Acute cholecystitis

Question 1

Define acute cholecystitis

Answer 1

Sudden inflammation of the gallbladder and one of the major complications of cholelithiasis/gallstones

Question 2

Explain the aetiology of acute cholecystitis (and difference from biliary colic)

Answer 2

• Fixed obstruction or passage of gallstones/cholelithiasis into the cystic duct causes acute inflammation of the gallbladder wall.
• This entraps bile in the gallbladder, causing irritation of the gallbladder and increases the pressure in the gallbladder
• This can result in a secondary bacterial infection leading to necrosis and gallbladder perforation
• Can occur in absence of gallstones, in which case it is called acalculous acute cholecystitis (more common in old over 65 patients)

Question 3

What is the function of the gallbladder and what are the consequences of its removal?

Answer 3

• Its primary function is to store and concentrate bile.
• The gallbladder serves as a reservoir for bile, releasing it when you eat to aid the digestion of fat.
• When the gallbladder is removed, bile is less concentrated and drains more continuously into the intestines, where it can have a laxative effect

Question 4

Explain the risk factors for acute cholecystitis?

Answer 4

ACUTE CHOLECYSTITIS (90%)

• Gallstones (risk factors for this include):
  
  • Female
  • Old age
  • Metabolic syndrome (Diabetes, Obesity, Dyslipidaemia)
  • Pregnancy/HRT
  • Haemoglobinopathy (bilirubin/pigment stones)
  • Weight cycling
  • TPN
  • Terminal Ileum resection/disease (e.g. Crohn’s)

ACALCULOUS (10%):

• Critical/Severe illness (gallbladder dysmotility/Ischaemia)
• Physical inactivity
• Total parenteral nutrition
  
  • leads to gallbladder hypomotility which causes bile stasis –> leads to accumulation of toxic agents in the gallbladder lumen which damages gallbladder mucosa
• Burns and Severe Trauma

Question 5

Summarise the epidemiology of acute cholecystitis

Answer 5

• It occurs in approximately 15% of adults
• 3x more common in women than in men up to the age of 50 years
• Acalculous acute cholecystitis accounts for 5% - 14% of cases of acute cholecystitis

Question 6

Recognise the presenting symptoms of acute cholecystitis?

Answer 6

• Sudden-onset Constant RUQ pain and localised tenderness may radiate to back/shoulder/interscapular region
• Febrile (high temperatures)
• Previous or Current Biliary colic
  
  • May present a history of colicky pain following meals but now presenting with constant pain
  • BILIARY COLIC: waxing and waning pain after eating fatty meals as this causes the gallbladder to contract against the stone to release bile into duodenum)

Question 7

Recognise the signs on physical examination/history

Answer 7

• Murphy’s sign positive (gallbladder hits fingers)
• Radiation to shoulder/interscapular region (Boas’ sign)
• Palpable abdominal mass
• Raised temperature (febrile)
• Tachycardia
• Severe RUQ pain ± guarding - RUQ peritonism 2ry to gallbladder/abscess

Question 8

Identify appropriate investigations for cholecystitis and interpret the results

Answer 8

• 1st LINE: Abdominal Ultrasound, this shows:
  
  • Gallbladder wall thickening
  • Gallbladder distension
  • Gallstones in the gallbladder
  • Pericholecystic fluid/abscess (fluid/pus accumulation around the gallbladder)
  • sonographic Murphy’s sign - pain worsens on pressure of the probe over the gallbladder
• Abdomen CT if septic to exclude gallbladder necrosis/perforation
  
  • It can be useful if ultrasound findings are limited by gaseous distension or obesity

Bloods:

• FBC: Look at CRP and WCC which will be elevated
• LFTs: normal
• Serum lipase and amylase to exclude pancreatitis

Question 9

Generate a management plan for acute cholecystitis

Answer 9

Non-surgical

• Nil-by-mouth (to rest gallbladder ahead of surgery)
• Analgesics (paracetamol/NSAID then move to opioids IF REQUIRED)
• IV Fluids
• Antibiotics if infection suspected

Surgical: EARLY Lap Chole (to be perfprmed with 1 week of diagnosis)
* if biliary colic, then ROUTINE Lap Chole

Question 10

Identify the complications of acute cholecystitis

Answer 10

• Gallbladder wall necrosis/perforation
• Peri-cholecystic abscess.
• Cholecystodudenal fistula (allows gallstones to travel into the small bowel, eventually getting stuck in the terminal ileum and causing ‘gallstone ileus’)
• Gallbladder carcinoma
• Ascending cholangitis if stone is lodged in CBD

Question 11

Summarise the prognosis for patients with cholecystitis

Answer 11

• Acute cholecystitis may resolve spontaneously 5 - 7 days after symptom onset - the impacted stone becomes dislodged, with re-establishment of cystic duct patency
• Cholecystectomy when biliary pain starts will prevent further biliary attacks and reduce the risk of developing cholecystitis