Cholecystitis

Question 1

Definition

Answer 1

Inflammation of the gallbladder

Usually develops due to a gallstone obstructing the cystic duct

Question 2

Aetiology/Types of stones

Answer 2

o Mixed Stones (80%)
· Contains cholesterol, calcium bilirubinate, phosphate and protein
· Form due to an imbalance between bile salts, phospholipids, cholesterol, nucleation factors and gallbladder motility

o Pure Cholesterol Stones (10%)

o Pigment Stones (10%)
· Black stones made of calcium bilirubinate
· Form due to increased bilirubin (e.g. due to haemolysis)

Question 3

Risk factors

Answer 3

o Age
o Female
o Fat
o Diabetes mellitus
o Drugs (OCP, octreotide)
o Family history
o Ethnicity (Caucasian)
o Pigment Stone Risk Factors: haemolytic disorders (e.g. sickle cell anaemia)

Question 4

Epidemiology

Answer 4

· Very COMMON

· UK prevalence of gallstone disease = 10%

· 3 x more common in FEMALES

· More common with increasing age

Question 5

Presenting symptoms

Answer 5

· Systemically unwell

· Fever

· Prolonged abdominal pain

· Pain may be referred to right shoulder (due to diaphragmatic irritation)

Question 6

Signs on physical examination

Answer 6

· Tachycardia
· Pyrexia
· RUQ pain or epigastric tenderness
· May be guarding or rebound tenderness
· Murphy's sign positive

Question 7

Investigations (bloods)

Answer 7

o FBC - high WCC in cholecystitis and cholangitis

o LFT - high ALP + GGT in ascending cholangitis

o Blood cultures

o Amylase (exclude pancreatitis)

Question 8

Investigations (imaging)

Answer 8

· Ultrasound
o Shows gallstones
o Increased thickness of gallbladder wall
o Dilatation of biliary tree

· AXR - but only 10% of gallstones are radio-opaque

· Other imaging - to exclude differentials (e.g. erect CXR, ERCP)

Question 9

Management plan (conservative)

Answer 9

If only mild biliary colic - follow a low-fat diet

Question 10

Management plan (medical)

Answer 10

o NBM
o IV fluids
o Analgesia
o Anti-emetics
o Antibiotics (if infection is present)

o NOTE: if symptoms persist despite antibiotic treatment, suspect a localised abscess or empyema, which would require drainage

o If there is an obstruction, urgent biliary drainage by ERCP or via a percutaneous route is necessary

Question 11

Management plan (surgical)

Answer 11

Laparoscopic cholecystectomy

Question 12

Possible complications (within gallbladder)

Answer 12

· Stones within the gallbladder

o Biliary colic
o Cholecystitis
o Gallbladder empyema
o Gallbladder cancer (RARE)

Question 13

Possible complications (outside gallbladder)

Answer 13

· Stones outside the gallbladder

o Obstructive jaundice
o Pancreatitis
o Ascending cholangitis
o Cholecystoduodenal fistula
o Gallstone ileus
o Bouveret syndrome (gallstones cause gastric outlet obstruction)
o Mirizzi syndrome

Question 14

Possible complications (from cholecystectomy)

Answer 14

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

Question 15

Prognosis

Answer 15

· Gallstones do NOT cause symptoms most of the time

· Surgery offers an excellent chance of cure if they were to become symptomatic