Acute Cholecystitis

Acute Cholecystitis
RUQ pain, fever, leukocytosis associated with gallbladder inflammation Acalculous cholecystitis same inflammation of gallbladder in absence of stones (typically critically ill) Chronic cholecystitis chronic inflammation of the gallbladder that may or may not cause symptoms

Pathogenesis
Gallstone irritation of the gallbladder Cystic duct obstruction Histologically can be mild edema and inflammation versus necrosis and gangrene

Clinical Appearance
RUQ pain after a fatty meal 4-6 hours Sometimes epigastric and radiating to shoulder or back Pain is steady and severe Nausea/Vomiting/Anorexia Usually ill appearing, febrile, tachycardic Peritoneal inflammation Voluntary/Involuntary Guarding

Murphys Sign
Palpate patients liver in the area of the gallbladder fossa Hold your hand in the area and ask patient to inspire deeply Gallbladder moves toward hand Inspiratory arrest will occur secondary to severe tenderness Elderly/Chronically Ill not as sensitive

Complications
Gangrene
Sepsis like picture pre-operatively Can have high morbidity/mortality

Cholecystoenteric Fistula
Direct fistula from gallbladder to duodenum or jejunum Secondary to pressure necrosis from stones more often than acute inflammation

Gallstone Ileus
Gallstone can travel through fistula down through GI tract and block the terminal ileum

Emphysematous cholecystitis
Secondary infection of gall bladder wall with gas-forming organism Crepitus can occur with palpation of skin overlying gallbladder Herald of impending necrosis and perforation

Perforation
Niemeyer classified gallbladder perforations in 1934
Type I patients with free perforation and generalized peritonitis Type II patients have localized perforation Type III patients cholecystoenteric fistula with or without gallstone ileus

Two studies in 1966 and 1971 looked at the incidence of perforation with acute cholecystitis and found 2-11% incidence

Perforation
Newer study looking at cases from 1996 to 2001 in India Postgraduate Institute of Medical Education and Research
524 cases of acute cholecystitis 31 patients with perforation Incidence of 5.9% 9 Type I patients 33% died Longer wait times in India for surgery

Laboratory
Leukocytosis often with left shift Alk Phos and Bilirubin are not typically elevated unless
Cholangitis Choledocolithiasis Obstruction of the CBD by cystic duct (Mirizzi Syndrome)

Ultrasound

Ultrasound
Look for wall thickening Look for sonographic Murphys 88% sensitivity 80% specificity

Cholescintigraphy
HIDA scan Technetium labeled hepatic iminodiacetic acid Taken up by hepatocytes and excreted in bile gallbladder should light up Sens 90%, Spec 97%

Limitations to HIDA
Severe liver disease Fasting patients receiving total parenteral nutrition Biliary sphincterotomy
Low resistance to bile flow Leads to preferential excretion of the tracer into the duodenum without filling of the gallbladder

Hyperbilirubinemia
Impaired hepatic clearance of iminodiacetic acid compounds

Morphine increases sphincter of Oddi pressure

Differential
Acute pancreatitis Appendicitis Acute hepatitis Peptic ulcer disease Diseases of the right kidney Right-sided pneumonia Fitz-Hugh-Curtis syndrome (perihepatitis caused by gonococcal infection Subhepatic or intraabdominal abscess Perforated viscus Cardiac ischemia Black widow spider envenomation

Treatment

Treatment
Patients diagnosed with acute cholecystitis should be admitted to the hospital Opioid analgesia or ketorolac Antibiotics coverage for E-coli, other gram negatives and enterococcus Surgery if patient well enough and cools down