Cholecystitis

Question 1

What is cholecystitis?

Answer 1

Cholecystitis = acute gallbladder inflammation

Calculous (presence of gallstones in cystic duct) or acalculous (no evidence of gallstones)

Question 2

What is the aetiology of cholecystitis?

Answer 2

Gallstones in cystic duct -> 90% of cases
Gallstones -> bile stasis, then bacteria from gut

Helminth infection is a major cause in Asia, Southern Africa and Latin America

No bacterial growth is obtained in >40% of surgical specimens

Question 3

What are the risk factors for cholecystitis?

Answer 3

Gallstones (90%)

Severe illness - Gallbladder dysmobility, ischaemia, vascular compromise and TPN

TPN
Fasting causes gallbladder hypomotility
60% exhibit biliary sludge after only 3 weeks

Physical inactivity
Low fibre
Trauma

Medications: Ceftriaxone, ciclosporin
Ceftriaxone is secreted into bile, which can precipitate with calcium and Ciclosporin can decrease bile secretion

Crohn’s, rheumatoid arthritis, psoriasis, nephrotic syndrome, immunosuppression

Different risk factors for calculous and acalculous cholecystitis
Calculous = similar to cholelithiasis
6 Fs
Obesity/rapid weight loss/fasting
Drugs – especially female HRT

Acalculous
Critical illness
Major surgery
Sepsis
Long term TPN
Prolonged fasting

Question 4

What is the epidemiology of cholecystitis?

Answer 4

Similar incidence/distribution to cholelithiasis
1-2% become symptomatic each year

Acute cholecystitis is the most frequent complication – occurs in 10% of symptomatic patients
2/3rds in females
Acalculous cholecystitis accounts for ~10%
Higher incidence in ICU and women

Question 5

What are the symptoms of cholecystitis?

Answer 5

Previous episode of biliary pain

RUQ pain
Epigastric -> RUQ
Colicky -> constant

Boas sign - right shoulder pain
Anorexia
Nausea and vomiting

Question 6

What are the signs of cholecystitis?

Answer 6

Murphy’s positive
Abdominal mass (30-40%)
Fever
Jaundice (15%)
Guarding + rebound tenderness

Local peritonism - Differentiates from biliary colic

Question 7

What are appropriate investigations for cholecystitis?

Answer 7

Bloods
Elevated WBC
Elevated CRP (>28.6)
Elevated ALP, GGT and bilirubin

Ultrasound
Pericholecystic fluid, distended gallbladder, gallstones

Other investigations

Cholescintigraphy = hepatobiliary iminodiacetic acid scan
Failure of gallbladder filling with normal hepatic uptake

Abdominal CT - Gallbladder wall inflammation

Abdominal MRI - Enlarged gallbladder with thickened wall

Plain AXR (only shows 10% of stones)

Question 8

How can cholecystitis be managed?

Answer 8

Mild = no signs of perforation/gangrene
Supportive care
Oral Abs
NSAIDs
Early laparoscopic cholecystectomy
Percutaneous cholecystectomy tube

Moderate
Supportive care
IV Abs - Cefuroxime
NSAIDs
Cholecystectomy (early or delayed with cholecystectomy)

Severe
ICU admission
Supportive care
IV ABs
Urgent cholecystectomy followed by delayed elective cholecystectomy
(Preferred for acalculous cholecystitis)

Question 9

What are possible complications of cholecystitis?

Answer 9

Perforation (10%) - Usually if patients are unresponsive to treatment or presented late
Free perforation associated with 30% mortality

Suppurative cholecystitis - Thickened gallbladder wall with WBC infiltration, intra-wall abscesses and necrosis

Gangrenous cholecystitis

Bile duct injury due to surgery

Gallstone ileus

Question 10

What is the prognosis of cholecystitis?

Answer 10

Uncomplicated has an excellent prognosis (70%)
Very low mortality
Complete remission within 1-4 days
Calculous cholecystitis has a much better mortality (4%) compared to acalculous cholecystitis (10-50%)

30% require surgery or develop a complication
15% get perforation
Risk of bile duct injury due cholecystectomy

Depends on severity of the cholecystitis