Acute Cholecystitis

Overview most common complication of gallstones disease. Inflammation of the gallbladder wall associated with abdominal pain, RUQ tenderness, fever, and leukocytosis is the hallmark. Gallstone prevalence: 8% of those over 40years. Up to 90% remain asymptomatic.

Clinical Presentation  Impaction of the neck of gallbladder causes acute cholecystitis which present as severe continous right upper quadrant pain, often radiating to the right flank and back associated with anorexia and pyrexia. Tenderness over gallbladder during inspiration -> Murphy's sign.

Examination

Murphy's Sign classic for acute cholecystitis

• Appendicitis
• Acute pancreatitis (can be due to gallstones)
• Pyelonephritis
• Hepatic abscess
• Hepatic tumour
• Gonococcal or chylamdial perihepatitis

Investigation Check bloods which will show increase WCC. Ultrasound can show a thick-wall, shrunken gall bladder (also seen in chronic), fluid, stones, +/-dilated common bile duct. HIDA can be used if uncertain after ultrasound. Plain abdominal X-ray only reveal 10% of calculi, and it may identify porcelain gallbladder.

Diagnosis

• History, examination suggestive of acute cholecytitis
• Wall thickening or oedema (ultrasound)
• Sonographic Murphy's sign

First few days, the gallbladder is usually distended and contains a stone embedded in the cystic duct. Histologically, range from mild acute inflammation with oedema to necrosis and perforation of the gallbladder wall.

Management Nil by mouth if the patient has a distended abdomen or persistent vomiting, use a nasogastric tube. Provide analgesia and anti-emetic. Oxygen and fluids if needed. Antibiotics (if patient appear toxic or is suspected of gallbladder perforation) and refer to surgeon. Surgical treatment is cholecystectomy.

Laproscopic vs. Open Cholecystectomy In acute cholecystitis, post-operative morbidity, mortality and hospital stay were reduced by laparoscopic cholecystectomy. Moreover pneumonia and wound infection rate were reduced by laproscopic cholecystectomy. Severe haemorrhage and bile leakage rates were not influenced by the technique. Cholecystectomy in acute cholecystitis should be attempted laparoscopically first.

Common

• Biliary colic +/- obstructive jaundice
• Cholangitis - bile duct infection

Uncommon

• Emphysematous cholecytisis - acute infection of the gallbladder wall caused by gas-forming organisms
• Cholesytoenteric fistula -> gallstone ileus
• Mirizzi's syndrome - gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct, resulting in obstruction and jaundice
• Porcelain gallbladder - calcification of gallbladder wall
• Chronic cholecystitis - repeasted episodes of infection causes thickening and fibrosis of gall bladder
• Carinoma of gallbladder
• Empyema and mucocele - obstructed gallbladder fills with mucus secreted by the gallbladder wall/pus from inflammation.
• Abscess (rare) indicated by swinging fever and pain.

Complications of Acute cholecystitis (biliary colic not included)

UpToDate
Best Practice
Oxford Handbook of Clinical Medicine
Oxford Handbook of Clinical Surgery