Acute cholecystitis

Background

Gallbladder anatomy

Clinical Features

Local Signs

• RUQ pain
• Murphy Sign
  • Highest positive LR of any clinical finding or lab value

Systemic signs

• Fever
• Nausea and vomiting

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Choledocholithiasis
  • Acalculous cholecystitis
• Peptic ulcer disease with or without perforation
• Pancreatitis
• Acute hepatitis
• Pyelonephritis
• Pneumonia
• Kidney stone
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Herpes zoster
• Myocardial ischemia
• Bowel obstruction
• Pulmonary embolism
• Abdominal aortic aneurysm

Evaluation

Laboratory Findings

• Leukocytosis
• LFT abnormalities (obstructive picture)

Imaging

Gallstone impacted in the neck of the gallbladder with gall bladder wall thickening.

Gallbladder wall thickening

Acute cholecystitis

• Biliary ultrasound
  • Gallstones
    • Distinguish by characteristic "shadowing"
    • Better seen with patient in left lateral decub
  • GB wall thickening (>3mm)
    • May also be seen with Pancreatitis, ascites, Congestive heart failure, alcoholic hepatitis
  • Pericholecystic fluid
  • Sonographic Murphy's Sign (PPV 92%)
    • May be absent in patients with DM, gangrenous cholecystitis
• CT
  • Useful when ultrasound results are equivocal

Management

Antibiotics

Coverage is targeted at E. coli, Enterococcus, Bacteroides, and Clostridium (anerobic)

Uncomplicated Cholecystitis

• Ertapenem 1g IV once daily OR
• Metronidazole 500mg IV q8hrs PLUS
  • Ciprofloxacin 400mg IV q12 hrs OR
  • Levofloxacin 750mg IV q24hrs OR
  • Ceftriaxone 1g IV q24hrs

Complicated

Complicated disease such as severe sepsis or hemodynamic instability

• Vancomycin 15-20mg/kg PLUS any of the following options

Options:

• Metronidazole 500mg IV q8hrs PLUS Ciprofloxacin 400mg IV q12hrs
• Piperacillin/Tazobactam 4.5g IV q8hrs
• Imipenem/Cilastin 500mg IV q6hrs
• Doripenem 500mg IV q8hrs
• Meropenem 1g IV q8hrs

Surgical consultation

• Definitive treatment involves surgical removal or decompression

Disposition

• Admit

Complications

• Gangrene
  • Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
  • Consider if patient presents with sepsis in addition to cholecystitis
• Perforation
  • Occurs in 2% after development of gangrene
  • Usually localized, leading to pericholecystic abscess
• Gallstone Ileus
  • Due to cholecystoenteric fistula
• Emphysematous cholecystitis
  • Due to secondary infection of GB by gas-forming organisms (C. perfringens)
  • Presents like cholecystitis but often progresses to sepsis and gangrene
  • IV antibiotic and cholecystectomy are essential
  • Ultrasound report may mistake GB wall gas for bowel gas
  • Mortality as high as 15% due to gangrene or perforation
• Mirizzi Syndrome
  • Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
  • Symptoms of acute cholecystitis + dilated intrahepatic ducts + jaundice
  • Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
    • US and CT can usually delineate the fistula
  • Treatment = open cholecystectomy
• Gallstone Ileus
  • Bowel obstruction due to impaction of gallstone at terminal ileum
    • Gallstone enters small bowel through biliary-duodenal fistula
  • Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone

See Also

• Gallbladder Disease (Main)
• Biliary ultrasound

References

Authors

Ross Donaldson