Cholecystitis and Ascending Cholangitis

Question 1

What is acute Cholecystitis?

Answer 1

Inflammation of the gallbladder, caused by blockage of the cystic duct preventing drainage

Question 2

Acute cholecystitis is an important complication of what?

Answer 2

Gallstones

Question 3

95% of cases of acute cholecystitis are caused by what?

Answer 3

gallstones (calculous cholecystitis)

Question 4

Classical presentation of acute cholecystitis?

Answer 4

RUQ pain which pain radiate to the right shoulder

Question 5

List 4 other presenting features of acute cholecystitis

Answer 5

Fever
Nausea and vomiting
Tachycardia and tachypnoea
RUQ tenderness
Murphy’s sign
Raised inflammatory markers and WBCs

Question 6

How is Murphy’s sign performed?

What indicates a positive finding?

Answer 6

1. Place a hand in RUQ and apply pressure
2. Ask patient to take a deep breath in
3. Gallbladder will move down during inspiration and come in contact with your hand
4. Stimulation of inflamed gallbladder results in acute pain and sudden stopping of inspiration

Question 7

Initial imaging for suspected acute cholecystitis?

Answer 7

Abdominal ultrasound scan

Question 8

List 3 USS findings of acute cholecystitis

Answer 8

1. Thickened gallbladder wall
2. Stones or sludge in gallbladder
3. Fluid around the gallbladder

Question 9

How can we visualise the biliary tree in more detail if a CBD stone is suspected but not seen on an USS

(eg. bile duct dilatation or raised bilirubin)

Answer 9

Magnetic resonance cholangiopancreatography (MRCP)

Question 10

Conservative management of acute cholecystitis?

Answer 10

1. Nil by mouth
2. IV fluids
3. Antibiotics (cefuroxime)
4. NG tube if required for vomiting

Question 11

Definitive management for acute cholecystitis?

Answer 11

Laparoscopic cholecystectomy (within 1 week of presentation)

Question 12

How may stones which are trapped in the CBD be removed?

Answer 12

ERCP

Question 13

List 4 complications of acute cholecystitis

Answer 13

1. Sepsis
2. Gallbladder empyema
3. Gangrenous gallbladder
4. Perforation

Question 14

What is Gallbladder Empyema?

Answer 14

Infected tissue and pus collecting in the gallbladder

Question 15

Management of Gallbladder empyema?

Answer 15

IV antibiotics and one of two main options:

• Cholecystectomy
• Cholecystostomy (drain insertion)

Question 16

Typically history of chronic cholecystitis?

Answer 16

Recurrent or untreated cholecystitis, which has led to a persistent inflammation of the gallbladder wall

Question 17

Presentation of chronic cholecystitis?

Answer 17

Ongoing RUQ or epigastric pain with associated nausea and vomiting

Question 18

Management of chronic cholecystitis?

Answer 18

Elective cholecystectomy

Question 19

What is ascending cholangitis?

Answer 19

Infection and inflammation in the bile ducts

Surgical emergency as it has a high mortality due to sepsis and septicaemia

Question 20

List the 2 main causes of ascending cholangitis

Answer 20

1. Obstruction in the bile ducts eg. Gallstones in the CBD
2. ERCP (Infection introduced)

Question 21

List the 3 most common organisms in ascending cholangitis

Answer 21

1. Escherichia coli
2. Klebsiella species
3. Enterococcus species

Question 22

What is Charcots Triad

Answer 22

1. RUQ pain
2. Fever
3. Jaundice

Question 23

Acute management of ascending cholangitis

Answer 23

1. Nil by mouth
2. IV fluids
3. Blood cultures
4. IV antibiotics
5. ERCP after 24-48 hours to relieve any obstruction

Question 24

First line investigation for suspected ascending cholangitis

Answer 24

Endoscopic Ultrasound