Cholecystitis (GI) Flashcards

1
Q

Define acute cholecystitis.

A

Acute gallbladder inflammation usually due to cystic duct obstruction by a gallstone

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2
Q

What are 90% of cases of acute cholecystitis caused by?

A

Gallstones

Complete cystic duct obstruction usually due to an impacted gallstone in the GB neck or cystic duct –> bile trapped in GB –> inflammation within GB wall

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3
Q

How do impacted gallstones cause acute cholecystitis?

A

Complete cystic duct obstruction usually due to an impacted gallstone in the GB neck or cystic duct –> bile trapped in GB –> irritation of surrounding nerves –> increases GB pressure

Trauma caused by gallstones stimulate PG synthesis (PGI2, PGE2), mucus enzyme production from GB mucosa –> inflammatory response

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4
Q

What happens if gallstone remains impacted in acute cholecystitis?

A

Pressure continues to build and can impact blood vessels –> compromised blood supply to GB –> ischaemia/necrosis of tissue

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5
Q

What can cause acalculous acute cholecystitis (without gallstones)? (7)

A
  • bile inspissation (due to dehydration)
  • bile stasis (trauma/systemic illness)
  • starvation
  • TPN
  • narcotic analgesics
  • immobility
  • EBV
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6
Q

What are the clinical features of acute cholecystitis? (4)

A
  • RUQ pain + tenderness
  • pain may radiate to right shoulder (parietal peritoneum involvement)
  • fever and signs of systemic upset
  • nausea and vomiting (more common if stone in CBD)
  • (jaundice - less common, inflammation and oedema around biliary tract, pressure on tract)
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7
Q

Why is jaundice rarely seen in acute cholecystitis?

A

Blockage of cystic duct or GB does not cause jaundice

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8
Q

What might you see on examination of acute cholecystitis? (3)

A
  • Murphy’s sign (sudden pause during inspiration upon deep palpation of RUQ due to pain as diaphragm hits enlarged GB)
  • palpable mass - distended, tender GB
  • Boas sign - hyperaesthesia below right scapula
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9
Q

What are some risk factors for acute cholecystitis? (4)

A
  • gallstones
  • total parenteral nutrition –> fasting = GB hypomotility and stasis, biliary sludge, gallstones (decreased emptying)
  • diabetes
  • severe illness
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10
Q

What are the first-line investigations for acute cholecystitis? (8)

A
  • abdominal USS
  • CT/MRI abdomen
  • FBC
  • CRP
  • LFTs
  • serum lipase/amylase
  • MRCP
  • EUS
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11
Q

What is the first-line investigation of choice for suspected acute cholecystitis?

A

Abdominal ultrasound (showing thick gallbladder wall)

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12
Q

What would you see on abdominal ultrasound in acute cholecystitis? (5)

A
  • pericholecystic fluid
  • distended gallbladder
  • thickened gallbladder wall (>3mm)
  • gallstones
  • positive sonographic Murphy’s sign (may be absent in gangrenous cholecystitis)
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13
Q

What do we do if abdominal ultrasound is unclear in suspected acute cholecystitis?

A

Technetium labelled HIDA scan

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14
Q

What investigation do we do if sepsis is suspected in acute cholecystitis?

A

CT/MRI abdomen - diagnosing gangrenous cholecystitis or perforation

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15
Q

What is the gold-standard (but not first-line) investigation for acute cholecystitis?

A
  • MRCP
  • can also show defects in biliary tree
  • use if US does not show stones but bile duct is dilated OR if LFTs are abnormal
  • use EUS if MRCP contraindicated
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16
Q

When is endoscopic ultrasound done in acute cholecystitis?

A

If MRCP contraindicated

17
Q

What would FBC show in acute cholecystitis?

A

Increased WCC and CRP

18
Q

What do LFTs show in acute cholecystitis?

A
  • typically normal
  • may show elevated ALP, ALT, GGT BR
  • ALT can be elevated if stone has passed down CBD or focal inflammation of liver parenchyma
19
Q

What can deranged LFTs in acute cholecystitis mean?

A

Mirizzi syndrome - gallstone impacted in distal cystic duct causing extrinsic compression of common bile duct –> jaundice

20
Q

Why do we do serum lipase/amylase in acute cholecystitis?

A

Serum lipase (preferred) to rule out pancreatitis (>3x upper limit)

21
Q

What are some differential diagnoses for acute cholecystitis? (9)

A
  • acute cholangitis - Charcot’ triad
  • chronic cholecystitis
  • peptic ulcer disease - burning pain after eating
  • acute pancreatitis
  • sickle cell crisis
  • acute appendicitis
  • right UL pneumonia
  • ACS
  • GORD
22
Q

What are the diagnostic criteria for acute cholecystitis (ultrasound)? (5)

A
  • pericholecystic fluid
  • distended GB
  • thickened GB wall >3mm
  • gallstones
  • positive sonographic Murphy’s sign
23
Q

What is the main surgical intervention for acute cholecystitis?

A

IV Abx + early laparoscopic cholecystectomy within 1 week of diagnosis

24
Q

What supportive management is needed for acute cholecystitis? (4)

A
  • NBM
  • IV fluids
  • analgesia
  • IV Abx
25
Q

How do we manage acute cholecystitis if unfit for surgery?

A

Percutaneous cholecystectomy - drain fluid from infected GB

26
Q

How do we manage acute cholecystitis if end-organ dysfunction?

A
  • ICU
    – IV Abx + analgesia + fluids
  • Abx for suspected sepsis or biliary infection
27
Q

What are some complications of acute cholecystitis? (5)

A
  • ascending cholangitis
  • Mirizzi syndrome - stone in Hartmann’s pouch compressing common hepatic duct –> obstructive jaundice
  • suppurative cholecystitis - WBC infiltration, intra-wall abscesses
  • cholecystoenteric fistulas/ileus - chronic inflammation + gallstone ileus (SBO)
  • empyema - pus in GB, strong inflammatory response
28
Q

What is the prognosis like if gallbladder perforates in acute cholecystitis?

A

30% mortality