Acute calculous cholecystitis: Difference between revisions
 
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==Background==
==Background==
[[File:Gallstones 2.jpg |thumb|Acute cholecystitis on gross pathology of removed gallbladder containing multiple stones.]]
{{Gallbladder disease types}}
{{Gallbladder disease types}}
{{Gallbladder background}}
{{Gallbladder background}}
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*[[RUQ pain]]
*[[RUQ pain]]
*Murphy Sign
*Murphy Sign
**Highest positive LR (2.8) of any clinical finding or lab value<ref>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>
**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>
*Boas sign: hyperaesthesia below the right scapula from referred pain<ref>Iyer HV. Boas' sign revisited. Ir J Med Sci. 2011;180(1):301. doi:10.1007/s11845-010-0640-x</ref>


===Systemic signs===
===Systemic signs===
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==Evaluation==
==Evaluation==
[[File:Ultrasonography of sludge and gallstones, annotated.jpg|thumb|Abdominal ultrasound showing biliary sludge and gallstones]]
[[File:Cholecystitis_Neck_Stone_Bowra.gif|thumbnail|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
[[File:Gallstones.png|thumb|Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.]]
[[File:GB_Thickening_Fluid_Bowra.gif|thumbnail|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
===Workup===
===Workup===
====Laboratory Findings====
====Laboratory Findings====
*Common findings:
*Common findings:
**Leukocytosis
**[[Leukocytosis]]
**LFT abnormalities (obstructive picture)
**[[LFTs|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>
*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>]]
*[[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>
[[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]]
*[[Biliary ultrasound]] (preferred test<ref>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"
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***May be absent in patients with DM, gangrenous cholecystitis
***May be absent in patients with DM, gangrenous cholecystitis
*HIDA scan
*HIDA scan
**Gold standard when other imaging modalities are equivocal<ref>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>
**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
*Other imaging
**CT: there is a lack of evidence to support diagnostic accuracy<ref>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>
**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>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===
===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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==Complications==
==Complications==
*Gangrene
===[[Gangrene]]===
**Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
*Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
**Consider if patient presents with sepsis in addition to cholecystitis
*Consider if patient presents with sepsis in addition to cholecystitis
*Perforation
 
**Occurs in 2% after development of gangrene   
===Perforation===
**Usually localized, leading to pericholecystic abscess
*Occurs in 2% after development of gangrene   
*Gallstone [[Ileus]]
*Usually localized, leading to pericholecystic abscess
**Due to cholecystoenteric fistula
 
*Emphysematous cholecystitis
===Gallstone [[Ileus]]===
**Due to secondary infection of GB by gas-forming organisms (C. perfringens)
*Due to cholecystoenteric fistula
**Presents like cholecystitis but often progresses to sepsis and gangrene
*[[Bowel obstruction]] due to impaction of gallstone at terminal ileum
**IV antibiotic and cholecystectomy are essential
**Gallstone enters small bowel through biliary-duodenal fistula
**Ultrasound report may mistake GB wall gas for bowel gas  
*Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone
**Mortality as high as 15% due to gangrene or perforation
 
*Mirizzi Syndrome
===Emphysematous cholecystitis===
**Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
*Due to secondary infection of GB by gas-forming organisms (C. perfringens)
**Symptoms of acute cholecystitis + dilated intrahepatic ducts + jaundice
*Presents like cholecystitis but often progresses to sepsis and gangrene
**Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
*IV antibiotic and cholecystectomy are essential
***US and CT can usually delineate the fistula
*Ultrasound report may mistake GB wall gas for bowel gas  
**Treatment = open cholecystectomy
*Mortality as high as 15% due to gangrene or perforation
*Gallstone Ileus
 
**Bowel obstruction due to impaction of gallstone at terminal ileum
===Mirizzi Syndrome===
***Gallstone enters small bowel through biliary-duodenal fistula
*Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
**Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone
*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==
==See Also==
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[[Category:GI]]
[[Category:GI]]
[[Category:ID]]
[[Category:ID]]
[[Category:Surgery]]

Latest revision as of 19:23, 24 December 2020

Background

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

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]
  • Boas sign: hyperaesthesia below the right scapula from referred pain[2]

Systemic signs

Differential Diagnosis

RUQ Pain

Evaluation

Abdominal ultrasound showing biliary sludge and gallstones
Gallstone impacted in neck of gallbladder[3]
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[4]

Workup

Laboratory Findings

  • Common findings:
  • Meta-analysis shows there is no history, physical exam, or lab test or combination thereof that allows rule-out or rule-in without imaging.[5]

Imaging

  • Biliary ultrasound (preferred test[1]; sensitivity 84%; specificity 99%)[6]
    • 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. ↑ Iyer HV. Boas' sign revisited. Ir J Med Sci. 2011;180(1):301. doi:10.1007/s11845-010-0640-x
  3. ↑ http://www.thepocusatlas.com/hepatobiliary/
  4. ↑ http://www.thepocusatlas.com/hepatobiliary/
  5. ↑ Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6.
  6. ↑ 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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