Biliary Tract Disease: Cholecystitis

Question 1

Definition

Answer 1

Acute inflammation of the gallbladder. 90% of cases caused by gallstone that has become impacted at teh neck of the gallbladder or cystic duct.

Question 2

Epidemiology

Answer 2

Fat
Female
Forty
Fertile

Question 3

Risk factors

Answer 3

Diabetes
Trauma,
Systemic illness,
Dehydration,
TPN/fasting
Ceftriaxone = secreted into bile can precipitate with calcium forming biliary sludge or stones

Question 4

Aetiology

Answer 4

Caused by a blockage of the cystic duct preventing the gall bladder from draining
- majority of cases (95%)
- allows bacteria to multiply
Patients on parenteral nutrition or having long periods of fasting where the gall bladder is not stimulated by food = build up pressure

Question 5

Pathophysiology

Answer 5

Stone is blocking the ducts. Bile builds up distending the gall bladder = bile stasis in the gallbladder
Inflammation follows these events secondary to the retained bile because chemical irritant = causes mucosa to secrete mucus + inflammatory enzymes. This causes the pressure to build up.
Bacteria can start to grow in the GB ( usually gram -ve rods or anaerobes = E.coli, Enterococci, clostridium) = invades the GB wall = can go through the wall + cause peritonitis (has rebound tenderness)
If pressure builds too much, the GB can press on the blood vessels supplying it = become ischaemic = gangrenous cell death = GB perforates causing bacteria to get into blood supply = SEPSIS

Question 6

Signs

Answer 6

SHOULD NOT BE JAUNDICED - unusual for CBD to be obstructed
RUQ abdominal tenderness: Murphy’s sign positive = palpating the RUQ whilst the patients breathes in deeply causes pain
Abdominal mass - distended gallbladder

Question 7

Symptoms

Answer 7

RUQ abdominal pain (>30 mins)
Referred right shoulder tip pain
Fever
Nausea + vomiting

Question 8

Diagnosis

Answer 8

First line = Transabdominal ultrasound:
- Positive Murphy’s sign on palpation with the probe
- Thickened gallbladder wall (≥3mm)
- Distended gallbladder with the presence of gallstones
- Pericholecystic fluid
GOLD STANDARD: Cholescintigraphy (HIDA) scan: consider if ultrasound is inconclusive. IV technetium-labelled HIDA is taken up by hepatocytes and excreted into bile. Cholecystitis is associated with cystic duct obstruction so the gallbladder will not be visualised
FBC: high neutrophils, high CRP
Serum amylase or lipase = Normal
Normal LFTs

Question 9

Treatment

Answer 9

FIRST LINE =
- IV fluids and analgesia
- Nil by mouth
- Antibiotics IV: CO-AMOXICLAV, or CEFUROXIME or METRONIDAZOLE
GOLD STANDARD: Laparoscopic Cholecystectomy
- within one weeks of diagnosis
SECOND LINE = Urgent Cholecystectomy

Question 10

Complications

Answer 10

Gall bladder empyema
Gall stone ileus
Acute ascending cholangitis
Bile duct injury from surgery