Acute calculous cholecystitis

Background

Acute cholecystitis on gross pathology of removed gallbladder containing multiple stones.

Gallbladder disease types

Gallbladder anatomy (overview).

Gallbladder anatomy

Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.

• Symptomatic cholelithiasis (biliary colic)
• Choledocholithiasis
• Acute calculous cholecystitis
• Ascending cholangitis
• Acalculous cholecystitis
• Biliary atresia
• Cholestasis of pregnancy

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Anatomy & Pathophysiology

• Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
• These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
• Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.

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Clinical Features

Local Signs

• RUQ pain
• Murphy Sign
  • Highest positive LR (2.8) of any clinical finding or lab value
• Boas sign: hyperaesthesia below the right scapula from referred pain

Systemic signs

• Fever
• Nausea and vomiting

Differential Diagnosis

RUQ Pain

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

Evaluation

Abdominal ultrasound showing biliary sludge and gallstones

Gallstone impacted in neck of gallbladder

Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.

Gallbladder wall thickening with pericholecystic fluid

Workup

Laboratory Findings

• Common findings:
  • Leukocytosis
  • LFT abnormalities (obstructive picture)
• Meta-analysis shows there is no history, physical exam, or lab test or combination thereof that allows rule-out or rule-in without imaging.

Imaging

• Biliary ultrasound (preferred test; sensitivity 84%; specificity 99%)
  • 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
• HIDA scan
  • Gold standard when other imaging modalities are equivocal
• Other imaging
  • CT: there is a lack of evidence to support diagnostic accuracy
  • MRI: Accuracy similar to ultrasound

Diagnosis

• "Combining clinical, laboratory and imaging investigations is recommended, although the best combination is not yet known"

Management

Antibiotics

Most often isolated organisms are Escherichia coli, Klebsiella pneumonia, and anaerobes, especially Bacteroides fragilis

Uncomplicated

Pathogenicity of Enterococci remains unclear and specific coverage is not routinely suggested for community-acquired infections

• 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 or Healthcare Associated

Examples of complication include 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: surgical cholecystectomy
  • More effective than antibiotics alone

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
• 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

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

See Also

• Gallbladder Disease (Main)
• Biliary ultrasound