Cholecystitis

Question 1

What is cholecystitis? What is it usually caused by?

Answer 1

inflammation of the gallbladder

90% caused by obstruction of the cystic duct by a gallstone (calculous cholecystitis)

10% inflammation without gallstones (acalculous cholecystitis)

Question 2

Give 3 characteristics of causes of acalculous cholecystitis

Answer 2

typically seen in critically ill

due to combination of factors that result in bile oasis (due to gallbladder hypomotility/ dysmotiliy) or bile thickening (due to dehydration)

in immunosuppressed, may develop secondary to Cryptosporidium or cytomegalovirus

Question 3

List 3 types of stones that can form in the gallbladder

Answer 3

Cholesterol Stones
Mixed Stones
Pigment Stones: due to increased BR (e.g. haemolysis)

Question 4

Describe the epidemiology of cholecystitis

Answer 4

Very COMMON
F > M
Peak incidence >50

Question 5

List 6 risk factors for cholecystitis

Answer 5

Age
Female
Fat
FH
Fair (Caucasian)

Pigment Stone RF: haemolytic disorders (e.g. SCA)

Question 6

Give 2 presenting symptoms of cholecystitis

Answer 6

Sudden onset, constant RUQ pain +/- radiation to R shoulder
N+V

Referred pain due to diaphragmatic irritation

Question 7

List 5 signs of cholecystitis

Answer 7

Positive Murphy’s sign
Fever +/- rigors/ SOB
Tachycardia
Guarding or rebound tenderness
RUQ mass

Question 8

Which bloods should be checked in cholecystitis?

Answer 8

FBC: high WCC
CRP: high
Amylase: r/o pancreatitis
LFTs: typically normal

Question 9

If LFTs are deranged in suspected cholecystitis, what may be an alternate diagnosis?

Answer 9

Mirizzi syndrome
gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct
a/w jaundice

Question 10

What first line imaging should be performed in cholecystitis?

Answer 10

Abdominal US: distension, wall thickening, gallstones, oedema + pericholecystic fluid

Question 11

What is the medical management plan for cholecystitis?

Answer 11

NBM
IV fluids
Analgesia: paracetemol
+/- Anti-emetics
+/- Abx (if infection is present)
Refer for cholecystectomy within 1w

Question 12

Describe additional management when there is associated organ dysfunction in acute cholecystitis

Answer 12

Admit to ICU to treat organ dysfunction
Consider urgent biliary drainage

Question 13

Describe choice of cholecystectomy

Answer 13

Fit for GA: Laparoscopic
Unfit for GA + not resolving despite medical Mx: Percutaneous

Question 14

How do you elicit Murphy’s sign?

Answer 14

1. Ask pt to exhale
2. Place hand below costal margin on the R side MCL
3. Instruct to Inspire
   +ve Murphy’s Sign=
   Pt stops breathing in + winces with a ‘catch’ in breath
   (as inflamed gallbladder being palpated as it descends on inspiration)

Question 15

What imaging may be performed second line if diagnosis is unclear in suspected cholecystitis?

Answer 15

Cholescintigraphy (HIDA scan)
Technetium-labelled HIDA injected IV; taken up selectively by hepatocytes + excreted into bile
In cholecystitis there is cystic duct obstruction (secondary to odema a/w inflammation or an obstructing stone) + gallbladder won’t be visualised

Question 16

List 4 possible complications of Stones within the gallbladder

Answer 16

Biliary colic
Cholecystitis
Gallbladder empyema
Gallbladder cancer (RARE)

Question 17

List 5 complications of stones outside the gallbladder

Answer 17

Obstructive jaundice
Pancreatitis
Ascending cholangitis
Cholecystoduodenal fistula
Gallstone ileus
Mirizzi syndrome

Question 18

List 5 complications of cholecystectomy

Answer 18

Bleeding
Infection
Bile leak
Post-cholecystectomy syndrome
Port-site hernia

Question 19

Describe surgical management of pregnant women with acute cholecystitis

Answer 19

early laparoscopic cholecystectomy: reduces chances of maternal-fetal complications