Acute calculous cholecystitis: Difference between revisions
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*[[RUQ pain]]
*[[RUQ pain]]
*Murphy Sign
*Murphy Sign
**Highest positive LR of any clinical finding or lab value
**Highest positive LR (2.8) of any clinical finding or lab value<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
 
===Systemic signs===
===Systemic signs===
*[[Fever]]
*[[Fever]]
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==Evaluation==
==Evaluation==
*Meta-analysis of 17 studies which evaluated role of history, physical, and lab tests in working up cholecystitis showed all likelihood ratios cross or almost cross 1.0.  There is no history, physical exam, or lab test that would comfortably allow you to rule-out or rule-in cholecystitis.<ref>Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6.</ref>
===Workup===
===Laboratory Findings===
====Laboratory Findings====
*Leukocytosis
*Common findings:
*LFT abnormalities (obstructive picture)
**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.<ref>Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6.</ref>


===Imaging===
====Imaging====
[[File:Cholecystitis_Neck_Stone_Bowra.gif|thumbnail|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
[[File:Cholecystitis_Neck_Stone_Bowra.gif|thumbnail|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
[[File:GB_Thickening_Fluid_Bowra.gif|thumbnail|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
[[File:GB_Thickening_Fluid_Bowra.gif|thumbnail|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
[[File:Acute cholecystitis.png|thumb|Acute cholecystitis]]
[[File:Acute cholecystitis.png|thumb|Acute cholecystitis]]
*[[Biliary ultrasound]]
*[[Biliary ultrasound]] (preferred test<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>; sensitivity 84%; specificity 99%)<ref>Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;154:2573–81.</ref>
**Gallstones
**Gallstones
***Distinguish by characteristic "shadowing"
***Distinguish by characteristic "shadowing"
***Better seen with patient in left lateral decub
***Better seen with patient in left lateral decub
**GB wall thickening (>3mm)
**GB wall thickening (>3mm)
***May also be seen with [[Pancreatitis]], ascites, [[Congestive heart failure]], alcoholic hepatitis
***May also be seen with [[pancreatitis]], [[ascites]], [[congestive heart failure]], alcoholic hepatitis
**Pericholecystic fluid
**Pericholecystic fluid
**Sonographic Murphy's Sign (PPV 92%)
**Sonographic Murphy's Sign (PPV 92%)
***May be absent in patients with DM, gangrenous cholecystitis
***May be absent in patients with DM, gangrenous cholecystitis
*CT
*HIDA scan
**Useful when [[ultrasound]] results are equivocal
**Gold standard when other imaging modalities are equivocal<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
*Other imaging
**CT: there is a lack of evidence to support diagnostic accuracy<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
**MRI: Accuracy similar to ultrasound<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
 
===Diagnosis===
*"Combining clinical, laboratory and imaging investigations is recommended, although the best combination is not yet known"<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>


==Management==
==Management==
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===Surgical consultation===
===Surgical consultation===
*Definitive treatment involves surgical removal or decompression
*Definitive treatment: surgical cholecystectomy<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
**More effective than antibiotics alone<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>


==Disposition==
==Disposition==
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*Gallstone [[Ileus]]
*Gallstone [[Ileus]]
**Due to cholecystoenteric fistula
**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
*Emphysematous cholecystitis
**Due to secondary infection of GB by gas-forming organisms (C. perfringens)
**Due to secondary infection of GB by gas-forming organisms (C. perfringens)
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***US and CT can usually delineate the fistula
***US and CT can usually delineate the fistula
**Treatment = open cholecystectomy
**Treatment = open cholecystectomy
*Gallstone Ileus
**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


==See Also==
==See Also==

Revision as of 03:57, 3 April 2019

Background

Gallbladder disease types

Gallbladder anatomy (overview).
Gallbladder anatomy

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.

Clinical Features

Local Signs

  • RUQ pain
  • Murphy Sign
    • Highest positive LR (2.8) of any clinical finding or lab value[1]

Systemic signs

Differential Diagnosis

RUQ Pain

Evaluation

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.[2]

Imaging

Gallstone impacted in neck of gallbladder[3]
Gallbladder wall thickening with pericholecystic fluid[4]
Acute cholecystitis
  • Biliary ultrasound (preferred test[1]; sensitivity 84%; specificity 99%)[5]
    • Gallstones
      • Distinguish by characteristic "shadowing"
      • Better seen with patient in left lateral decub
    • GB wall thickening (>3mm)
    • 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[1]
  • Other imaging
    • CT: there is a lack of evidence to support diagnostic accuracy[1]
    • MRI: Accuracy similar to ultrasound[1]

Diagnosis

  • "Combining clinical, laboratory and imaging investigations is recommended, although the best combination is not yet known"[1]

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[1]

Complicated or Healthcare Associated

Examples of complication include severe sepsis or hemodynamic instability

  • Vancomycin 15-20mg/kg PLUS any of the following options

Options:

Surgical consultation

  • Definitive treatment: surgical cholecystectomy[1]
    • More effective than antibiotics alone[1]

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

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5
  2. ↑ Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6.
  3. ↑ http://www.thepocusatlas.com/hepatobiliary/
  4. ↑ http://www.thepocusatlas.com/hepatobiliary/
  5. ↑ Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;154:2573–81.
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