Cholecystitis

Question 1

Define cholecystitis.

Answer 1

Acute cholecystitis is acute gallbladder inflammation, and is one of the major complications of cholelithiasis (the presence of gallstones).

In most cases (90%), acute cholecystitis is caused by complete cystic duct obstruction due to an impacted gallstone in the gallbladder neck or cystic duct, which leads to inflammation within the gallbladder wall

Question 2

What is the name for gallstone formation?

Answer 2

Cholelithiasis

Question 3

How common are gallstones?

Answer 3

Cholelithiasis occurs in 10-15% of people and only 1-2% becomes symptomatic each year. Only 10% of those patients get acute cholecystitis.

3 times more common in women than in men up to the age of 50yrs then 1.5 times more common

Question 4

What is acute acalculous cholesystitis and what percentage of cases are made up by it ?

Answer 4

Acute acalculous cholecystitis (inflammation of the gallbladder without any sign of gallstones) accounts for 5% to 14% of cases of acute cholecystitis

Most common in critically ill patients over 65yrs.

Question 5

Describe the pathophysiology of acute cholecystitis.

Answer 5

1. Fixed obstrcution of gallstones into gallbladder neck/cystic duct –> acute inflammation of gallbladder wall
2. Gallstone causes bile to become trapped in the gallbladder –> irritation and increased pressure
3. Trauma by gallstone –> inflammatory response
4. Secondary bacterial infection can lead to necrosis and gallbladder perforation

Question 6

What is Mirizzi’s syndrome?

Answer 6

Mirizzi syndrome is defined as common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder. Jaundice in 10% of acute cholecystitis caused by Mirizzi’s syndrome.

Question 7

How can cholecystitis be classified?

Answer 7

BY TYPE:

• Calculous - 90-95%
• Acalculous - 3-14%

BY PATHOLOGY:

• Oedematous - 2-4days and oedema is ubserosal layer
• Necrotising - 3-5days, oedema with areas of haemorrhage and necrosis(not all layers)
• Suppurative - 7-10days, WBCs within wall, areas of necrosis and suppuration, intra-wall abscesses involving entire thickness of wall. Pericholecystic abscesses present.
• Chronic - after repeated mild attacks, mucosal atrophy and fibrosis of gallbladder wall
• Emphysematous - air in gallbladder wall due to infection with gas forming anaerobes and often in diabetic patients.

Question 8

What are the clinical features of cholecystitis?

Answer 8

Sudden-onset, constant, severe pain in the upper right quadrant, lasting several hours + tenderness with or without guarding

• RUQ pain - may begin in epigastrium or LUQ and move to the right subcostal region. Most often occurs after eating a fatty meal. Lasts more than 3-6 hours and is severe and steady
• Palpable mass (30-40%)
• Murphy’s sign - palpation causes inspiratory arrest due to pain
• Right shoulder pain
• Anorexia
• Nausea and vomiting
• Fever and chills - seen in complicated disease

Acalculous - difficult to diagnose; often in critically ill on TPN, but usually diagnosis of exclusion.

Question 9

Where is pain from the gallbladder referred?

Answer 9

Right shoulder

Question 10

What are the risk factors for cholecystitis?

Answer 10

• Gallstones
• Severe illness
• TPN
• Diabetes
• Physical inactivity
• Low fibre diet
• Trauma/severe burns/infection
• Hepatic arterial embolisation
• Medication- ceftriaxone(secreted into bile), ciclosporin(reduces bile acide secretion)

Question 11

Why does TPN lead to cholecystitis?

Answer 11

Fasting –> gallbladder hypomobility –> stasis, sludge formation and gallstones due to reduced emptying

Toxic agents build up in gallbladder lumen causing gallbladder mucosa damage

Question 12

What are the first line investigations for cholecystitis?

Answer 12

Bloods:

• FBC (elevated WBC), LFTs (elevated ALP, GGT and Bil), CRP (elevated >28nmol/L)

Scans:

• RUQ US (fluid around gallbladder, distended gallbladder, thickened wall, positive sonographic Murphy’s sign, gallstones)
• Abdo CT/MRI (gallbladder wall inflammation; linear high-density areas in pericholecystic fat tissue)

Question 13

How do you manage a patient with cholecystitis?

Answer 13

Diagnosis and simultaneous resuscitation

• Analgesia e.g. paracetamol or diclofenac
• Monitoring
• Fluids

Assess severity - Tokyo guideline grading

Sepsis bundle - take cultures + start antibiotics (ampicillin/cirpofloxacin +/- metronidazole)

Exclusion of CBD stones - ERCP if present

Plan for cholecystectomy - if within 72hrs of symptom onset then do immediate cholecystectomy as not enough time has passed for adhesions/inflammation to occur

If high risk patient unsuitable for GA: percutaneous cholecytostomy to relieve symptoms

Question 14

What are the complications of cholecystitis and its management?

Answer 14

• Necrosis of the gallbladder wall (gangrenous cholecystitis).
• Perforation of the gallbladder.
• Biliary peritonitis.
• Pericholecystic abscess.
• Fistula (between the gallbladder and duodenum).
• Jaundice (due to inflammation of adjoining biliary ducts — Mirizzi’s syndrome).
• Sepsis.

Question 15

What is the prognosis for cholecystitis?

Answer 15

If the gallbladder perforates, mortality is 30%.

Untreated acute acalculous cholecystitis is life-threatening and is associated with up to 50% mortality.

About 50% of the people who have had one episode of biliary pain will have another within 12 months.

Without treatment, acute cholecystitis may resolve spontaneously within 1–7 days. However, 25–30% of people will require surgery or develop complications.

Question 16

What differential diagnoses would you consider?

• Acute pancreatitis
• Acute cholecystitis
• Chronic pancreatitis
• Acute appendicitis
• Coeliac disease
• Perforated duodenal ulcer
• Acute hepatitis
• Acute pyelonephritis
• Renal colic

What three further investigations would you request to help you establish the diagnosis?

• Serum amylase
• Erect chest radiograph
• Supine abdominal radiograph
• Ultrasound abdomen
• Lateral decubitus abdominal radiograph
• Erect abdominal radiograph

Answer 16

1. Acute cholecystitis, acute pancreatitis and perforated duodenal ulcer. - pyelonephritis can cause fever and abdominal pain (classically loin-to-groin) but would be unlikely with the negative urine dip. Renal colic causes loin-to-groin pain but is likely to cause at least blood on the urine dip and wouldn’t explain her fever and level of illness – also the abdomen would usually be soft

2. Serum amylase, erect CXR, US abdomen - musct exclude perforated viscus and pancreatitis. US will show biliary tree. Lateral decubitus films are used to detect small amounts of free intra-peritoneal air otherwise occult, but are difficult often to interpret

Question 17

An ultrasound image of the gallbladder fossa is demonstrated below. Several structures are indicated by labels A-D. Link the labels on the left with the correct response in the right hand column.

Serum amylase and liver function tests are within normal limits and chest/ abdominal radiographs show no abnormality. Ultrasound has confirmed gallstones in the gallbladder with appearances consistent with acute cholecystitis. The biliary tree is normal with no dilatation. What further investigations are now indicated?

• Computed Tomography (CT) abdomen
• ERCP
• Magnetic resonance imaging with MRCP (magnetic resonance cholangiopancreatography).
• Barium meal
• None at this time
• Nuclear medicine HIDA scan to assess gallbladder function

How would you manage this patient?

• Intravenous fluids, analgesia, nil by mouth
• Intravenous antibiotics
• Arrange gallbladder drainage percutaneously to allow acute inflammation to subside.
• Arrange ERCP and stent insertion to drain biliary tree
• Consider cholecystectomy as an emergency (during this admission)

Answer 17

1. The gallbladder contains echogenic material – sludge and also calcified stones (hyperchoic – white) which shadow. The gallbladder wall is thickened – these appearances are in keeping with acute cholecystitis.

• A- liver
• B - thickened wall of gallbladder
• C - gallbladder sludge/bile
• D - calculi in gallbladder

2. None at this time - normal LFTs and non dilated biliary tree so CBD stone unlikely. MRCP only indicated if still doubt and HIDA scans assess gallbladder function. CT is for complications of cholecystitis.

3. IV fluids, analgesia, NBM; IV antibiotics and consider cholecystectomy - Cholecystectomy can be performed acutely (consider laparoscopic removal) or at a delay of a few months.

Question 18

With regard to gallstones which five of the following statements are true?

• 10% are radio-opaque an abdominal radiographs
• 90% are asymptomatic
• They are complication of sickle cell disease
• Late cholecystectomy is associated with fewer complications than early cholecystectomy for acute cholecystitis
• Gallbladder percutaneous drainage may suffice as a treatment for acute cholecystitis in the elderly
• Smoking is a risk factor for gallstones becoming symptomatic

Which six of the following are complications of gallstones?

• Small bowel obstruction
• Gall bladder carcinoma
• Acute pancreatitis
• Bile salt malabsorption
• Pancreatic cancer
• Duodenal ulcer
• Porcelain gallbladder
• Mucocele of the gallbladder
• Cholangitis

Answer 18

1.

• 10% are radio-opaque an abdominal radiographs
• 90% are asymptomatic
• They are complication of sickle cell disease
• Gallbladder percutaneous drainage may suffice as a treatment for acute cholecystitis in the elderly
• Smoking is a risk factor for gallstones becoming symptomatic

There are increased complications associated with late rather than early cholecystectomy. Any condition associated with haemolysis (e.g. sickle cell disease) can cause pigment stone formation.

2.

• Small bowel obstruction - stones can migrate via a fistula into the bowel with impaction and obstruction (gallstone ileus). Duodenal ulcer is not related to gallstones.
• Gall bladder carcinoma
• Acute pancreatitis - if stones in CBD
• Porcelain gallbladder - Porcelain gallbladder is secondary to chronic inflammation secondary to stones and is a risk factor for malignant change – look for gallbladder mural calcification on radiograph.
• Mucocele of the gallbladder
• Cholangitis - stones in CBD

Question 19

A 78-year-old female presents to the surgical assessment unit with right upper quadrant pain. She has had pain in the right upper quadrant for several years intermittently and the current episode has lasted for 48 hours. She does feel nauseated but has not been sick. She does also complain of intermittent bloating and flatulence. Her weight is steady however she has a history of mild hypertension for which she takes a diuretic but has no other medical or drug history. She smokes 5 cigarettes per day.

On examination, she is mildly overweight but baseline observations are normal and she is apyrexial. Cardio-respiratory examination is normal. She is mildly tender in the right upper quadrant on abdominal palpation but has no guarding and bowel sounds are normal. No masses are palpable. Her abdomen is mildly distended. Bloods are normal except for elevated CRP.

What is the most likely diagnosis?

Answer 19

CHRONIC cholecystitis

Acute cholecystitis would be associated with more pain and systemic upset, a fever and an elevated WCC. LFT’s are normal and no mass is palpable making stones in the duct, liver metastases and hepatitis is unlikely. She is not ill enough to have acute pancreatitis (it would be worth checking serum amylase if you are concerned).

Question 20

Answer 20

A - splenic artery calcification

B - gallbladder wall calcification

C- right iliac artery calcification

D - phlebolith

E - costal cartilage calcification

Question 21

Which of these is true?

• The bowel gas pattern is within normal limits
• Dilated loops of small bowel are present in keeping with ileus
• Air is noted in the biliary tree in keeping with gallstone ileus
• There is an abnormal thick-walled structure in the right upper quadrant consistent with a distended gallbladder
• Air is present within the wall of the right upper quadrant structure
• Mottled gas densities are present in the right upper quadrant consistent with a liver abscess.
• Large renal calculus noted in the right kidney

Answer 21

• The bowel gas pattern is within normal limits
• There is an abnormal thick-walled structure in the right upper quadrant consistent with a distended gallbladder
• Air is present within the wall of the right upper quadrant structure

The gallbladder is distended and thick-walled and curvilinear lucency in keeping with gas is seen in the gallbladder wall.

Question 22

Which of these is true about air in the gallbladder wall?

• If is not usually of clinical significance and occurs often in elderly patients
• It is more common in diabetics
• CT is the ideal modality for further delineation
• ERCP is helpful for further investigation
• It is known as emphysematous cholecystitis
• Air in the wall arises as a combination of gallbladder ischaemia and infection with gas-forming organisms
• Treatment is conservative
• Symptoms and signs are initially minor but mortality is high

Answer 22

More common in diabetics

CT is the ideal modality for delineation and is superior to US

Symptoms and signs are initially minor but mortality is high - Initial symptoms/signs are often minor but mortality due to sepsis is high. Oedema changes obstruct the cystic duct with distension/ischaemia of the gallbladder and sepsis supervenes

It is known as emphysematous cholecystitis

Air in the wall arises as a combination of gallbladder ischaemia and infection with gas-forming organisms

Treatment is surgical.