Cholecystitis (GI)

Question 1

Define acute cholecystitis.

Answer 1

Acute gallbladder inflammation usually due to cystic duct obstruction by a gallstone

Question 2

What are 90% of cases of acute cholecystitis caused by?

Answer 2

Gallstones

Complete cystic duct obstruction usually due to an impacted gallstone in the GB neck or cystic duct –> bile trapped in GB –> inflammation within GB wall

Question 3

How do impacted gallstones cause acute cholecystitis?

Answer 3

Complete cystic duct obstruction usually due to an impacted gallstone in the GB neck or cystic duct –> bile trapped in GB –> irritation of surrounding nerves –> increases GB pressure

Trauma caused by gallstones stimulate PG synthesis (PGI2, PGE2), mucus enzyme production from GB mucosa –> inflammatory response

Question 4

What happens if gallstone remains impacted in acute cholecystitis?

Answer 4

Pressure continues to build and can impact blood vessels –> compromised blood supply to GB –> ischaemia/necrosis of tissue

Question 5

What can cause acalculous acute cholecystitis (without gallstones)? (7)

Answer 5

• bile inspissation (due to dehydration)
• bile stasis (trauma/systemic illness)
• starvation
• TPN
• narcotic analgesics
• immobility
• EBV

Question 6

What are the clinical features of acute cholecystitis? (4)

Answer 6

• RUQ pain + tenderness
• pain may radiate to right shoulder (parietal peritoneum involvement)
• fever and signs of systemic upset
• nausea and vomiting (more common if stone in CBD)
• (jaundice - less common, inflammation and oedema around biliary tract, pressure on tract)

Question 7

Why is jaundice rarely seen in acute cholecystitis?

Answer 7

Blockage of cystic duct or GB does not cause jaundice

Question 8

What might you see on examination of acute cholecystitis? (3)

Answer 8

• Murphy’s sign (sudden pause during inspiration upon deep palpation of RUQ due to pain as diaphragm hits enlarged GB)
• palpable mass - distended, tender GB
• Boas sign - hyperaesthesia below right scapula

Question 9

What are some risk factors for acute cholecystitis? (4)

Answer 9

• gallstones
• total parenteral nutrition –> fasting = GB hypomotility and stasis, biliary sludge, gallstones (decreased emptying)
• diabetes
• severe illness

Question 10

What are the first-line investigations for acute cholecystitis? (8)

Answer 10

• abdominal USS
• CT/MRI abdomen
• FBC
• CRP
• LFTs
• serum lipase/amylase
• MRCP
• EUS

Question 11

What is the first-line investigation of choice for suspected acute cholecystitis?

Answer 11

Abdominal ultrasound (showing thick gallbladder wall)

Question 12

What would you see on abdominal ultrasound in acute cholecystitis? (5)

Answer 12

• pericholecystic fluid
• distended gallbladder
• thickened gallbladder wall (>3mm)
• gallstones
• positive sonographic Murphy’s sign (may be absent in gangrenous cholecystitis)

Question 13

What do we do if abdominal ultrasound is unclear in suspected acute cholecystitis?

Answer 13

Technetium labelled HIDA scan

Question 14

What investigation do we do if sepsis is suspected in acute cholecystitis?

Answer 14

CT/MRI abdomen - diagnosing gangrenous cholecystitis or perforation

Question 15

What is the gold-standard (but not first-line) investigation for acute cholecystitis?

Answer 15

• MRCP
• can also show defects in biliary tree
• use if US does not show stones but bile duct is dilated OR if LFTs are abnormal
• use EUS if MRCP contraindicated

Question 16

When is endoscopic ultrasound done in acute cholecystitis?

Answer 16

If MRCP contraindicated

Question 17

What would FBC show in acute cholecystitis?

Answer 17

Increased WCC and CRP

Question 18

What do LFTs show in acute cholecystitis?

Answer 18

• typically normal
• may show elevated ALP, ALT, GGT, BR
• ALT can be elevated if stone has passed down CBD or focal inflammation of liver parenchyma

Question 19

What can deranged LFTs in acute cholecystitis mean?

Answer 19

Mirizzi syndrome - gallstone impacted in distal cystic duct causing extrinsic compression of common bile duct –> jaundice

Question 20

Why do we do serum lipase/amylase in acute cholecystitis?

Answer 20

Serum lipase (preferred) to rule out pancreatitis (>3x upper limit)

Question 21

What are some differential diagnoses for acute cholecystitis? (9)

Answer 21

• acute cholangitis - Charcot’ triad
• chronic cholecystitis
• peptic ulcer disease - burning pain after eating
• acute pancreatitis
• sickle cell crisis
• acute appendicitis
• right UL pneumonia
• ACS
• GORD

Question 22

What are the diagnostic criteria for acute cholecystitis (ultrasound)? (5)

Answer 22

• pericholecystic fluid
• distended GB
• thickened GB wall >3mm
• gallstones
• positive sonographic Murphy’s sign

Question 23

What is the main surgical intervention for acute cholecystitis?

Answer 23

IV Abx + early laparoscopic cholecystectomy within 1 week of diagnosis

Question 24

What supportive management is needed for acute cholecystitis? (4)

Answer 24

• NBM
• IV fluids
• analgesia
• IV Abx

Question 25

How do we manage acute cholecystitis if unfit for surgery?

Answer 25

Percutaneous cholecystectomy - drain fluid from infected GB

Question 26

How do we manage acute cholecystitis if end-organ dysfunction?

Answer 26

- ICU - IV Abx + analgesia + fluids - Abx for suspected sepsis or biliary infection

Question 27

What are some complications of acute cholecystitis? (5)

Answer 27

- **ascending cholangitis** - Mirizzi syndrome - stone in Hartmann's pouch compressing common hepatic duct --> obstructive jaundice - suppurative cholecystitis - WBC infiltration, intra-wall abscesses - cholecystoenteric fistulas/ileus - chronic inflammation + gallstone ileus (SBO) - empyema - pus in GB, strong inflammatory response

Question 28

What is the prognosis like if gallbladder perforates in acute cholecystitis?

Answer 28

30% mortality