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Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

Mortality from acute cholecystitis is estimated to be less than 10%. Acute acalculous cholecystitis is a life-threatening condition with a mortality rate of up to 50% and has its own topic.

About

• Gallstones are seen in 10% of the population.
• 90% are asymptomatic and need no action
• A gallstone blocking cystic duct or Hartmann's pouch can cause acute cholecystitis
• Affects 15% of males and 24% of females by age of 70
• Symptoms means needs cholecystectomy usually laparoscopically
• Need to check no other stones in CBD causing biliary obstruction

Aetiology

• Lithogenic bile where there is excess insoluble cholesterol and an insufficient amount of bile acids
• There is almost always the obstruction of the gallbladder neck or cystic duct by a gallstone
• Inflammation is more likely chemical rather than infective at first as in many cases the bile is sterile
• Deficiency of bile salts and phospholipids leads to the formation of cholesterol nucleation and crystal formation
• Black Pigment stones are seen more commonly in the far east and in those with chronic haemolysis
• Infection within the biliary system. Prolonged stasis within the gallbladder may be seen in pregnancy. Ileal dysfunction reduces bile salt reabsorption
• Empyema of the gallbladder is a suppurative infection of the gallbladder, in which the gallbladder fills with infected fluid, eventually leading to pus

Risk factors for Gallstones

• Age > 50, Female, Caucasians, Diabetes
• Obesity, Rapid weight loss
• Terminal ileal disease (e.g. Crohn's disease), Cholestyramine usage
• Pregnancy, Cystic fibrosis

Stones

Clinical

• Gallstones can occur at any age and not necessarily in fair, fat, fertile females of 40
• A history of sudden-onset, constant, severe pain in the upper right quadrant, lasting several hours. Anorexia, nausea, or vomiting.
• Fever and Tenderness in the upper right quadrant
• Murphy's sign may be seen on examination (inspiration is inhibited by pain on palpitation when the examiner's hand is positioned along the costal margin).
• Murphy's sign is positive - pressure on RUQ catches patient on inspiration
• Jaundice if a stone blocks the common bile duct

Investigations

• FBC: Low Hb Haemolytic anaemias which can cause stones.
• WCC elevated and high CRP suggest complications e.g. infection and Acute cholecystitis.
• Mild: Elevated Bilirubin/ALP and GGT. Mild ALT and AST rises may be seen and many suggest stone in CBD which needs MRCP
• Abdominal USS - shows any obstruction or presence of gallstones. Can also show a thickened walled gallbladder. The gallbladder is typically enlarged with a thickened wall, containing stones or debris, in the presence of a sonographic Murphy's sign (pain worsens on the pressure of the probe over the gallbladder). There may also be pericholecystic fluid or abscess.
• Abdominal CT scan with intravenous contrast may be useful in the evaluation of acute biliary tract disease as it can show gallbladder distension, wall thickening, and complications such as abscess and perforation. It can be useful if ultrasound findings are limited by gaseous distension or obesity
• Other investigations which may be used in secondary care in the assessment of acute cholecystitis include radioisotope Chole scintigraphy (Tc-HIDA scan)
• ERCP may be needed for common bile ductal stones
• MRCP - can show stones in the common bile duct

Calot's triangle or the Cystohepatic triangle is the region in the liver bed bounded by the cystic artery, cystic duct and common hepatic duct, all of which must be identified and protected during laparoscopic cholecystectomy.

Complications

Differential

• Peptic ulcer disease, liver disease
• Pancreatitis, and cardiac disease.

Management

• Pain relief and Nil by mouth (NBM) and IV fluids. Analgesia.
• IV Cefuroxime and Metronidazole may be added
• Early Laparoscopic Cholecystectomy is the surgical treatment of choice for acute calculous cholecystitis with surgery or within 5 days of onset of symptoms otherwise, the patient is prone to further episodes.
• Delayed Cholecystectomy may be considered when there are comorbidities. Usually done after 6 weeks.
• ERCP should be performed if there are stones within the common bile duct
• At least 90% of gallstones are symptom-free and cause no problems and do not warrant any action.

References

• Acute cholecystitis at NICE