Acute Cholecystitis

Question 1

Aetiology of acute cholecystitis

Answer 1

inflammation of the gallbladder → caused by blockage of the cystic duct preventing the gallbladder from draining

Question 2

Pathophysiology of acute cholecystitis

Answer 2

• majority of cases (95%) caused by gallstones (calculous cholecystitis)
• gallstones may be trapped in the neck of the gallbladder or in the cystic duct
• small number of cases → 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 3

Clinical presentation of acute cholecystitis?

Answer 3

pain in the right upper quadrant (RUQ) → may radiate to right shoulder

• fever
• nausea
• vomiting
• tachycardia and tachypnoea
• right upper quadrant tenderness
• murphy’s sign
• raised inflammatory markers and white blood cells

Question 4

What is murphy’s sign

Answer 4

• place 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 5

Investigation/diagnosis of acute cholecystitis?

Answer 5

First step → abdominal ultrasound scan, signs include:
- thickened gallbladder wall
- stones or sludge in gallbladder
- fluid around the gallbladder

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 dilation or raised bilirubin)

Question 6

Treatment of acute cholecystitis

Answer 6

emergency admission for management

• nil by mouth
• IV fluids
• Antibiotics
• NG tube if required for vomiting

ERCP → remove stones trapped in common bile duct

Cholecystectomy(removal of gallbaldder) is usually performed during the acute admission, within 72 hours of symptoms. in some cases, it may be delayed for 6-7 weeks after the acute episode to allow the inflammation to settle

Question 7

Complications of acute cholecystitis

Answer 7

• sepsis
• gallbladder empyema
  • refers to infected tissue and pus collecting in the gallbladder.

management involves IV antibiotics and one of 2 main options
1. cholecystectomy (to remove the gallbladder)
2. cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)

• gangrenous gallbladder
• perforation

Question 8

Common presentation: 50 year old woman presents with constant right upper quadrant pain. she has a history of gallstones. she is pyrexial and has raised inflammatory markers

Answer 8

acute cholecystitis