Cholecystitis

Question 1

Define cholecystitis

Answer 1

Acute gallbladder inflammation, a major complication of cholelithiasis or gallstones in the cystic duct

Question 2

Aetiology of cholecystitis

Answer 2

Complete cystic duct obstruction (90%), usually due to gallstone in the neck or cystic duct
Bile inspissation (due to dehydration) or bile stasis (trauma or severe systemic illness (5%)
Acalculous cholecystitis may be predisposed by starvation, total parenteral nutrition, narcotic cholecystitis and immobility
May arise during acute EBV infection, could be an atypical presentation
Helminthic infection is a major cause in Asia, Southern Africa and Latin America
Salmonella infection secondary to typhoid fever

Question 3

Risk factors for cholecystitis

Answer 3

Gallstones
Previous biliary pain episodes
Severe illness
Physical activity level
Ceftriaxone, ciclosporin
Severe trauma or burns
Major surgery
Long-term fasting
Total parenteral nutrition
Sepsis

Question 4

Symptoms of cholecystitis

Answer 4

RUQ pain
- Constant pain present for several hours
- Severe and steady
- May radiate to the back
RUQ tenderness
Fever or chills
Nausea
Right shoulder pain
Anorexia
Vomiting
Jaundice

Question 5

Signs of cholecystitis

Answer 5

Murphy’s sign +ve
Palpable mass in the gall bladder region

Question 6

Investigations for cholecystitis

Answer 6

FBC: raised WCC
CRP: raised
Renal screen
Clotting
LFTs: AST/ALT normal, ALP raised
Amylase/lipase: raised
Bood cultures: ? infection

Abdominal US:
- Pericholecystic fluid
- Distended gallbladder
- Thickened gallbladder wall >3mm
- Gallstones
- Positive sonographic Murphy’s sign
HIDA scan (hepatobiliary scintigraphy)
MRCP → ERCP
CT abdo

Question 7

Management for mild-moderate cholecystitis

Answer 7

1. Analgesia
   - Paracetamol PO
   - Move on to morphine sulphate 5-10mg PO 4 hourly
2. Consider fluid resuscitation
3. Antibiotics IV according to guidelines e.g. penicillin, quinolones
4. Laparoscopic cholecystectomy or percutaneous cholecystostomy

Not possible to control inflammation/organ dysfunction → urgent biliary drainage with percutaneous cholecystostomy

Collection/empyema → contact IR

Question 8

Complications of cholecystitis

Answer 8

Chronic diarrhoea (Removed GB → more bile in the large intestine → draws water and salt into the bowel)
Vitamin malabsorption
Increased bleeding risk (reduced vit K)
Biliary sepsis
Common bile duct stone
Gallstone ileus
Suppurative/emphysematous cholecystitis
Cholecystoenteric fistula (duodenum + hepatic flexure of colon)

Question 9

Prognosis of cholecystitis

Answer 9

Removing the gallbladder and the gallstone when biliary pain starts prevents further biliary attacks and reduces risk of cholecystitis development
Gallbladder perforation - mortality 30%
Untreated acute acalculous cholecystitis is life-threatening and associated with 50% mortality