Acute cholecystitis Flashcards
Describe how gallstones are formed.
- increased cholesterol in bile/raised calcium bilirubinate in bile
- bile becomes supersaturated with these substances
- precipitate from solution as microscopic crystals, become trapped in gallbladder mucous producing gallbladder sludge
- crystals grow, aggregate and fuse over forming macroscopic stones
- ducts occluded causing symptoms
How does acute cholecystitis usually present?
- High fever (differentiated cholecystitis from biliary colic)
- Local peritonism
- Continuous epigastric or RUQ pain that refers to the scapula
- N+V
- Murphy’s sign
- Toxaemia
- Leukocytosis
- Jaundice (rare, but can occur if swollen gallbladder presses against CBD)
- Raised WCC/CRP
What is Murphy’s sign?
- Place 2 fingers over the RUQ
- Ask patient to breathe in
- +ve sign = causes pain and arrest of inspiration as the inflamed GB impinges fingers
- Sign os only +ve if a similar manoeuvre in the LUQ does not cause pain
How does chronic cholecystitis usually present?
- Colicky pain
- Flatulent dyspepsia = abdo discomfort, distension, nausea, flatulence and fat intolerance
*repeated episodes of inflammation results in chronic fibrosis and thickening of the entire gallbladder wall, which may contain thick + infected bile
What causes cholecystitis?
- Gallstones
- Tumour
- Infection
- Typhoid
- Brucellosis
- Cryptosporidiosis
- High pressure sphincter of Oddi
- Cystic duct structural abnormalities
- Complication of para-enteral nutrition
What are the differential diagnoses of cholecystitis?
- Reflux
- Peptic ulcers
- IBS
- Relapsing pancreatitis
- Tumour
- Hepatitis
- CHF
- Pyelonephritis
- Appendicitis
- Right lobar pneumonia
- MI
- Perforated oesophagus
How is cholecystitis diagnosed?
- US:
- thickened gallbladder wall (>3cm)
- pericholecystic fluid
- air in the gallbladder or the gallbladder wall - MRCP
What is the initial management for acute cholecystitis?
- NBM
- IV fluids
- Pain relief
- IV abx (cefuroxime)
- Cholecystectomy must be performed within 72h of acute attach, or must be performed after 6-12 weeks
What are the potential complications of acute cholecystitis?
- Empyema (abscess of the gallbladder where it becomes distended with pus)
- Perforation (due to necrosis of the gallbladder wall)
- Abscess (perforation may be walled off by momentum, resulting in localised abscess formation)
- Subphrenic abscess
- Generalised peritonitis
- Ascending cholangitis
What causes biliary colic and how does it present?
Cause: sudden + complete obstruction of the cystic duct or CBD by a stone
Presentation: severe RUQ/epigastric pain
- no fever
- no tenderness (no inflammation of gallbladder)
- no jaundice
How do you differentiate between acute cholecystitis and cholangitis?
- both present with RUQ pain
- both present with fever/raised WCC
- only common for cholangitis to present with jaundice
What are the risk factors for gallstones? (5 Fs)
- Fair
- Fat
- Fertile
- Female
- Forty
Other RFs:
- +ve family history
- Diabetes
- Rapid weight loss
- Pregnancy
- Crohn’s disease
- Hyperlipidaemia
- Loss of bile salts
What are the main symptoms of gallstones?
- RUQ/epigastric pain of sudden onset
- Colicky or constant pain (ascending cholangitis)
- Pain can radiate to the back
- Exacerbated by fatty food
- N+V
- If cholestasis present: jaundice, dark urine + pale stools
What are the differential diagnoses for gallstones?
- Appendicitis
- Bile duct strictures
- Bile duct tumours
- Cholangiocarcinoma
- Cholecystitis
- Gallbladder cancer
- Gastritis and peptid ulcer disease
- Gastroenteritis
- Pancreatic cancer
- Acute pancreatitis
What are the drawback of using x-ray when scanning for gallstones?
Will only pick up pigment stones - could miss cholesterol or mixed gallstones
