# Acute Cholecystitis
Pert +/- history: Pt c/o of RUQ / epigastric abdominal pain. Pain radiates to R shoulder/back. Pain is steady and severed. Associated symptoms include fever, nausea, vomiting, anorexia. There was a history of fatty food ingestion one hour or more before the initial onset of pain. The episodes of pain are typically prolonged (greater than four to six hours).
Pert +/- PE: RUQ tenderness, involuntary guarding, Murphy’s sign, +/- palpable gallbladder. Pt is ill appearing, febrile, and tachycardic, and lie still on the examining table (because cholecystitis is associated with true local parietal peritoneal inflammation that is aggravated by movement.)
Pert +/- Labs: Incr. WBC, +/- mild elevations in bilirubin, Alk phos, ALT/AST, and amylase. [AST/ALT 500 U/L, bili 4 mg/dL, or amylase 1,000 U/L points to choledocholithiasis].
Pert +/- Imaging/Studies:
– RUQ U/S: high Se & Sp for stones, but need specific signs of cholecystitis: GB wall thickening 5 mm, pericholecystic fluid, and a sonographic Murphy’s sign
– HIDA scan: most Se test (80–90%) for acute cholecystitis
Treatment:
– NPO, IV fluids, NGT if intractable vomiting, analgesia
– Zofran for Nausea
– Pain management
– IV Antibiotics Zosyn (Pip-Tazo) to cover for Anaerobes + Gram Negatives (GNR). Alternatives are Ampicillin / Sulbactam or a combination of (2nd- or 3rd-generation cephalosporin or FQ) PLUS Metronizadole.
– Consult surgery for early cholecystectomy (usually w/in 72 h). Delaying surgery 2–3 months decreases operative time w/o changing the rate of complications or conversion to open procedure.
– Consider cholecystostomy and percutaneous drainage if the patient becomes too sick for surgery
– Consider intraoperative cholangiogram or ERCP to r/o choledocholithiasis if patient develops jaundice, cholangitis, or stone in BD on U/S
– After cholecystectomy, in preparation for discharge, consider switching from IV Zosyn to PO Augmentin (Amoxicillin Clavulanate) for 7 days if cholecystitis was severe. If not, may d/c abx on POD#1
——————————–
Potential Complications
• Gangrenous cholecystitis: necrosis w/ risk of empyema and perforation
• Emphysematous cholecystitis: infection by gas-forming organisms (air in GB wall)
• Post CCY: bile duct leak, BD injury or retained stones, cystic duct remnant, sphincter of Oddi dysfxn
Definitions / Intro
Acute cholecystitis: stone impaction in cystic duct→ inflammation behind obstruction → GB swelling secondary infection (50%) of biliary fluid
Acalculous cholecystitis: gallbladder stasis and ischemia → inflammatory response; occurs mainly in critically ill, hosp. Pts (postop major surgery, TPN, sepsis, trauma, burns, opiates, immunosuppression, infxn [eg, CMV, Crypto, Campylobacter, typhoid fever])
The clinical manifestations of acute cholecystitis include prolonged (more than four to six hours), steady, severe RUQ or epigastric pain, fever, abdominal guarding, a positive Murphy’s sign, and leukocytosis.
Source: Pocket Med, Uptodate, etc.