CHOLECYSTITIS
I. Definition
Inflammation of the gallbladder, acute or chronic, associated with gallstones (cholelithiasis) in more than 90% of cases
II. Etiology/contributing factors/risk factors
A. Gallstones
1. Become impacted within the cystic duct
2. Inflammation occurs behind the obstruction.
3. Most common form of gallbladder disease
4. Most stones are formed from cholesterol.
B. Acalculous cholecystitis
1. Five percent of cases
2. Should be considered with unexplained fever 2 to 4 weeks after surgery or any stressful situation
a. Multiple trauma
b. Critical illness with a prolonged period of poor oral intake
C. Bacteria/infectious agents, especially in patients with AIDS (cytomegalovirus, Cryptosporidium)
D. Neoplasms (primary or metastatic)
E. Strictures of the common bile duct
F. Ischemia
G. Torsion (twisting of cystic duct)
H. Possible contributing factors:
I. Risk factors:
1. Female
2. Advanced age
3. Rapid weight loss
4. Fad diets
5. High levels of cholesterol
III. Clinical manifestations
A. Can be present for years without causing symptoms. When symptoms do develop, they often present similarly to indigestion (i.e., bloating, gassiness, and abdominal discomfort).
B. A stone may become lodged, causing biliary colic.
1. Sudden onset
2. Intense epigastric or right upper quadrant pain that may radiate to the shoulder or back (infrascapular region)
3. Often associated with a full or fatty meal
C. Nausea and vomiting
1. Occurs in approximately 70% of cases
2. Vomiting offers some relief for many patients.
D. Feeling of abdominal fullness
E. Anorexia (inability to finish an average-sized meal)
F. Dyspepsia
G. Recurrent episodes of biliary colic lasting longer than 12 hours
IV. Physical findings
A. Elevated body temperature
B. Local tenderness that is almost always accompanied by muscle guarding and rebound pain
C. Positive Murphy’s sign (deep pain on inspiration while fingers are placed under the right rib cage)
D. Palpable gallbladder in 5% of cases
E. Jaundice in 20% of cases
F. Right upper quadrant pain, tenderness, guarding, fever, and leukocytosis that continues or progresses after 2 to 3 days indicate severe inflammation and possible gangrene, empyema, or perforation.
V. Laboratory/diagnostics
A. Mild leukocytosis: WBC count, 12,000 to 20,000/microliter
B. Serum bilirubin mildly increased (greater than 4 mg/dl)
C. Increased levels of the following:
1. Alanine transaminase (ALT) (normal, 1 to 35 units/L)
2. Aspartate transaminase (AST) (normal, 0 to 35 units/L)
3. Lactate dehydrogenase (LDH) (normal, 50 to 150 units/L)
4. Alkaline phosphatase (normal, 30 to 120 units/L)
D. Amylase level (normal, 0 to 130 units/L)
E. ECG
1. Normal
2. ECG is important to rule out myocardial infarction as the cause of symptoms.
F. Chest x-ray to rule out pneumonia
G. Flat plate of the abdomen may show radiopaque gallstones (20% of cases).
H. Hepato-iminodiacetic acid (HIDA) scan to visualize cystic duct obstruction. A positive test consists of nonvisualization of the gallbladder after 4 hours. This test is reliable if bilirubin is below 5 mg/dl.
I. Ultrasound: best study for diagnosing gallstones; dilated gallbladder with a thickened gallbladder wall, pericholecystic fluid, and sonographic Murphy’s sign are seen in patients with acute cholecystitis
J. Endoscopic retrograde cholangiopancreatography (ERCP)
1. Can be used to diagnose stones in the gallbladder if noninvasive studies have been found negative
2. Gives information on the status of biliary and pancreatic ducts
VI. Treatment
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A. NPO or low-fat, low-volume meals
B. If NPO, nasogastric tube to low wall suction
C. IV fluids
1. To maintain intravascular volume and electrolytes, 5% dextrose in ½ normal saline (NS), 125 ml/hour
2. Note signs of dehydration, and increase fluids as needed.
a. Tachycardia
b. Hypotension
c. Decreased urinary output
D. Pain can be controlled with antispasmodics (e.g., glycopyrrolate), NSAIDs, and if necessary, opiate analgesics (morphine, hydromorphone [Dilaudid], or meperidine [Demerol]).
E. IV antibiotics: typically, a third-generation cephalosporin (e.g., cefotaxime sodium [Claforan]) with the addition of metronidazole (Flagyl) in severe cases
F. Antispasmodics and antiemetics
G. Surgery consultation: Open cholecystectomy rather than a laparoscopic procedure is recommended for symptomatic cholecystitis because of the higher risk of future complications associated with laparoscopy.
H. ERCP with sphincterectomy and extraction of stones can be performed along with cholecystectomy for patients with a stone in the common bile duct (choledocholithiasis).
I. Gallstones that are primarily composed of cholesterol and are smaller than 2 cm in diameter can be treated by pharmacologic dissolution.
1. Ursodiol/ursodeoxycholic acid (10-15 mg/kg/day) for 12 to 24 months
a. Monitor every 6 months with an ultrasound scan of the gallbladder.
b. Recurrence rate has been found to be high after discontinuation of the medication.
3. Contact dissolution by instillation of methyl tert- butyl ether (MTBE) percutaneously into the gallbladder
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