Acute cholecystitis

Question 1

What is it?

Answer 1

inflammation of the gallbladder, which is caused by a blockage of the cystic duct preventing the gallbladder from draining. It is a key complication of gallstones, and the majority of cases (around 95%) are caused by gallstones (calculous cholecystitis). Gallstones may be trapped in the neck of the gallbladder or in the cystic duct.

In a small number of cases, the dysfunction in gallbladder emptying is caused by something other than gallstones (acalculous cholecystitis). One scenario where this may occur is in patients on total parental nutrition or having long periods of fasting (for example in ICU for other serious conditions), where the gallbladder is not being stimulated by food to regularly empty, resulting in a build-up of pressure.

Question 2

Presentation?

Answer 2

The main presenting symptom of cholecystitis is pain in the right upper quadrant (RUQ). This may radiate to the right shoulder.

Other features include:

Fever
Nausea
Vomiting
Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate)
Right upper quadrant tenderness
Murphy’s sign
Raised inflammatory markers and white blood cells

Murphy’s sign is suggestive of acute cholecystitis:

Place a hand in RUQ and apply pressure
Ask the patient to take a deep breath in
The gallbladder will move downwards during inspiration and come in contact with your hand
Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration

Question 3

Diangosis?

Answer 3

The first step is an abdominal ultrasound scan. Signs of acute cholecystitis on ultrasound are:

Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder

Magnetic resonance cholangiopancreatography (MRCP) may be used to visualise the biliary tree in more detail if a common bile duct stone is suspected but not seen on an ultrasound scan (e.g., bile duct dilatation or raised bilirubin).

Question 4

Management?

Answer 4

Patients with suspected acute cholecystitis need emergency admission for investigations and management.

Conservative management involves:

Nil by mouth
IV fluids
Antibiotics (as per local guidelines)
NG tube if required for vomiting

Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to remove stones trapped in the common bile duct.

Cholecystectomy (removal of the gallbladder) is usually be performed during the acute admission, within 72 hours of symptoms. In some cases, it may be delayed for 6-8 weeks after the acute episode to allow the inflammation to settle.

Question 5

Complications?

Answer 5

Sepsis
Gallbladder empyema
Gangrenous gallbladder
Perforation

Question 6

Treatment of gallbladder empyema

Answer 6

Cholecystectomy (to remove the gallbladder)
Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)