Cholecystitis Revision Notes

Cholecystitis revision notes

 

Definition

Cholecystitis Defined:

  • Inflammation of gallbladder.
  • Often due to gallstone blockage.
  • Can be acute or chronic.
  • May lead to complications.

 

Cholecystitis Details:

  • Mainly caused by gallstone or, rarely, tumors or parasites.
  • Gallbladder inflammation results from bile duct blockage.
  • Symptoms: RUQ pain, fever.
  • Infection risk higher in elderly and diabetics.
  • Common infectious organisms: Escherichia coli, Klebsiella, Pseudomonas, Enterococcus, and Bacteroides fragilis.

Aetiology

Cholecystitis Causes:

  • Primary Cause: Gallstones obstructing the cystic duct.
  • Other Causes: Bile duct blockage, infection, tumors, or gallbladder trauma.

Risk Factors

Cholecystitis Risk Factors:

  • Demographics: Obesity, female gender, older age.
  • Medical History: History of gallstones, rapid weight loss, fasting, pregnancy, sedentary lifestyle.
  • Medications and Conditions: Certain medications (e.g., hormone replacement therapy), medical conditions (e.g., diabetes, cirrhosis, Crohn’s disease).

Pathophysiology

Cholecystitis Pathophysiology:

  • Bile Flow Blockage: Obstructed cystic duct leads to gallbladder bile buildup.
  • Consequences: Buildup causes inflammation, distension, and potential infection.
  • Progression: Inflammation can worsen cystic duct blockage, potentially leading to gangrene or perforation.
  • Complications: Untreated cholecystitis can result in abscesses, peritonitis, and sepsis.

Differential Diagnosis

Cholecystitis Differential Diagnosis

  • Similar symptoms to biliary colic, acute pancreatitis, peptic ulcer, GORD, appendicitis.

Epidemiology

Epidemiology of Cholecystitis in the UK:

  • Estimated 10-15% of UK adults develop gallstones.
  • Subset may develop cholecystitis.
  • Higher prevalence in women.
  • Incidence increases with age.

Clinical Presentation (Signs and Symptoms)

Clinical Presentation of Cholecystitis:

  • Typical Presentation:
    • Severe right upper abdominal pain, may radiate to back or right shoulder
    • Fever, nausea, vomiting
    • Tenderness over gallbladder area
    • Jaundice if common bile duct is obstructed

 

  • Chronic Cholecystitis:
    • Milder, intermittent symptoms
    • Includes intermittent pain and indigestion

 

Main Clinical Features:

  • Right upper quadrant pain (may refer to right shoulder)
  • Fever, nausea, anorexia
  • Jaundice in up to 10% of cases
  • Palpable mass in up to 30% of cases
  • Vomiting (uncommon as a presenting feature)

 

Additional Presentation Details:

  • Impaction of Stone in Cystic Duct:
    • Continuous epigastric/RUQ pain, vomiting, fever
    • Local peritonism, possible gallbladder mass

 

  • Murphy’s Sign:
    • Positive if pain and cessation of inspiration when gallbladder touches fingers
    • Negative in left upper quadrant

 

  • Repeated Attacks and Chronic Cholecystitis:
    • Thickening, scarring of gallbladder walls
    • Shrinking of gallbladder

Investigations

Investigations for Cholecystitis

  • Basic Observations:
    • Respiratory rate (RR), heart rate (HR), blood pressure (BP), temperature, oxygen saturation.

 

  • Blood Tests:
    • Full Blood Count (FBC): May show leukocytosis.
    • C-Reactive Protein (CRP): May be raised, indicating inflammation.
    • Liver Function Tests (LFTs): May reveal elevated bilirubin, ALT, ALP, and GGT.
    • Amylase/Lipase: To exclude pancreatitis.

 

  • Abdominal Ultrasound (USS):
    • Key imaging modality for cholecystitis.
    • Findings: Gallbladder wall thickening (>3 mm), distended gallbladder, presence of gallstones, may show pericholecystic fluid or air in the gallbladder or its wall.

 

  • Additional Imaging:
    • Abdominal CT: Reserved for cases suspected of sepsis or gallbladder perforation.

 

  • HIDA Cholescintigraphy:
    • May be used to reveal a blocked cystic duct.
    • Typically performed if other imaging is inconclusive.

 

  • Severe Cholecystitis:
    • In severe cases with contaminated obstructed common bile duct (CBD):
      • Symptoms: Pain in the right upper quadrant (RUQ), jaundice, high swinging fevers with rigors and chills (Charcot’s triad).

 

  • Note: Consider acalculous cholecystitis if the gallbladder wall is thickened without the presence of gallstones on ultrasound.

Management

Cholecystitis Management

  • Acute Cholecystitis:
    • Hospitalization and IV antibiotics.
    • Laparoscopic cholecystectomy for definitive treatment.

 

  • Chronic Cholecystitis (mild symptoms):
    • Conservative management: dietary changes, avoid fatty foods.

 

  • Pain management and complications monitoring.

 

Diagnosis and Emergencies:

  • Prescribing Management:
    • Pain: Paracetamol, NSAIDs (ibuprofen), then opioids (morphine).
    • Nausea: Anti-emetic (e.g., cyclizine).
    • Hydration: IV fluids due to nil-by-mouth status.
    • Suspected infection: Administer IV antibiotics as per guidelines.

 

  • Non-Prescribing Management:
    • Maintain nil-by-mouth status to rest gallbladder.
    • Laparoscopic cholecystectomy within a week if possible.
    • Delayed surgery: Wait 6 weeks post-symptom resolution to reduce post-op risks.
    • Unfit for surgery: Consider percutaneous cholecystotomy to drain inflamed gallbladder.

Prognosis

Cholecystitis Prognosis

  • Favourable prognosis with proper treatment.
  • Cholecystectomy provides symptom relief and low recurrence risk.
  • Untreated or severe cases can lead to gangrene, perforation, abscesses, sepsis.

Complications

Cholecystitis Complications:

  • Gallbladder gangrene, perforation, abscess, bile peritonitis, sepsis, and common bile duct stone development.
  • Severe cases may require emergency surgery.
  • Other complications: Mirizzi’s syndrome, acute cholecystitis-related gallbladder perforation, gallbladder empyema.
  • Empyema: Gallbladder filled with pus, managed with laparoscopic cholecystectomy or percutaneous drainage if surgery is not feasible.

References

Oxford Handbook of Clinical Medicine (10th edition)

Kumar and Clarke’s Clinical Medicine (9th ed tion)

https://bestpractice.bmj.com/topics/en-gb/3000084

https://radiopaedia.org/articles/gallbladder-perforation?lang=’gb

NICE (2014) Gallstone disease: Diagnosis and Management. Clinical guideline [CG188]. Available at:  < href=”https://www.nice.org.uk/guidance/cg188″>https://www.nice.org.uk/guidance/cg188

 

 

 

 

 

 

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