Cholecystitis

Inflammation of the gallbladder

Causes/Aetiology/Risk Factors

  • Most common cause is due to gallstones (Cholelithiasis) in the cystic duct.  Around 5% of cases are acalculous and are usually a complication of more severe disease/trauma.
    • e.g. after major surgery; severe trauma; sepsis; unusual infections in the immunocomprimised patient etc
  • Risk factors include age, female sex, obesity, rapid weight loss, pregnancy, Crohn’s disease, hyperlipidaemia, diabetes, family history, certain drugs (oestrogens; ceftriaxone; narcotic withdrawal; anticholinergics etc)

In calculous cholecystitis, obstruction of the cystic duct leads to distention of the gallbladder and bile stasis.  This predisposes the gallbladder to infection by colonic bacteria e.g. E coli and bacteroides and also causes reduced blood flow and lymphatic drainage and subsequent mucosal ischaemia and necrosis.

Presentation

  • History
    • Sudden onset, colicky or constant (early or late, respectively); severe pain in the upper right quadrant
    • May be associated with anorexia, nausea, vomiting, sweating
    • NB Elderly patient may not present with classical features, but may have vague symptoms like nausea and vomiting
    • History of gallstones
  • Examination
    • Low grade fever may be present (a high temperature is uncommon); as may a mild tachycardia
    • Tenderness in the right upper quadrant
      • Murphy’s sign
        • Push your hand up into the right upper quadrant and ask the patient to breathe in.  If this is acutely painful, they are Murphy’s sign positive.
    • Evidence of severe disease/complications include
      • A palpable mass in the RUQ- usually in severe disease due to size of gallbladder
      • Jaundice may or may not be a sign of severity, but may be present in 10-15%

Investigations

  • Blood work
    • FBC- White cells; CRP
    • Serum Amylase (always do this after an ERCP investigation- to assess any damage to the pancreas)
    • LFTs- Alk Phos is an indirect marker of cholestasis (often raised in disease of the biliary tree); bilirubin may also be raised in patients with cholecystitis.  ALT/AST is usually normal (more a marker of liver disease) but may be elevated if stones have blocked the common bile duct.
  • Ultrasound of the gallbladder is usually the first mode of imaging used.  CT may also be used but more likely to be second line either if stones were not seen on USS or if surgery is thought to be required.
  • MRCP is the gold-standard for imaging the bile duct and identifying stones/inflammation
  • Endoscopic Retrograde Cholangiopancreatography (ERCP)- This is a very useful investigation because you are able to stent the bile ducts to help relieve some of the symptoms.

Management

  • Admit someone with suspected acute cholecystitis for confirmation of the diagnosis; monitoring; treatment (see below) and surgical assessment
    • NB The patient will not require admission if they are not acutely unwell.  For gallstones without cholecystitis (either with mild intermittent symptoms or completely asymptomatic), patients should be routinely referred to GI/Hepatology.
  • IV fluids should be given if required
  • Antibiotic treatment of IV Amoxicillin and Metronidazole (according to NHS Tayside formulary) can be given to patients with acute disease who have severe symptoms
  • Analgesia should be given
    • NSAIDs can be good (NB BEWARE of misdiagnosis of peptic ulcer where these are contraindicated)
    • If pain is severe, pethidine IM may be considered (according to NICE)
  • Ultimately, cholecystectomy is definitive treatment.
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