Cholecystitis

Question 1

Cholecystitis is

Answer 1

inflammation of the gallbladder that is usually caused by an obstructing gallstone

Question 2

is the most common complication of gallstone disease

Answer 2

Biliary colic

Question 3

occurs when the inflamed gallbladder becomes infected with gas-producing organisms.

Answer 3

Emphysematous cholecystitis

Question 4

Choledocholithiasis, gallstones within the common bile duct, may be either primary (arising from within the____________) or, more commonly, secondary (____________).

Answer 4

bile ducts

forming in the gallbladder and then migrating to the common bile duct

Question 5

Chronic cholecystitis

Answer 5

is a state of prolonged gallbladder inflammation typically caused by recurrent episodes of cystic duct obstruction by gallstones

Question 6

is microlithiasis composed of cholesterol crystals, calcium bilirubinate pigment, and other calcium salts.

may be visualized on CT or US.

The clinical course is variable. It may resolve spontaneously or progress to cause complications including biliary colic, cholecystitis, cholangitis, or pancreatitis.

Answer 6

Biliary sludge

Question 7

occurs in the absence of gallstones. It occurs much less commonly than calculous cholecystitis but is more likely to result in complications.

Answer 7

Acute acalculous cholecystitis

Question 8

Biliary colic description

Answer 8

presents with pain in the epigastrium or right upper quadrant of the abdomen that occasionally radiates to the back

described as steady

accompanied by nausea and vomiting

association with food intake is variable

circadian periodicity, with a peak in symptom occurrence around midnight

typically last a few hours or less

Fatty food intolerance is not a reliable predictor of gallstone presence

Question 9

Murphy’s sign

Answer 9

the sudden cessation of deep inspiration due to pain when examining fingers reach the inflamed gallbladder upon palpation of the right subcostal region

is 65% sensitive and 87% specific for acute cholecystitis

Question 10

Jaundice in the setting of biliary tract stone disease implies

Answer 10

obstruction of the common bile duct from choledocholithiasis or
extrinsic compression of the bile duct by an impacted cystic duct or gallbladder stone or

adjacent inflammation (Mirizzi’s syndrome)

Question 11

classic presentation of cholangitis is Charcot’s triad:

Answer 11

fever, right upper quadrant abdominal pain, and jaundice

Question 12

Reynolds’ pentad adds_____________ and__________ to Charcot’s triad.

Answer 12

altered mental status

shock

Question 13

Abnormal______________________ is the most sensitive and specific serum marker of choledocholithiasis

Answer 13

γ-glutamyl transpeptidase

Question 14

is the imaging modality of choice for acute cholecystitis. ‘

Answer 14

Abdominal US

Question 15

Normal common bile duct diameter is_______, although diameter is increased in patients with prior _______________

Answer 15

<5 mm

cholecystectomy and in the elderly

Question 16

True or false

All opioids cause some degree of sphincter of Oddi spasm

Answer 16

True

Question 17

ED management of biliary colic includes

Answer 17

symptom control and referral to a general surgeon for outpatient laparoscopic cholecystectomy. Symptom management includes antiemetics and analgesics. NSAIDs are first-line therapy.

Question 18

Acute cholecystitis management

Answer 18

Acute cholecystitis and its complications are managed in the hospital with surgical consultation. Early laparoscopic cholecystectomy is often the treatment of choice. ED treatment includes the provision of anal- gesia, administration of antiemetics for nausea and vomiting, cessation of oral intake, volume and electrolyte replacement, and administration of antibiotics. Appropriate antibiotic regimens include second- and third-generation cephalosporins, carbapenems, β-lactam/β-lactamase inhibitor combinations, or the combination of metronidazole and a fluoroquinolone.

Question 19

is the decompression procedure of choice in Cholangitis

Answer 19

Endoscopic retrograde cholangiopancreatography

Question 20

is an alternative when endoscopic retrograde cholangiopancreatography is not feasible or is unsuccessful.

Answer 20

Percutaneous or surgical drainage

Question 21

Disposition

Answer 21

Once symptoms are adequately controlled, patients with biliary colic are typically discharged from the ED to follow up with a general surgeon. They should be instructed to return to the ED if symptoms of gallstone complications (e.g., prolonged pain, fever, jaundice) arise. Patients who present to the ED with acute cholecystitis or cholangitis require hospital admission. For suspected cholangitis, emergency consultation or transfer to an institution with treatment capabilities for endoscopic retrograde cholangiopancreatography is necessary. Patients with severe illness, including many with cholangitis, should be admitted to a critical care unit.