cholecystitis

see also:

• the patient with acute RUQ pain in ED
• biliary colic
• ascending cholangitis
• USC Essentials 2008 conference video - how not to miss the diagnosis of acute cholecystitis - subscription required
• Western Health surgical pathway - cholecystitis

• 90% are due to cholelithiasis (gallstones)
• 10% are acalculous:
  • these patients are generally very unwell hospitalised patients such as post-op or ICU patients, but it may occur in outpatients
  • high morbidity and mortality rates
• emphysematous cholecystitis is caused by secondary infection of the gallbladder wall with gas-forming organisms (such as Clostridium welchii)
  • 50% have gallstones
  • 30-50% are diabetic
  • most are 50-80 yr old men
  • mild to moderate unconjugated hyperbilirubinemia may be present because of haemolysis induced by clostridial infection
• liver function tests (LFTs) should be relatively normal unless there is also:
  • choledocholithiasis or perhaps due to passage of pus or sludge down the CBD
  • ascending cholangitis
  • Mirizzi syndrome - impacted cystic duct stone also presses on CBD
• untreated cases may resolve within 7-10 days but there is a high risk of gangrenous cholecystitis (~20% of untreated cases) which may then perforate (2% of cases) which tends to result in a localised pericholecystic abscess, but also may cause generalised peritonitis

• sensitivity of US ranges from 23-95% depending upon fasting status, operator skill, equipment quality, patient factors but in fasting patients > 6hr fast, with normal body habitus, good equipment and an experienced sonographer, sensitivity should be close to 90%
• The sonographic features used to diagnose acalculous cholecystitis include:
  • Gallbladder Wall Thickening: This is a common finding, with a thickness greater than 3 mm often reported as a diagnostic criterion
  • Pericholecystic Fluid: Fluid around the gallbladder is another key indicator of acalculous cholecystitis
  • Gallbladder Distension: An enlarged gallbladder, often greater than 40 mm in diameter
  • Sonographic Murphy Sign: This is a specific sign where there is pain upon pressing with the ultrasound probe over the gallbladder
  • Wall Edema: Indicated by a striated appearance of the gallbladder wall, suggesting inflammation and oedema.
  • Mucosal Sloughing: This refers to the shedding of the mucosal layer into the gallbladder lumen
  • Intramural Gas: Presence of gas within the gallbladder wall, indicative of emphysematous cholecystitis, a severe form of the disease

• nil orally
• iv 0.9% saline
• fluid balance chart
• iv analgesia as needed
• urinalysis to exclude acute pyelonephritis
• send bloods for FBE, U&E, LFTs, and lipase (and HCG if potentially pregnant)
• contact surgical team ASAP
• biliary ultrasound preferably within 24 hours although not mandatory
  • if US does NOT confirm acute cholecystitis (eg. abnormal gall bladder wall):
    • consider:
      • accuracy of study (sensitivity 90%, specificity 80%)
      • other US findings such as gallstones, duct dilatation, lesion in liver or right kidney
      • if no gallstones or duct dilatation, consider other causes of the patient with acute RUQ pain in ED
      • if gallstones or duct dilatation, surgical team to consider discussion with radiology the need for further imaging such as:
        • nuclear medicine hepatobiliary scan +/- morphine augmentation
        • DIDA scan
        • CT scan

• contact surgical team ASAP
• nil orally
• continue iv fluids (2-3L dextrose/saline per day) and analgesia
• fluid balance chart
• 4hrly obs
• mobilise as tolerated
• DVT prophylaxis as per surgical protocol

• commence iv antibiotics on diagnosis of acute cholecystitis pending your local antibiotic regime (unlike appendicitis when they are given at induction), for example:
• dual Rx:
  • iv ampicillin 1g qid, PLUS
  • iv gentamicin 4-6mg/kg/day with subsequent doses depending upon age, creatinine clearance and serum gentamicin levels
  • if HS penicillins or gentamicin C/I, use iv ceftriaxone 1g daily
• triple Rx if severe sepsis and likely biliary source:
  • iv ampicillin 2g qid, PLUS
  • iv gentamicin 4-6mg/kg/day with subsequent doses depending upon age, creatinine clearance and serum gentamicin levels, PLUS
  • iv metronidazole 500mg bd
  • if immediate HS to penicillins, use iv vancomycin 1g bd adjusted to renal function

• surgical team to obtain consent, book theatre, and review blood results (including coags if on anticoagulants or jaundiced)
• ECG if patient over 50 years
• CXR as clinically indicated
• fast for minimum of 6 hours
• maintain iv therapy and fasting
• 4/24 obs, fluid balance charting
• surgical clipping in theatre
• ensure antibiotics and DVT prophylaxis have been administered as above

• routine post-op obs
• if bile duct exploration then requires overnight stay and repeat LFT's next day
• analgesia to allow mobilisation
• iv fluids until tolerating > 100ml/hr of oral fluids
• commence clear fluids orally as tolerated
• commence free fluids once tolerating clear fluids for 6 hours
• commence diet after tolerating free fluids for 12 hours
• encourage leg exercises and deep breathing to prevent complications
• DVT prophylaxis as per surgical guidelines
• continue iv antibiotics

• care as for lap chole but:
  • initial PCA for analgesia
  • 3-5 day length of stay
  • enoxaparin DVT prophylaxis until discharge
  • wound will require checking and re-dressing
  • provide discharge instructions for open chole.

• tolerating diet
• afebrile for 24 hours
• haemodynamically stable
• bowel function returning to normal

• sick certificate
• provide written and verbal advice
• discharge meds
• outpatient followup

• derived from South Australia's Flinders Medical Centre cholecystectomy guidelines 2009