Acute cholecystitis is managed with intravenous antibiotics, fluids and cholecystectomy.

Question 20

Acute cholecystitis - Initial management should follow an ABC approach in those who are acutely unwell. The sepsis 6 protocol should be implemented when indicated. Key components of management include:

Answer 20

Antibiotics: IV Augmentin would be a standard initial agent. A stat dose of an aminoglycoside (e.g. Gentamicin) may also be given.
Fluids: intravenous fluids should be commenced in most patients, both resuscitation and maintenance fluids are required. Where patients are able to maintain hydration with oral intake this should be encouraged.
Analgesia: should be tailored to the patient’s needs, age and co-morbidities. An example regimen would include regular codeine and paracetamol with oramorph as required for breakthrough pain.

Question 21

Gallbladder drainage - when is this more appropriate in acute cholecystitis over a laparoscopic cholecystectomy?

Answer 21

Some patients become very unwell with their cholecystitis, do not improve with medical management and may develop gallbladder empyemas. Often the patient is not suitable for a ‘hot’ laparoscopic cholecystectomy.

In these patients, a percutaneous cholecystostomy (drain into the gallbladder placed by interventional radiology) may be more appropriate. Once recovered, patients are often discharged with this drain in situ until definitive management can be arranged.

Question 22

In patients with simple cholecystitis, the definitive management is with laparoscopic cholecystectomy. There are two main options:
What are they?

Answer 22

‘Hot’ laparoscopic cholecystectomy: surgery is arranged within 72 hours (or at some centres up to one week) of the onset of symptoms. After this, the operation becomes technically more difficult until the inflammation settles.
Interval laparoscopic cholecystectomy: if the ‘hot’ operation is not available or appropriate interval surgery may be indicated after a period of recovery.

Question 23

‘Hot’ laparoscopic cholecystectomy vs Interval laparoscopic cholecystectomy?

Answer 23

‘Hot’ laparoscopic cholecystectomy: surgery is arranged within 72 hours (or at some centres up to one week) of the onset of symptoms. After this, the operation becomes technically more difficult until the inflammation settles.
Interval laparoscopic cholecystectomy: if the ‘hot’ operation is not available or appropriate interval surgery may be indicated after a period of recovery.

Question 24

Prior to cholecystectomy, it is key that what is excluded?

Answer 24

Prior to cholecystectomy, it is key that CBD stones are excluded. All patients will have had a USS and set of LFTs as a minimum. If there is suspicion of CBD stones (e.g. dilated CBD or CBD stone on USS, raised bilirubin on LFTs) then there are two main options:

MRCP +/- ERCP or on-table cholangiogram:

Question 25

If there is suspicion of CBD stones in acute cholecystitis prior to surgery, (e.g. dilated CBD or CBD stone on USS, raised bilirubin on LFTs) then there are two main options:

Answer 25

MRCP +/- ERCP: MRCP allows for confirmation of stones in the biliary tree (if confirmed on other imaging you may proceed straight to ERCP). When present, ERCP allows for therapeutic intervention with stone retrieval +/- sphincterotomy +/- stent placement prior to cholecystectomy.
On-table cholangiogram: less commonly available and technically challenging. During the laparoscopic cholecystectomy, the bile duct is intubated to allow the injection of dye with fluoroscopy in theatre to diagnose stones in the biliary tree. Various techniques may then be used to retrieve/expel stones.

Question 26

A 64-year-old man is admitted under the surgical team with suspected acute cholecystitis. He is treated with intravenous antibiotics and intravenous fluids. An abdominal ultrasound shows evidence of multiple gallstones in the gallbladder with surrounding pericholecystic fluid suggestive of acute cholecystitis. The common bile duct is mildly dilated at 9 mm with some intrahepatic dilatation. The team decides to opt for an outpatient cholecystectomy.

What is the most appropriate management prior to cholecystectomy?

A Continue antibiotics until the time of operation
B Arrange an MRCP to look for a CBD stone
C Repeat LFTs to see if interval improvement
D Arrange a gastroscopy to exclude peptic ulcer disease
E Request a CA19-9 to exclude pancreatic cancer

Answer 26

Prior to cholecystectomy, it is key that CBD stones are excluded.

In this case, a common bile duct (CBD) stone is highly suspected due to a dilated biliary tree.

Question 27

A 48-year old woman presents to accident and emergency with abdominal pain. She started to develop pain this morning, which then intensified over the last 6 hours. She has pain in the right upper quadrant with some radiation to the back. On the way to the hospital, she vomited once and now feels feverish. She has a background of hypercholesterolaemia and takes atorvastatin daily. She is a non-smoker and drinks minimal alcohol. On examination, there is tenderness and guarding in the right upper quadrant. Murphy’s sign is positive. Observations are HR 105 bpm, BP 134/82 mmHg, RR 22 bpm, T 38.4º, sats 98% (room air). Urgent blood is taken, which are shown:

Hb 145 (135-165 g/L)

WCC 12.6 (4.0-11.0 x10^9/L)

Urea 6.2 (2.5-7.0 mmol/L)

Creatinine 78 (60-110 umol/L)

Bilirubin 34 (1-22 umol/L)

ALT 78 (5-35 U/L)

ALP 236 (45-105 U/L)

Amylase 130 (60-180 U/L)

What is the most likely diagnosis?

A	Acute pancreatitis
B	Acute cholecystitis
C	Biliary colic
D	Peptic ulcer disease
E	Acute hepatitis

Answer 27

Acute cholecystitis refers to inflammation of the gallbladder most commonly occurring due to impacted gallstones.

Acute cholecystitis presents with abdominal pain, tenderness, and signs of infection. Murphy’s sign is indicative of cholecystitis. As the patient breathes out, place your hand below the right costal margin. As the patient breathes in the inflamed gallbladder moves inferiorly to the hand causing the patient to catch their breath. To be considered positive, it should be absent on the left side.

In this case, this patient has evidence of sepsis (fever, tachycardia, elevated white cell count) and should be treated urgently with respect to the ‘sepsis six’ with intravenous fluids and antibiotics to cover for an intra-abdominal source. She requires further imaging to assess the biliary system that can be with CT or US. The normal amylase and typical biliary symptoms make pancreatitis unlikely. Systemic upset and fever would not be seen in biliary colic. Acute hepatitis can cause fevers, but you would expect a marked derangement in the liver function tests with a hepatocellular picture (raised ALT/AST > ALP). Peptic ulcer disease classically causes epigastric pain and may be associated with GI bleeding.