Biliary Tract: Cholecystitis

Cholecystitis

Basics

  • Cystic Duct Obstruction
  • Initially Sterile Inflammation Until Secondarily Infected
    • Most Common Organism: E. coli

Presentation

  • RUQ Pain
    • Murphy’s Sign – Sudden “Catch” During Inspiration with Gentle RUQ Pressure
    • Boas Sign – Hyperesthesia (Increased Sensitivity) Below the Right Scapula on Back
  • Nausea & Vomiting
  • Fever
  • Leukocytosis

Diagnosis

  • Diagnosis: US 95% Sensitive
  • Labs:
    • Most Sensitive Lab: CCK-Hida
    • LFT’s Normal or Only Slightly Elevated
    • Important to Rule Out Choledocholithiasis During Work-Up

Tokyo Guidelines – Severity Classification

  • Grade I (Mild): No Organ Dysfunction & Limited Disease in Gallbladder
    • Cholecystectomy Low-Risk
  • Grade II (Moderate): No Organ Dysfunction but Extensive Disease in Gallbladder
    • Cholecystectomy May be More Difficult
    • Characterized by Leukocytosis, Palpable-Tender Mass, Duration > 72 Hours & Significant Inflammation on Imaging
  • Grade III (Severe): Organ Dysfunction Present

Treatment

  • General Treatment: Early Cholecystectomy
  • Early (< 72 Hours) vs Late (7-45 Days) Cholecystectomy:
    • Early Has Shorter Length of Stay, Fewer Work Days Lost, Lower Total Costs & Less Wound Infection
    • Similar Complications, Conversion to Open, CBD Injury Rate and Mortality
    • No Benefit to “Cooling Off Period”
  • If Unstable or Unfit for Surgery: Percutaneous Cholecystostomy Tube
    • 90% Effective at Relieving Symptoms
    • Repeat Cholecystogram in 3-6 Weeks
      • Contrast Injected Through Catheter
      • Can Remove Catheter if Cystic Duct Patent
    • Strongly Consider Elective Interval Cholecystectomy

Pregnancy Considerations

  • Surgery Has a Lower Risk of Adverse Pregnancy Outcomes in Acute Cholecystitis Across All Trimesters
    • Greatest Benefit Seen in the Third Trimester
  • *Historically, Nonoperative Management Was Recommended During the First Trimester (Risk of Organogenesis) and Third Trimester (Risk for Preterm Labor) with Percutaneous Cholecystostomy Tube if Fails, However Newer Evidence Recommends Surgery Across All Trimesters

Cholecystitis with Thickened Wall on US 1

Gangrenous Gallbladder at Surgery 2

Emphysematous Cholecystitis

Basics

  • Infection by Gas-Forming Organisms
  • More Common in Diabetics & Elderly Men
  • Often Heralds Development of Gangrene, Perforation or Other Complications
  • Gallbladder Complications
    • 75% are Gangrenous
    • 20% are Perforated
  • Mortality: 25%

Organisms

  • Clostridium perfringens (GPR) – Most Common
  • E. coli – Second Most Common

Treatment

  • Stable: Emergent Cholecystectomy
  • Unstable: Cholecystostomy Tube

CT Showing Emphysematous Cholecystitis 3

Acalculous Cholecystitis

Basics

  • Gallbladder Inflammation Without Stones
  • From Biliary Stasis, Increased Viscosity & Ischemia
  • Often Present in Otherwise Ill Patients

Risk Factors

  • Trauma
  • Burns
  • Surgery
  • AIDS
  • Infection or Sepsis
  • CPR
  • TPN
  • Diabetes
  • Immunosuppression
  • Childbirth

Diagnosis

  • Diagnosis: US
  • If Uncertain: HIDA
    • Morphine Decreases False Positive Rate
    • If Critically Ill: US Sufficient, Do Not Wait for HIDA

Treatment

  • Stable: Cholecystectomy
  • If Unstable or Unfit for Surgery: Percutaneous Cholecystostomy Tube
    • If Fails: Cholecystectomy
    • Delayed Cholecystectomy Not Necessary Once Cholecystitis Resolved & Acute Illness Improves (No Stones)

References

  1. Cwik G, Skoczylas T, Wyroślak-Najs J, Wallner G. The value of percutaneous ultrasound in predicting conversion from laparoscopic to open cholecystectomy due to acute cholecystitis. Surg Endosc. 2013 Jul;27(7):2561-8. (License: CC BY-4.0)
  2. Gomes RM, Mehta NT, Varik V, Doctor NH. No 72-hour pathological boundary for safe early laparoscopic cholecystectomy in acute cholecystitis: a clinicopathological study. Ann Gastroenterol. 2013;26(4):340-345. (License: CC BY-NC-SA-3.0)
  3. Sunnapwar A, Raut AA, Nagar AM, Katre R. Emphysematous cholecystitis: Imaging findings in nine patients. Indian J Radiol Imaging. 2011 Apr;21(2):142-6. (License: CC BY-NC-SA-3.0)