Cholecystitis

Question 1

What causes cholecystitis?

Answer 1

Blockage of cystic duct which prevents the gall bladder from emptying causing inflammation

I.e. gallstones trapped in neck of gall bladder or cystic duct
Can occur cancer of head of pancreas

Question 2

How would someone with cholecystitis commonly present?

Answer 2

RUQ pain that can radiate to right shoulder (irritation of phrenic nerve)

• colicky in nature due to SM in cystic duct or neck of gall bladder contracting around stone
• comes on with eating

Fever

N+V

Question 3

Why is cholecystitis pain exacerbated by eating?

Answer 3

Cholecystic kinin released with eating which should stimulate contraction of gall bladder to release bile to aid with digestion of food
Contraction against obstruction leads to biliary colic

Question 4

What imaging is done 1st in suspected cholecystitis and what would you expect to see?

Answer 4

Abdo USS

Thickened gall bladder wall= will appear more white
Stones in gall bladder= will cast ACOUSTIC SHADOW
Fluid around gall bladder(oedematous)

Question 5

When is MRCP indicated for investigation of cholecystitis?

Answer 5

When bile duct stone suspected but not visualised on US

Question 6

What bloods would you order if cholecystitis suspected and what would the results be?

Answer 6

FBC= raised WCC +CRP
LFT= raised ALP >ALT and raised GGT

Question 7

How is cholecystitits managed?

Answer 7

NBM
IV fluids
IV Antibiotics (due to N+V meaning cannot rely on oral abx to be absorbed)
NG tube (aids with vomiting)
Analgesia
ERCP= removes the stones
Cholecystectomy w/i 72hrs of symptoms or 6-8 weeks after acute episode to allow for inflammation to settle

Question 8

What are the possible complications of cholecystitis?

Answer 8

Sepsis
Gall bladder empyema= infected tissue and puss collection in gall bladder
Gangrenous gall bladder
Perforation

Question 9

What might you expect to find on examination of someone with acute cholecystitis?

Answer 9

Tachycardia

+ve Murphy signs

Tenderness and localised guarding in RUQ

Question 10

What positive murphy’s sign and why does it occur in acute cholecystitis but not in biliary colic?

Answer 10

When placing + pressing hand in RUQ and asking pateint to take deep breath in, leads to acute pain and sudden stopping of inspiration

Occurs due to inflammed gall bladder being pushed down during inspiration by diaphragm so causes pain when comes in contact with hand
Therefore won’t occur in biliary colic because gall bladder not inflamed

Question 11

How is gallbladder empyema managed?

Answer 11

IV antibiotics 
AND 
Cholecystectomy (remove gallbladder)
OR 
Cholecystotomy (drainage of gallbladder)

Question 12

What is acalculous cholecystitis?

Answer 12

AC in absence of gallstones causing the inflammation of the gallbladder
Associated with microvascular ischaemia and gangrene in the gallbladder wall which can increase the risk of rupture

Question 13

How would you differentiate between a patient with cholecystitis and acalculous cholecystitis?

Answer 13

USS shows absence of gallstones in acalculous cholecystitis