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cholecystitis

cholecystitis

introduction

  • 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:
  • 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

ED Mx of patient with suspected acute cholecystitis

initial assessment of suspected cholecystitis

  • 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

initial Mx of confirmed acute cholecystitis

  • 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

antibiotics

  • commence iv antibiotics on diagnosis of acute cholecystitis (unlike appendicitis when they are given at induction)
  • dual Rx:
  • triple Rx if severe sepsis and likely biliary source:

Mx of the patient for emergency laparoscopic cholecystectomy

pre-op care

  • 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

post-op care

  • 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

if open cholecystectomy

  • 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.

discharge ready when

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

discharge planning

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

references

  • derived from South Australia's Flinders Medical Centre cholecystectomy guidelines 2009
cholecystitis.txt · Last modified: 2014/04/03 15:54 (external edit)