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Acute Cholecystitis
Aka: Acute Cholecystitis, Hydrops Gallbladder, Cholecystitis- See Also
- Definitions
- Cholecystitis
- Gallbladder inflammation resulting from cystic duct blockage by Gallstones
- Cholecystitis
- Precautions
- Acute Cholecystitis may present cryptically yet requires emergent management
- Fever and chills are frequently absent
- Fever or chills are only present in a third of patients with Acute Cholecystitis
- Right upper quadrant pain or tenderness may be absent
- As many as a quarter of Acute Cholecystitis cases do not have RUQ findings
- Risk Factors
- See Gallstone (Cholelithiasis)
- Symptoms
- Biliary Colic with additional characteristics below
- Acute Cholecystitis is typically preceded by at least one Biliary Colic episode
- Characteristics
- Starts as dull visceral poorly localized pain
- Develops into sharp parietal focal RUQ Pain
- Timing
- Pain persists beyond typical 5-6 hours
- Associated Symptoms
- Fever is present in only 35% of Acute Cholecystitis
- Chills are present in only 13% of Acute Cholecystitis
- Biliary Colic with additional characteristics below
- Signs
- Appearance
- Toxic appearance in moderate to severe discomfort
- Tachycardia
- Non-specific gastrointestinal findings
- RUQ Abdominal tenderness
- Test Sensitivity: 77%
- Test Specificity: 54%
- Hypoactive bowel sounds
- RUQ Abdominal tenderness
- Peritoneal Signs
- Localized irritation is comon
- Generalized signs (rare) suggests perforation
- Murphy Sign positive
- Examiner palpates the abdominal RUQ while the patient takes a deep breath
- Positive test if the patient suddenly halts their inspiration due to pain
- Appearance
- Labs
- Complete Blood Count
- Leukocytosis with Left Shift
- Normal WBC Count does not rule out Acute Cholecystitis
- Very high WBC Count may suggest gallbladder gangrene or perforated gallbladder
- Liver Function Tests (LFTs)
- Serum Bilirubin elevated (typically mild)
- Serum Alkaline Phosphatase elevated
- Serum Aminotransferases normal
- Pancreatic Studies (for gallstone Pancreatitis)
- Serum Lipase (some also obtain Serum Amylase)
- Urine Studies
- Urinalysis
- Urine HCG
- Complete Blood Count
- Imaging: First-Line
- RUQ Ultrasound (preferred)
- See Gallbladder Ultrasound for diagnostic criteria
- Consider serial Ultrasound in 12-16 hours if non-diagnostic Ultrasound
- Repeat Ultrasound may demonstrate increased gallbladder wall thickness, ultrasonic murphy's sign
- Abdominal CT
- Indicated for non-diagnostic Ultrasound
- Evaluation of Cholecystitis complications (Ascending Cholangitis, gallstone Pancreatitis, post-operative findings)
- Hepatobiliary Iminodiacetic Acid Scan (HIDA Scan)
- Acute Cholecystitis evaluation for cystic duct obstruction
- Normal gallbladder visualization on HIDA Scan has high Negative Predictive Value (99%)
- Magnetic Resonance Cholangiopancreatography (MRCP)
- Indicated for suspected Common Duct Stone (Choledocholithiasis)
- RUQ Ultrasound (preferred)
- Imaging: Other
- XRay Abdomen
- Test Sensitivity for Gallstones: 10-20%
- Most stones are Cholesterol (radiolucent)
- Chest XRay
- Assess for Right Lower Lobe Pneumonia
- Assess for Pleural Effusion (seen in Pancreatitis)
- Assess for free air under the diaphragm
- XRay Abdomen
- Management
- Intravenous Fluid hydration
- Nasogastric suction
- Antibiotics (start within 1 hour of skin incision)
- Initial antibiotic regimen (see Cholecystectomy)
- Piperacillin-Tazobactam 4.5 g IV q8 hours OR
- Ertapenem 1 g IV every 24 hours
- Alternative antibiotic regimens
- Metronidazole 1 g IV load, then 500 mg IV every 6 hours AND
- Ceftriaxone 2 g IV OR (Moxifloxacin 400 IV q24h or Ciprofloxacin 400 mg IV q12 h)
- Risk of Fluoroquinolone resistance
- Consider broadening antibiotics for severe cases
- References
- (2017) Sanford Guide
- Initial antibiotic regimen (see Cholecystectomy)
- Laparoscopic Cholecystectomy
- Recommended within first 48 hours
- In poor surgical candidates, strongly consider decompression (e.g. percutaneous)
- Immediate Cholecystectomy is safe and preferred
- Recommended within first 48 hours
- Percutaneous cholecystostomy drainage (with delayed Cholecystectomy)
- Indicated for older or critically ill patients with gallbladder empyema (and associated Sepsis)
- Alternatives to surgery
- Course
- Spontaneous resolution in 60% of cases
- Complications
- Acute Pancreatitis
- Ascending Cholangitis
- Gallbladder Empyema
- Gallbladder Gangrene (Emphysematous Cholecystitis)
- References