History

Fact Explanation
Sudden onset pain [1] Is the commonest and most distressing symptom. May develop even without preceding features of dyspepsia. Felt in the right hypochondrium and often radiates by encirclement to the tip of the right scapula. The pain is severe, continuous and lasts up to 6 hours. Exacerbated by breathing and movement. [1] The pain occurs due to obstruction of the gallbladder at the cystic duct by a gallstone. This leads to distention of the gallbladder, subsequently impeding the vascular and lymphatic pathways. Leading to mucosal ischemia and necrosis, that stimulate nociceptive fibers to cause pain. The inspissisated bile becomes secondarily infected by gram negative bacteria such as E.coli, Klebsiella and Enterococci. As the inflammation spreads to the peritoneum the pain becomes sharper and more localized.
Nausea [2] May precede an attack of acute cholecystitis or even be associated with a high-fat meal in patients with gallstones. When occurring during an acute attack it is due to the severe pain.
Vomiting [2] Is a fairly constant symptom. Occurs due to the severe pain that occurs as a result of inflammation. [3], [4]
Belching [2] An isolated symptom of the spectrum of 'flatulent dyspepsia' that often plague patients with gallstones. Often dyspeptic symptoms precede and worsen during an attack of acute cholecystitis. Dyspeptic symptoms may be the only complaint in chronic cholecystitis. [4]
Fever [2] Pyrexia occurs as inspissated bile becomes infected with bacterial pathogens. However a high swinging fever should raise the possibility of abscess formation, cholangitis or perforation. [5]
Jaundice [2] One third of patients with cholecystitis will be jaundiced. [6] This could be due to either Mirizzi's Syndrome or choledocholithiasis. [5]
Risk factors for gallstone formation Obese individuals are at risk of gallstones due to high dietary cholesterol intake, with over 90 percent of stones being mixed cholesterol stones. Past medical or family history of a hemolytic disease is significant in the formation of pigment stones. Fertile, females, in their fifth decade are also at risk of gallstone as estrogen causes stasis of bile, that predisposes to stone formation. [1],[3]
Complications of gallstone diease Previous episodes of biliary colic, gallstone pancreatitis, gallstone ileus and obstructive jaundice are pointers to the diagnosis of acute calculous cholecystitis. [1],[2],[3]
References
  1. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG ed. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th Edition. London. Hodder Arnold. 2005.
  2. MCCLAIN Alan, Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery. 16th edition. Bristol. John Wright and Sons. 1980.
  3. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher JK ed. Bailey and Love's Short Practice of Surgery. 23rd edition. London. Hodder Arnold. 2000.
  4. McEACHEM JD, Diagnosis of Chronic Cholecystitis. Can Med Assoc J. [Online] Aug 1921; 11(8): 516–519. [Viewed 19 April 2014]. Available from: PMCID: PMC1524295
  5. YUSOFF Ian F, BARKUN Jeffrey S, BARKUN Alan N. Diagnosis and management of cholecystitis and cholangitis. Gastroenterol Clin N Am [Online] 32 (2003) 1145–1168. [viewed 19 April 2014]. Available from: http://www.docunator.com/bigdata/2/1365618503_84094a731f/gastroclinnacholecystitisandcholangitis.pdf
  6. FISH Jay C, WILLIAMS Drew D, WILLIAMS Roger D. Jaundice With Cholecystitis. Arch Surg. [Online] 1968;96(6):875-877.[viewed 19 April 2014] Available from: doi:10.1001/archsurg.1968.01330240021005

Examination

Fact Explanation
Appears ill, febrile and tachycardic [1] The patient is often distressed by the severe pain and is extremely toxic in an attack of acute cholecystitis. Pyrexia and tachycardia can be attributed to the secondary bacterial infection of the inspissated bile. [2]
Jaundice [1] Affects one third of patients with cholecystitis. Obstructive jaundice may manifest with pale stools and dark urine. Jaundice occurs due to extra hepatic impaction of a gallstone causing Mirizzi's syndrome, choledocholithiasis or super added acute cholangitis. [1],[2],[3]
Zackary Cope Sign [1] On inspection there may be fullness of the right hypochondrium. This is seen in the early stages of inflammation, occurs due to the impaction of a gallstone in the cystic duct or Hartmann's pouch. [1],[4],[5]
Murphy's Sign [1] Elicited by palpation of the abdomen, just below the ninth costal cartilage. When the patients inhales, the gallbladder descends and strikes the examiner's thumb causing a sharp pain that halts further inspiration. [1] This sign has a sensitivity of 97% and is highly predictive at 93%, for the diagnosis of cholecystitis. [6]
Boas Sign [1] As gallbladder pain radiates circumferentially to the tip of the scapula, the affected dermatome is hyper aesthetic, this can be detected by lightly drawing a pin across the back of the patients chest. [1],[4]
Palpable gallbladder [1] Usually presents in a later stage. When the inflammation has bee present for several days and the tenderness begins to subside, a tender mass may be palpable. This usually indicates the possibility of an empyema or abscess. [1]
Absent bowel sounds [1] Absent bowel sounds are a sinister sign, as it indicates a perforated gallbladder causing biliary peritonitis. [1]
References
  1. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG ed. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th Edition. London. Hodder Arnold. 2005.
  2. YUSOFF Ian F, BARKUN Jeffrey S, BARKUN Alan N. Diagnosis and management of cholecystitis and cholangitis. Gastroenterol Clin N Am [Online] 32 (2003) 1145–1168. [viewed 19 April 2014]. Available from: http://www.docunator.com/bigdata/2/1365618503_84094a731f/gastroclinnacholecystitisandcholangitis.pdf
  3. WARNER Clinton, DENSLER James, WARNER Warner,GODWIN John. Can Acute Cholecystitis Produce Obstructive Jaundice in the Absence of Choledocholithiasis? J Natl Med Assoc.[Online] Oct 1986; 78(10): 993–994. [Viewed 19 April 2014]. Available from: PMCID: PMC2571484
  4. MCCLAIN Alan, Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery. 16th edition. Bristol. John Wright and Sons. 1980.
  5. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher JK ed. Bailey and Love's Short Practice of Surgery. 23rd edition. London. Hodder Arnold. 2000.
  6. MUSANA Kenneth, YALE Steven H. John Benjamin Murphy (1857 – 1916). Clinical Medicine & Research [Online] May 1, 2005 vol. 3 no. 2 110-112 [viewed 19 April 2014]. Available from: doi: 10.3121/cmr.3.2.110

Differential Diagnoses

Fact Explanation
Biliary colic Biliary colic is caused by severe spasm of the gallbladder as it tries to force a gallstone down the cystic duct. It is considered to be an atypical colic as the pain does not remit between exacerbations. Differentiating features are: patient is aferbrile,less toxic and the pain abates in a few hours. [1]
Cholangitis Classically described Charcot's triad of ascending cholangitis: jaundice, high spiking fever and right upper quadrant pain. Occurs in a setting of bile stasis due to gallstones,stricture or tumor. [1],[2]
Acute pancreatitis Presents with sudden onset pain often precipitated by a bout of heavy drinking, pain radiates directly through the body to the back; is relieved by bending forwards and strong opoid analgesics. [1],[3],[4]
Cholelithiasis Asymptomatic gallstones are a common feature it occurs due to precipitation of supersaturated bile and the concomitant crystallization of cholesterol or calcium bilirubinate into stone material. Most patients with gallstones are asymptomatic, others will complain of a spectrum of symptoms classified as 'flatulent dyspepsia.' [3],[5]
Mucocele of the gallbladder Presents with right upper quadrant discomfort and associated nausea and vomiting. There will be an obvious palpable mass, with minimal inflammatory signs. [3]
Hydrops gallbladder Hydrops gallbladdder may be congenital,[6] or acquired due to other medical diseases such as Kawasaki or Dengue Fever. This can be differentiated from cholecystitis on Ultrasound imaging.
References
  1. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG ed. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th Edition. London. Hodder Arnold. 2005.
  2. WADA Keita, TAKADA Tadahiro, KIM Myung-Hwan. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg.[Online] Jan 2007; 14(1): 52–58. [Viewed 19 April 2014]. Available from: doi: 10.1007/s00534-006-1156-7
  3. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher JK ed. Bailey and Love's Short Practice of Surgery. 23rd edition. London. Hodder Arnold. 2000.
  4. YOUNG Simon P, THOMPSON Jonathan P. Severe acute pancreatitis. Contin Educ Anaesth Crit Care Pain [Online] (2008) 8 (4): 125-128.[Viewed 19 April 2014]. Available from: doi: 10.1093/bjaceaccp/mkn020
  5. SIEGEL Jerome H, KASMIN Franklin E. Biliary tract diseases in the elderly: management and outcomes. Gut [Online} 1997;41:433-435 [Viewed on 19 April 2014] Available from: doi:10.1136/gut.41.4.433
  6. ZHONG Liang, CHEN Ping, WANG Lei, HE Chunlan et al. A case of congenital giant gallbladder with massive hydrops mimicking celiac cyst. Oncology Letters Oncology Letters 5.1[Online] (2013): 226-228. [Viewed 19 April 2014]. Available from: DOI: 10.3892/ol.2012.1010

Investigations - for Diagnosis

Fact Explanation
Full blood count [1] Can observe a neutrophilic leukocytosis with a sharp left shift. This occurs due to the secondary bacterial infection of the inspissated bile. [2]
Serum aspartate aminotransferase [1] Is used to evaluate the presence of hepatitis, and may even be mildly elevated in isolated cholecystitis and common bile duct obstruction. [1]
Serum alanine aminotransferase [1] Is used to evaluate the presence of hepatitis, and may even be mildly elevated in isolated cholecystitis and common bile duct obstruction. [1]
Serum bilirubin [1] Obstruction in common hepatic duct or bile duct causes hyperbilirubinemia. [1]
Alkaline phosphatase [1] Is elevated in acute calculous cholecystitis, may even herald a common bile duct stone. [3]
Ultrasound scan [1] Is the investigation of choice in patient suspected to have acute cholecystitis. Will demonstrate pericholecystic fluid, distended gallbladder with an edematous wall and gall stones. In addition it is possible to elicit Murphy's sign during ultrasound examination(sonographic Murphy's), this increases sensitivity of the sign, as direct visualization of the gallbladder is possible. [1],[2],[4],[5]
Endoscopic retrograde cholangio pancreaticography (ERCP) [1] Useful in visualizing the common bile duct in patients with high risk of stones, if common bile duct obstruction is present.
Hepatobiliary scintigraphy Biliary scintigraphy (HIDA scan) is the gold standard investigation if the diagnosis remains in doubt after ultrasound scanning. [2]
Computed tomography (CT) CT used if obesity or gaseous distention limits the use of ultrasonography. Gallbladder wall thickening, pericholecystic fluid, subserosal edema and intramural gas are suggestive of the diagnosis.
Magnetic Resonance Imaging (MRI) An alternative to CT if Ultrasonography is inconclusive; may demonstrate the same morphologic changes as CT scanning.
References
  1. WALLING Anne D. Diagnosing Biliary Colic and Acute Cholecystitis. Am Fam Physician. [Online] 2000 Sep 15;62(6):1386-1388. [Viewed 19 April 2014]. Available from: http://www.aafp.org/afp/2000/0915/p1386.html
  2. INDAR Adrian A, BECKINGHAM Ian J. Acute cholecystitis. BMJ. [Online] Sep 21, 2002; 325(7365): 639–643. [Viewed 19 April 2014]. Available from: PMCID: PMC1124163
  3. THAPA PB, MAHARAJAN DK, SUWAL B, BYANJANKAR B, SINGH DR. Serum gamma glutamyl transferase and alkaline phosphatase in acute cholecystitis.J Nepal Health Res Counc. [Online] 2010 Oct;8(2):78-81.[Viewed 19 April 2014]. Available from: PMID: 21876567RUSSELL
  4. RCG, WILLIAMS Norman S, BULSTRODE Christopher JK ed. Bailey and Love's Short Practice of Surgery. 23rd edition. London. Hodder Arnold. 2000.
  5. YUSOFF Ian F, BARKUN Jeffrey S, BARKUN Alan N. Diagnosis and management of cholecystitis and cholangitis. Gastroenterol Clin N Am [Online] 32 (2003) 1145–1168. [viewed 19 April 2014]. Available from: http://www.docunator.com/bigdata/2/1365618503_84094a731f/gastroclinnacholecystitisandcholangitis.pdf

Investigations - Fitness for Management

Fact Explanation
Ultrasound scan [1] To exclude the presence of common bile duct stones, in patients with features that are suggestive: obstructive jaundice. If not identified and treated may cause a post-cholecystectomy cystic duct leak. (stump blow-out). [1],[2]
Endoscopic retrograde cholangio pancreaticography (ERCP) [1] Has both diagnostic and therapeutic value in the presence of common bile duct stones. Such stones should be removed prior to or during cholecystectomy to avoid a post-cholecystectomy cystic duct leak. (stump blow-out). [1],[2]
Assessment of fitness for general anesthesia Open, laparoscopic cholecystectomy are performed under general anesthesia, therefore fitness for general anesthesia should be established. This should include : Electrocardiogram (ECG), baseline renal functions, chest X ray and venous plasma glucose. [2],[3]
References
  1. SHAIKH I, THIMAS H, JOGAK, AMIN AI, DANIEL T. Post-cholecystectomy cystic duct stump leak: a preventable morbidity. J Dig Dis. [Online] 2009 Aug;10(3):207-12.[viewed 19 April 2014] Available from: doi: 10.1111/j.1751-2980.2009.00387.x.
  2. RCG, WILLIAMS Norman S, BULSTRODE Christopher JK ed. Bailey and Love's Short Practice of Surgery. 23rd edition. London. Hodder Arnold. 2000.
  3. KUMAR Aditya, SRIVASTAVA Uma. Role of routine laboratory investigations in preoperative evaluation. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol [Online] 2011;27:174-9. [Viewed 19 April 2014]. Available from: doi: 10.4103/0970-9185.81824.

Management - General Measures

Fact Explanation
Conservative management Most patients respond to conservative management. During this period the gall stone falls back into the gall bladder allowing the cystic duct to empty. Measures to rest the gallbladder should be instituted: nil oral regime, intravenous fluid resuscitation and adequate analgesia. [1]
Analgesia Can be provided with NSAIDS or opioids. Indometacin can reverse the inflammation and the prokinetic action of indometacin will also improve postprandial emptying of the gall bladder in patients with gallbladder disease. [1]
Intravenous antibiotics Started empirically due to the risk of bacterial infection. A second generation or newer (Cefuroxime) cephalosporin should be used with metronidazole, since commonly encountered organisms are gram negative. [1],[2]
References
  1. INDAR Adrian A, BECKINGHAM Ian J. Acute cholecystitis. BMJ. [Online] Sep 21, 2002; 325(7365): 639–643. [Viewed 19 April 2014]. Available from: PMCID: PMC1124163
  2. YUSOFF Ian F, BARKUN Jeffrey S, BARKUN Alan N. Diagnosis and management of cholecystitis and cholangitis. Gastroenterol Clin N Am [Online] 32 (2003) 1145–1168. [viewed 19 April 2014]. Available from: http://www.docunator.com/bigdata/2/1365618503_84094a731f/gastroclinnacholecystitisandcholangitis.pdf

Management - Specific Treatments

Fact Explanation
Emergency surgery [1] About 20% of patients require emergency surgery. It is indicated if the patient deteriorates and when generalized peritonitis or emphysematous cholecystitis is present as these are suggestive of gangrene/perforation of the gall bladder. [1],[2]
Open cholecystectomy [1] Open cholecystectomy traditionally has been performed 6-12 weeks after the acute episode to allow the inflammatory process to resolve. [1],[3]
Laparoscopic cholecystectomy [1] Early laparoscopic cholecystectomy within (72-96 hours of symptoms) have lower complication rates and conversion rates, in addition to shorter hospital stays, early intervention 'edema planes' allow the gall bladder to be dissected laparoscopically. If inflammation has been present for more than 72 hours, features of chronic inflammation (such as fibrosis) predominate and make it more difficult to dissect the gall bladder. Thus, optimal treatment should be initial resuscitation, followed by laparoscopic cholecystectomy on the next surgical list. [1],[2],[3]
Percutaneous cholecystostomy [1] Percutaneous cholecystostomy is a minimally invasive procedure that can be performed at the bedside under local anesthesia. It is suitable for patients with multiple co morbidities and are thus, poor candidates for general anesthesia. [1],[4],[5]
Non operative management [1] Solvent dissolution therapy or extracorporeal shockwave lithotripsy is used in chronic cholecystitis for patients unfit for surgery. However it has no place in the management of acute cholecystitis. [1],[4]
References
  1. INDAR Adrian A, BECKINGHAM Ian J. Acute cholecystitis. BMJ. [Online] Sep 21, 2002; 325(7365): 639–643. [Viewed 19 April 2014]. Available from: PMCID: PMC1124163
  2. FERRARESE AG, SOLEJ M, ENRICO S, FALCONE A et al. Elective and emergency laparoscopic cholecystectomy in the elderly: our experience. BMC Surg. [Online] 2013;13 Suppl 2:S21. [viewed 19 April 2014] Available from: doi: 10.1186/1471-2482-13-S2-S21.
  3. DIAZ GOMEZ D, PARRA MEMBRIVES P, VILLEGAS-PORTERO R, MOLINA-LINDE M et al. Analysis of the most appropriate surgical treatment for acute cholecystitis by applying the RAND/UCLA method. Cir Esp. [Online] 2012 Aug-Sep;90(7):453-9. [viewed 19 April 2014] Available from: PMID: 22771292
  4. RCG, WILLIAMS Norman S, BULSTRODE Christopher JK ed. Bailey and Love's Short Practice of Surgery. 23rd edition. London. Hodder Arnold. 2000.
  5. KUMAR Aditya, SRIVASTAVA Uma. Role of routine laboratory investigations in preoperative evaluation. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol [Online] 2011;27:174-9. [Viewed 19 April 2014]. Available from: doi: 10.4103/0970-9185.81824.