Cholecystitis and Cholangitis Flashcards
What is acute cholecystitis?
Inflammation/ often followed by infection of the gallbladder caused by blockage of the cystic duct. Obstruction can often lead to infection, most commonly cause by E.coli
Explain the presentation of cholecystitis
- RUQ pain,
- Fever,
- Vomiting,
- Tachycardia and tachypnoea,
- Positive Murphy’s sign,
- NO JAUNDICE OR ABNORMAL LFTs
Explain the diagnosis of cholecystitis
- Do abdominal ultrasound which will show: Thickened gallbladder wall, stones/sludge in gallbladder and fluid around gallbladder.
- May to MRCP
What are features of:
Mild cholecystitis,
Moderate cholecystitis,
Severe cholecystitis
Mild - Stable with minimal patients
Moderate - Elevated WCC, palpable mass in RUQ, symptoms >72h, and localized inflammation.
Severe - Resistant hypotension, low GCS, oliguria, hepatic dysfunction and lowered O2 sats (requires ITU admission)
Explain the management of acute cholecystitis?
Supportive unless immediate threat to life - nil-by-mouth, IV fluids, antibiotics and analgesia.
Definitive treatment is a cholecystectomy (within 1 week) as inflammation is likely to reoccur, Can do ERCP to remove stone.
What is gallbladder empyema?
Pus collecting in gallbladder. Managed with IV antibiotics and cholecystectomy or cholecystostomy (drain insertion)
What is acute/acending cholangitis and the two main causes
It is infection and inflammation of bile duces. It is a surgical emergency due to high mortality.
Two main causes are obstruction (stones) or post ERCP proceedure
What are the most common organisms that cause acute cholangitis?
E.coli
Klebsiella
Enterococcus
Explain the presentation of acute cholangitis
Charcot’s triad:
RUQ pain,
fever,
Jaundice (raised billirubin)
How can you diagnose ascending cholangitis?
Most sensitive test is endoscopic ultrasound or MRCP. Can also use CT or abdominal USS.
Patient will have deranged LFTs and a high WCC
What is the management of ascending cholangitis?
Nil by mouth,
IV fluids,
Blood cultures,
IV antibiotics (start sepsis 6)
Involvement of HDU/ICU
ERCP to remove any stones/drainage
Percutaneous drainage (PTC)
WHat are the complications of acute cholecystitis?
Sepsis, gallbladder empyema, gangrenous gallbladder or perforation
What is acalculous cholecystitis?
Gallbladder inflammation without gallstones. It typically occurs in critically ill patients due to bile stasis or bile thickening (due to dehydration)
What are the causes of cholecystitis?
90% are due to gallstones. 10% are due to acalculous cholecystitis
What is Mirizzi syndrome?
A gallstone stuck in the cystic duct which then causes compression of the common bile duct. Therefore causing deranged LFTs
What is the pathophysiology of gallstones?
Different causes:
- Increase in cholesterol resulting in cholesterol supersaturation
- Poor emptying of gall bladder
- Reduced bile acid salts (due to poor absorption at ileum)
- Excess billirubin (Haemolytic patients)
What are the symptoms of biliary colic?
RUQ/epigastric pain
Initiated by eating and drinking
Radiates to the back
Colicky in nature
N&V, dyspepsia, flatulence, food intolerance
What are the investigations for biliary colic?
- Ensure bloods are normal because they should be
- Transabdominal ultrasound for diagnosis of stones
- X-ray to exclude pneumoperitoneum
What is Raynaud’s pentad?
Seen in severe ascending cholangitis:
- Charcot’s triad (fever, RUQ pain and jaundice)
- CNS depression
- Shock
What is Calot’s triangle?
Medial boarder - CHD
Inferior boarder is cystic duct
Superior boarder - Inferior surface of lever
The triangle and its contents are dissected in laparoscopic cholecystectomy
What is Boas’s sign?
Increased sensitivity to light touch in right lower scapular region or RUQ.
Classically seen in acute cholecystitis
