Acute Cholecystitis

Author: Learning in 10

Today, we are presenting a VAP on acute cholecystitis. Acute cholecystitis is a common surgical condition. It is important to understand the pathophysiology and recognize the constellation of clinical findings that are associated with this condition. This lecture will emphasize on the technical aspects of acute cholecystitis, with a brief introduction to the management options that may be considered.

I will first define acute cholecystitis, then discuss the pathogenesis of this condition and its complications. A more detailed discussion of its clinical presentation and physical findings, followed by appropriate investigations will be undertaken. Finally, management options will be briefly introduced. Acute cholecystitis is inflammation of the gallbladder, resulting in a clinical syndrome of right upper quadrant pain, fever, and leukocytosis and is a common complication of cholelithiasis.

Most patients with gallstones are asymptomatic. Biliary colic develops in about 1% to 4% annually. And acute cholecystitis eventually develops in about 20% of these symptomatic patients if they are left untreated. Acute cholecystitis may also occur in the absence of underlying gallstone disease.

But these make up a minority of the cases. This usually occurs in patients who are very ill, such as those in the intensive care unit, who have severe sepsis or are on long-term total parenteral nutrition. These patients may be too ill to communicate a history of symptoms. But physical examination may reveal fever and right upper quadrant tenderness. More than 90% of cases of acute cholecystitis are associated with cholelithiasis.

Acute Cholecystitis

The key elements and pathogenesis seem to be an obstruction of the cystic duct in the presence of bile supersaturated with cholesterol. Brief impaction may cause pain only. But if impaction is prolonged over many hours, inflammation can result.

With inflammation, the gallblader becomes enlarged and tense. Wall thickening and a pericholecystic fluid exudate may develop. The inflammation is usually sterile. But in most cases, secondary infection eventually occurs with organisms such as Enterobactericiae, enterococci, or anaerobes. The wall of the gallbladder may undergo necrosis and become gangrenous.

Bacterial superinfection with gas-forming organisms may lead to gas in the wall of the gallblader, a severe form of cholecystitis known as emphysematous cholecystitis. Without appropriate treatment, the gallbladder may perforate and result in the development of an abscess in the vicinity of the gallbladder or, less commonly, generalized peritonitis, which constitutes a surgical emergency. The most common complication of acute cholecystitis is the development of gallbladder gangrene, which may occur in up to 20% of the cases, resulting in subsequent perforation. Gangrenous cholecystitis occurs particularly in elderly or diabetic patients, and also those who seek treatment late. Perforation usually results in a pericholecystic abscess or, less commonly, generalized peritonitis. This carries a high risk of mortality and is a surgical emergency. Secondary infection with gas-forming bacteria, such as clostridium, result in emphysematous cholecystitis.

Other associated organisms are as listed in the slide. Patients with acute cholecystitis typically complain of abdominal pain, most commonly in the right upper quadrant or epigastrium. The pain may radiate to the right shoulder or back. Characteristically, acute cholecystitis pain is steady and severe. Associated complaints may include nausea, vomiting, and anorexia.

There is often a history of fatty food ingestion, about one hour or more before the initial onset of pain. An episode of prolonged right upper quadrant pain, greater than four to six hours, especially if associated with fever, should arouse suspicion for acute cholecystitis as opposed to an attack of simple biliary colic. Patients with acute cholecystitis may be ill, febrile, and tachycardic, especially in cases of gangrenous or emphysematous cholecystitis. Abdominal examination demonstrates tenderness in the right upper quadrant, with guarding. The patient usually lies still on the examining table because cholecystitis is associated with true local parietal peritoneal inflammation that is aggravated by movement.

Elicitation of Murphy's sign is a useful diagnostic maneuver. While palpating the area of the gallblader fossa just beneath the liver edge, the patient is asked to inspire deeply, causing the gallblader to descend towards the examining fingers. This causes the patient discomfort. And is classically described as a positive Murphy's sign, when there is an abrupt inspiratory arrest due to the pain.

The sensitivity of Murphy's sign may be diminished in the elderly. Initial investigations should include a full blood count, which would demonstrate leukocytosis with left shift, in keeping with an acute infection. Other inflammatory markers, such as C-reactive protein, may be elevated. Mild derangements in liver function tests may be due to a passed stone or sludge in the biliary tract.

Bilirubin is usually not raised in acute cholecystitis as the obstruction is limited to the gallbladder. Raised bilirubin or alkaline phosphatase should raise concerns of complicating conditions, such as cholangitis, choledocholithiasis, perforation, or, less commonly, Mirizzi's syndrome, where a gallstone impacted in the distal cystic duct causes extrinsic compression of the common bowel duct. Patients presenting with clinical features suggestive of acute cholecystitis should undergo imaging tests to confirm the diagnosis. Ultrasonography is usually the first test of choice and can often establish a diagnosis. Ultrasonography detects gallstones in about 98% of patients. The presence of stones in the gallbladder, in the clinical setting of right upper quadrant pain and fever, supports the diagnosis, but is not diagnostic.

Additional sonographic features include gallbladder wall thickening, more than four to five millimeters or edema. Ultrasonographic Murphy's sign may also be elicited, which is similar to that elicited during abdominal palpation, except that the examining hand is now replaced by the ultrasound transducer. CT scans are used commonly for the diagnosis of cholecystitis, for its practical convenience as an imaging modality. It easily demonstrates gallbladder wall edema, with acute cholecystitis and other findings, such as pericholecystic stranding and fluid. It is particularly useful when one is suspecting complications of acute cholecystitis, such as emphysematous cholecystitis or a gallbladder perforation. A CT scan will also help to rule out other conditions which may present with similar signs and symptoms. General management for a patient with acute cholecystitis includes intravenous fluids, intravenous antibiotics, and analgesia. Antibiotic therapy should be instituted if infection is suspected on the basis of clinical and laboratory findings.

This should include coverage against microorganisms in the Enterobactericiae family, such as a second generation cephalosporin or a combination of quinolone and metronidazole. Lab cultures should be taken prior to commencement of antibiotics. And gall cultures should be taken at the time of surgery to find an antibiotic choice in the post-operative period, particularly if aseptic complications should arise. Cholecystectomy may be performed by the open method, which employs a cautious incision, or by laparoscopy, which is the current gold standard of treatment. Timing of surgery may be early, during the initial admission, or after the acute episode has settled, which is known as an interval cholecystectomy.

Recent studies have shown that early treatment has been associated with a shorter overall hospitalization, compared to interval cholecystectomy. And that there is no significant difference between the groups in terms of morbidity, mortality, or rates of conversion to open surgery. Percutaneous cholecystostomy can be performed under local anesthesia with videological guidance and is often considered as a treatment option in cases of severe sepsis or when conservative treatment fails and the patient is a poor candidate for surgery. This allows for decompression of the gallbladder, with a low complication rate. Drainage may be followed by delayed cholecystostomy or percutaneous stone extraction in patients who are poor surgical candidates. In summary, acute cholecystitis is a common surgical condition, which is easily recognizable by its constellation of clinical and laboratory features. This diagnosis is also readily confirmed on simple imaging studies, such as ultrasonography A high index of suspicion and prompt institution of treatment in the acute setting is essential for the optimal management of these patients.

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