Gallbladder disease (main)
Cholecystitis versus Cholangitis versus Symptomatic Cholelithiasis
Acute Cholecystitis==- Diagnosis==
- RUQ pain + fever + leukocytosis associated with gallbladder inflammation
- Ultrasound
- GB wall thickening (greater than 4-5mm) or edema (double wall sign)
- Sonographic Murphy's Sign
- Treatment
- Antibiotics
- Although clear evidence is lacking, assoc/ w/ decreased wnd infection and bacteremia
- CTX + metronidazole OR piperacillin/tazobactam (Zosyn) OR ampicillin-sulbactam (Unasyn)
- Admit
- Complications
- Gangrene
- Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
- Consider if pt 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
- Presents like cholecystitis (crepitus in abdominal wall may rarely be detected)
- IV abx and cholecystectomy are essential
- Ultrasound report may mistake GB wall gas for bowel gas
Cholangitis ==- Diagnosis==
- Charcot's Triad: Fever + jaundice + RUQ pain
- Occurs in 50-75%
- Reynold's Pentad: The triad + AMS + hypotension
- Hypotension may be the only presenting sign in elderly pts
- Labs
- Leukocytosis with neutrophil predominance
- Elevated alk phos, conj. bilirubin
- Blood culture is indicated
- Imaging
- Ultrasound
- Dilatation of CBD ( > 6mm) and presence of choledocholithiasis
- May miss small CBD stones and in acute cases CBD may not have had time to dilate
- ERCP
- Should be obtained to confirm the diagnosis and to intervene
- Treatment
- Broad-spectrum parenteral Abx covering gram - and anerobes
- CTX + metronidazole OR piperacillin/tazobactam (Zosyn) OR ampicillin-sulbactam (Unasyn)
Symptomatic Cholelithiasis==- Diagnosis==
- History
- RUQ pain that is usually constant, not colicky
- Usually does not occur during fasting
- Physical Exam
- Often benign; as compared to cholecystitis, usually negative Murphy's Sign
- Labs
- LFT, CBC normal
- Ultrasound
- Sensitivity 84%, Specificity 99%
- Treatment
- IV/IM Ketorolac (as effective as meperidine) with Rx for Ibuprofen
Source: UpToDate