Acute Cholestystitis

Question 1

define acute cholecystits?

Answer 1

inflammation of the gallbladder-> one of the major complications of cholelithiasis or gallstones

Question 2

outline the aetiology of acute cholecystitis?

Answer 2

It develops in up to 10% of patients with symptomatic gallstones.

In most cases ( 90%)-> caused by complete cystic duct obstruction usually due to an impacted gallstone in the gallbladder neck or cystic duct-> leads to inflammation within the gallbladder wall

Question 3

what are the risk factors of acute cholecystitis

Answer 3

gallstones- cause 90% of cases->become impacted within cystic duct-> leads to gallbladder inflammation

severe illness- gall bladder dysmotility, gallbladder ischaemia, TPN

Total Parenteral Nutrition- Prolonged TPN causes gallbladder stasis, biliary sludge, and gallstones due to decreased gallbladder emptying

Diabetes

Question 4

what are the presenting symptoms of acute cholecystitis?

Answer 4

Fever chills

Prolonged upper abdominal pain that may be referred to the right shoulder (due to diaphragmatic irritation) - this is exacerbated by movement and resp

N + V

anorexia

Question 5

what are the signs of acute cholecystitis?

Answer 5

Tachycardia

Pyrexia

RUQ pain or epigastric tenderness

May be guarding and/or rebound tenderness

Murphy’s sign positive

Question 6

what are the appropriate investigations for acute cholecystitis?

Answer 6

bloods

ultrasound of biliary tree- GOLD STANDARD

CT/MRI

Question 7

What bloods do we need to diagnose acute cholecystitis and describe what can be seen?

Answer 7

FBC- hgih white cell

bilirubin- elevated

CRP- elevation indicates infection or inflammation of gallbladder

LFT - high ALP + GGTin ascending cholangitis

Blood cultures

amylase- exclude pancreatitis

Question 8

what may be seen on the ultrasound for acute cholecystitis?

Answer 8

Pericholecystic fluid

Distended gallbladder

Thickened gallbladder wall (>3 mm)

Gallstones

Positive sonographic Murphy’s sign (may be absent in gangrenous cholecystitis)

Question 9

what can be seen on the CT or MRI for acute cholecystitis?

Answer 9

Irregular thickening of the gallbladder wall

Poor contrast enhancement of the gallbladder wall (interrupted rim sign)

Increased density of fatty tissue around the gallbladder

Gas in the gallbladder lumen or wall

Membranous structures within the lumen (intraluminal flap or intraluminal membrane)

Peri‐gallbladder abscess

Question 10

outline the medical management for acute cholecystitis?

Answer 10

Admission

NBM (nil by mouth)

IV fluids

Analgesia

Anti-emetics

Antibiotics (if infection is present)

NOTE: if symptoms persist despite antibiotic treatment, suspect a localised abscess or empyema, which would require drainage – percutaneously by cholecystostomy and pigtail catheter

If there is an obstruction, urgent biliary drainage by ERCP or via a percutaneous route is necessary

Question 11

outline the surgical management for acute cholecystitis?

Answer 11

Laparoscopic Cholecystectomy+/- on table cholangiogram – must ensure LFTs are normal

The hepatobiliary triangle is bordered by the common hepatic duct (medially), the cystic duct (inferiorly) and the inferior edge of the liver (superiorly). This anatomical space is of clinical importance during laparoscopic cholecystectomy for the safe ligation and division of the cystic duct and cystic artery.

In acute setting: performed within 72 hours of symptom onset – there are complications associated with a late cholecystectomy, or after several weeks for inflammation to settle

Question 12

what are the possible complications of cholecystitis?

Answer 12

Stones within the gallbladder

• Biliary colic
• Cholecystitis
• Gallbladder empyema(abscess in gallbladder)
• Gallbladder cancer(RARE)

Stones outside the gallbladder

• Obstructive jaundice
• Pancreatitis
• Ascending cholangitis
• Cholecystoduodenal fistula
• Gallstone ileus
• Bouveret syndrome(gallstones cause gastric outlet obstruction)
• Mirizzi syndrome(common hepatic duct ob)

Complications of cholecystectomy

• Bleeding
• Infection(sepsis)
• Bile leak
• Fat intolerance due to inability to secrete a large amount of bile into the intestine as pt no longer has a gall bladder
• Post-cholecystectomy syndrome – abdominal symptoms e.g. dyspepsia, nausea/vomiting, RUQ pain
• Port-site hernia

Question 13

what is emphysematous cholecystitis?

Answer 13

Acute infection of gallbladder wall caused by gas-forming organisms (eg, Clostridium or Escherichia coli) => surgical emergency (cholecystectomy)

more common in diabetics

Initial symptoms/signs are often minor but mortality due to sepsis is high. Oedema changes obstruct the cystic duct with distension/ischaemia of the gallbladder and sepsis supervenes.