Cholecystitis

Question 1

Define cholecystitis

Answer 1

Acute gallbladder inflammation, a major complication of cholelithiasis or gallstones in the cystic duct

Question 2

Aetiology of cholecystitis

Answer 2

Complete duct obstruction (90%) usually due to gallstone sin the neck or cystic duct 
Bile inspissation (due to dehydration) or bile stasis 
Trauma/severe systemic illness (5%)

Acalculous - predisposed by starvation, total parenteral nutrition, narcotic, immobility

Infections: Acute EBV, helminth infection, Salmonella secondary to typhoid

Question 3

Risk factors for cholecystitis

Answer 3

Gallstones
Previous biliary pain episodes (biliary colic)
Sever illness
Low physical activity
Drugs: ceftriaxone, cyclosporins
Severe trauma or burns
Long-term fasting, total parenteral nutrition

Question 4

Epidemiology of cholecystitis

Answer 4

Follows incidence of cholelithiasis, occurring in 15% of adults
3x more common in women up to 50

Question 5

Symptoms of cholecystitis

Answer 5

RUQ pain (constant for several hours, severe and steady, may radiate to the back)
RUQ tenderness
Fever or chills
Nausea
Right shoulder pain 
Anorexia 
Vomiting 
(Jaundice)

Question 6

Signs of cholecystitis on examination

Answer 6

RUQ tenderness
Murphy’s sign (sudden cessation of inhalation on palpation of the gallbladder)
Palpable mass (gall bladder)

Question 7

Investigations for cholecystitis

Answer 7

Abdominal USS: pericholecystic fluid | distended gallbladder | thickened gallbladder wall >3mm | gallstones | positive sonography Murphy’s sign

Sepsis => CT/MRI abdomen: irregular gallbladder thickening | Interrupted rim sign | increased fatty tissue density around gallbladder | gas in gallbladder | peri-gallbladder abscess

FBC: leukocytosis
CRP/ESR: raised
LFTs + enzymes: may show evidence of CBD stones (obstructive picture)
Lipase/amylase: elevated (focal liver inflammation or stones in CBD) / exclude pancreatitis
Blood cultures: positive for causative organism (infection)

Question 8

Management for cholecystitis with no associated organ dysfunction

Answer 8

1. Analgesia (paracetamol/diclofenac -> morphine)
2. Fluid resus (oral or IV)
3. Consider antibiotics
4. Early laparoscopic cholecystectomy or percutaneous cholecystectomy
5. Post-op: simple analgesia + monitor

Question 9

Management for cholecystitis with associated organ dysfunction

Answer 9

1. Admit to intensive care
2. Consider urgent biliary drainage
3. Analgesia (paracetamol/diclofenac -> morphine)
4. Fluid resus
5. Consider antibiotics
6. Percutaneous cholecystostomy
7. Consider cholecystectomy
8. Post-op: simple analgesia + monitor

Question 10

Complications of cholecystitis

Answer 10

Emphysematous/suppurative cholecystitis 
Bile duct injury due to surgery 
Gallstone lieu’s 
Cholecystoenteric fistula (duodenum + hepatic flexure of colon)
Gangrene/necrosis

Question 11

Prognosis of cholecystitis

Answer 11

Cholecystectomy reduces development
Perforation has a mortality of 30%
Untreated acalculous cholecystitis is life threatening - 50% mortality