Cholecystitis

Question 1

Define Cholecystitis:

Answer 1

Inflammation of the gallbladder

Question 2

What causes acute Cholecystitis?

Answer 2

1. Gallstone trapped in cystic duct
2. After meal, Gallbladder stimulated to contract
3. Flow backed up - Cholestasis
4. Inflammation and growth of bacteria in the gallbladder
5. Bacteria can migrate through the wall into peritoneum
6. Pressure builds up and occludes vascular supply
7. Ischaemia causes gangrenous necrosis
8. Gallbladder may rupture

Question 3

What are the types of gallstones that can cause Cholecystitis?

Answer 3

Mixed Stones (80%) - Contain cholesterol. calcium billirubinate, phosphate and protein

Form due to an imbalance between bile salts, phospholipids and cholesterol

Pure Cholesterol Stones (10%)

Pigment Stones (10%)

Question 4

What are the risk factors for acute Cholecystitis?

Answer 4

Increased age
Female
Fat
Diabetes
Drugs (OCP, octreotide)
Family history
White

Pigment stone risk factors (e.g. haemolytic disorders - sickle cell)

Question 5

What’s the Epidemiology of Cholecystitis?

Answer 5

Prevalence of gallstone disease in UK = 10%

3x more common in females

Question 6

What are the presenting symptoms of Cholecystitis?

Answer 6

Malaise

Fever

Prolonged abdo pain (referred to right shoulder (diaphragm irritation))

Question 7

What are the common signs o/e of Cholecystitis?

Answer 7

Epigastric → RUQ tenderness/pain

Guarding/Rebound tenderness possible

Murphy’s sign: exhale, place hand below the right costal margin, ask to inhale - stops breathing in (due to liver pressing down on fixed gallbladder)

Question 8

What bloods would you request and what results would you expect in Cholecystitis?

Answer 8

FBC: high WCC

LFTs: High ALP + GGT if ascending cholangitis
(ALP stored in bile duct hepatocytes - released when under pressure)

Blood Culture

Amylase - to exclude pancreatitis

Question 9

What are the appropriate investigations in diagnosing Cholecystitis?

Answer 9

Ultrasound - shows gallstones in GB, increased thickness of GB wall, dilatation of biliary tree

AXR - only 10% of stones are radio-opaque

ERCP - to exclude obstruction of CBD

Question 10

Generate a management plan for acute Cholecystitis:

(conservative, medical, surgical)

Answer 10

Conservative: if only mild biliary colic follow low-fat diet

Medical:

• NBM
• IV fluids, analgesia
• Antibiotics if infection

Surgical:

• Laparoscopic Cholecystectomy

Question 11

What are the possible complications of Cholecystectomy?

Answer 11

Infection
Haemorrage
Bile leak
Injury to CBD

Post-Cholecystectomy syndrome (dyspeptic symptoms)
Port-site hernias

Question 12

What would you see if a gallstone blocked

a) the cystic duct
b) the common bile duct

Answer 12

a) Cholecystitis
b) Cholangitis and possible cholecystitis