cholecystitis

Question 1

What is cholecystitis?

Answer 1

Inflammation of the gall bladder, usually due to cystic duct obstruction by a gallstone

Question 2

What are the risk factors for cholecystitis?

Answer 2

Gallstones (90% of patients), TPN “total parenteral nutrition” (fasting = gallbladder hypomotility & stasis), Diabetes

Question 3

What are the presenting symptoms/ signs of cholecystitis?

Answer 3

1. Right upper quadrant/epigastric pain, which can radiate to the right shoulder tip if the diaphragm is irritated
2. Signs of inflammation (fever)
3. Nausea, anorexia and vomiting
4. Right upper quadrant tenderness
5. Positive Murphy’s sign (pain occurs from asking the patient to take in and hold a deep breath while palpating the right subcostal area.)
6. In cases with associated biliary obstruction, patients may exhibit jaundice, dark urine, and pale stools. However, these are not key features of cholecystitis.
7. Palpable mass
8. Rebound tenderness

Question 4

Describe the pathophysiology behind cholecystitis

Answer 4

Cholecystitis predominantly results from the obstruction of the cystic duct by gallstones. This obstruction can lead to an infection in the gallbladder caused by organisms including:

• E.coli (most common)
• Klebsiella
• Enterococcus

Question 5

What are the 2 main types of cholecystitis?

Answer 5

1. Acute Cholecystitis: This is characterised by the sudden onset of inflammation in the gallbladder.
2. Chronic Cholecystitis: This is a long-term, smoldering inflammation of the gallbladder, usually caused by the repeated irritation of gallstones. Over time, chronic cholecystitis can lead to thickening of the gallbladder wall and a decrease in its overall function.

Question 6

What investigations are used to diagnose/ monitor cholecystitis?

Answer 6

1. Abdominal Ultrasound → if sepsis not suspected. Thick gallbladder wall.
   - CT or MRI of Abdomen → if sepsis suspected
2. FBC → increased WCC and CRP
3. Normal LFT’s
4. Serum Lipase → exclude pancreatitis

Question 7

How is cholecystitis managed?

Answer 7

1. Non-Operative (Supportive) → NBM, IV Fluids, Analgesia, IV Antibiotics
2. Operative (Definitive) → Laparascopic Cholecystectomy, within 1 week of diagnosis
3. Urgent percutaneous cholecystostomy -> If pt is deteriorating despite antibiotics and has evidence of an empyema in the gallbladder. This should be urgently drained.

Question 8

What is meant by “Post-cholecystectomy syndrome”?

Answer 8

Colicky abdominal pain, diarrhoea and new jaundice.
- It is thought to be due to the lost of the gall bladder as a reservoir for bile moving through the biliary system.
- It is a common complication of the procedure and is often transient.