This issue of eMedRef provides information to clinicians on the pathophysiology, diagnosis, and therapeutics of cholecystitis

Kaapuraala, Abhishake

University of Missouri: MOspace

Biliary Infections:  Cholecystitis Page 1 of 6    9.9.09 Biliary Infections: Cholecystitis Background 1. Definitions  o Acute cholecystitis   Clinical syndrome of RUQ pain, fever and leukocytosis due to gallbladder inflammation   Usually caused by gallstones in cystic duct o Acalculous cholecystitis   Associated with biliary stasis from burns, major surgery or sepsis  Gallbladder inflammation without gallstones   Usually in critically ill patients, carries high morbidity and mortality o Ascending cholangitis   Bile duct bacterial infection caused by biliary flow obstruction  Usually due to choledocholithiasis (common duct stones)   Pathophysiology 1. Pathology  o Acute cholecystitis   95% of cases due to gallstones or biliary sludge obstructing cystic duct7,8,9   Prolonged obstruction, cholesterol-supersaturated bile and gallstone-induced trauma trigger acute gallbladder wall inflammatory response and edema mediated by PGE2 & 6-keto PGF1 alpha  Gallbladder dysmotility develops, distention and increased intraluminal pressure compromise blood flow to the mucosa  Bacterial contamination may develop as a late sequelae (E. coli most common) o Acalculous cholecystitis   Stasis and obstruction in setting of stress, trauma, shock, TPN   Believed to be from direct ischemic compromise of gallbladder 2. Incidence, prevalence  o 10% of people in Western society o 80% asymptomatic o 1-3% of patients with symptomatic gallstones develop acute cholecystitis 3. Risk factors  o Gallstone risk factors   Obesity, rapid weight loss, childbearing, meds, postmenopausal estrogens, increasing age, hereditary o Biliary colic   30% of patients with biliary colic develop acute cholecystitis within 2 years o Acalculous cholecystitis   Severe illness   Sepsis, major surgery, severe burns, multisystem organ failure, prolonged TPN, sickle cell disease, Salmonella infection  Elderly patients   Likely an ischemic process, similar risk factors as atherosclerosis Biliary Infections:  Cholecystitis Page 2 of 6    9.9.09 o Gender   <50 yo   3x more common in women  >50 yo   Equal risk for both genders 4. Morbidity/mortality  o Spontaneous resolution in 7-10 days if untreated in majority o Complications   Gallbladder gangrene (20% of untreated)  Perforation of gallbladder (2% of untreated)   Occurs after gangrene  Usually localized with pericholecystic abscess  Less commonly into peritoneum leading to generalized peritonitis  Cholecystoenteric fistula   Perforation of gallbladder into duodenum or jejunum  Gallstone ileus   Passage of gallstone through cholecystoenteric fistula leading to mechanical small bowel obstruction  Emphysematous cholecystitis   Secondary infection with gas-forming organisms like Clostridia perfringens, E. coli, staph, strep, klebsiella and pseudomonas  30% cases are diabetics  Heralds the development of gangrene, perforation, and other complications  Diagnostics 1. History/symptoms  o RUQ/epigastric pain   Constant, severe, radiating to back/R shoulder, lasting > 3 hr o Fatty food ingestion >1 hr before onset of pain o Fever o Malaise o Anorexia o Nausea, vomiting 2. Physical exam  o Febrile, tachycardia o Patients may lie motionless   Movement aggravates pain o Guarding   Voluntary and involuntary o Palpable gallbladder in 30-40% o Jaundice in 15% o + Murphy's sign   Severe RUQ pain with inspiration   Biliary Infections:  Cholecystitis Page 3 of 6    9.9.09 3. Diagnostic tests  o Laboratory evaluation   Leukocytosis with left shift  If total bilirubin and alk phos elevated, possible cholangitis or gallstone in common bile duct (choledocholithiasis) o Diagnostic imaging (SOR:B)  Ultrasound is first choice imaging modality   81-100% sensitivity and 60-100% specificity in detecting acute cholecystitis   84% sensitivity and 99% specificity in detecting gallstones >2 mm  Findings include distended gallbladder with pericholecystic fluid, gallbladder wall edema (>4 mm), presence of gallstones, positive sonographic Murphy's sign  HIDA scan   Gold standard   Does have problems with acalculous cholecystitis and cannot view pericholecystic structures  Indicated if ultrasound nondiagnostic  97% sensitivity and 90% specificity in detecting cystic duct obstruction   Positive test shows absence of radiolabeled substance filling the gallbladder due to cystic duct obstruction, usually from edema of acute cholecystitis or obstructive stone o Abdominal CT   Usually unnecessary given above modalities  More sensitive and specific than US  Findings include gallbladder wall edema, pericholecystic stranding and fluid, and high attenuation bile  Useful to rule out complications   Gallbladder perforation  Emphysematous cholecystitis o Plain abdominal radiographs   Radiopaque gallstones in 10% of cases  Gas within gallbladder wall in emphysematous cholecystitis usually from E.coli or Clostridium  Differential Diagnosis 1. Key DDx  o Biliary colic   Transient obstruction of cystic duct, pain subsides after <3 hrs and patient feels well, usually afebrile o Choledocholithiasis   Obstruction of the common bile duct by a stone  Pain, jaundice, LFT elevations o Ascending cholangitis  Biliary Infections:  Cholecystitis Page 4 of 6    9.9.09  Acute obstruction of biliary tree causing infection and inflammation; patients appear toxic, fevers and chills, jaundice, leukocytosis, elevated alk phos and total bilirubin o Chronic cholecystitis   Chronic inflammation after recurrent acute cholecystitis, thickened gallbladder, long-standing postprandial discomfort o Hepatitis   Jaundice, fever, + hepatitis serologies 2. Extensive DDx  o Other GI causes of abdominal pain   PUD, gastritis, pancreatitis, infectious colitis, diverticulitis, IBD, SBO, appendicitis, DKA gastroenteritis  Spontaneous bacterial peritonitis, amoebic hepatic abscess o Non-GI causes of abdominal pain   MI, intestinal ischemia, renal colic, pyelonephritis, PID, right lower lobe  Acute Treatment (SOR:B) 1. Admit to hospital 2. Conservative treatment for 24-48 hr then cholecystectomy  3. NPO, NG tube if vomiting 4. IV hydration, correct electrolyte abnormalities 5. Analgesia  o Ketorolac 30-60 mg IM (adjusted for age and renal function) o IV narcotic analgesia may be required 6. Antibiotics  o Benefit unclear o Cover enterococcus, anaerobes and gram-negatives  o Administer if   Systemic signs: fever, tachycardia, hypotension  No improvement after 12 hr conservative tx o Ampicillin 2 g IV q4hr plus gentamicin (dosed by weight and renal function)  o Piperacillin/tazobactam 3.375 g IV q6 or 4.5g IV q8hr o Ampicillin sulbactam 3 g IV q6hr o Ticarcillin clavulanate 3.1 g IV q6hr o 3rd gen cephalosporin   Ceftriaxone 1 g IV q24hr + metronidazole 500 mg IV q8hr o Fluoroquinolones   Ciprofloxacin 400 mg IV q12hr / levofloxacin 500 mg IV q24hr AND metronidazole 500 mg IV q8hr o If life-threatening, imipenem 0.5 g IV q6hr or meropenem 1 g IV q8hr or ertapenem 1 g q24hr 7. Immediate cholecystectomy  o If patient appears toxic, or gangrene or perforation suspected    Biliary Infections:  Cholecystitis Page 5 of 6    9.9.09 Further Management (SOR:C) 1. Low surgical risk patients  o 24-48 hr supportive care followed by laparoscopic cholecystectomy  o Early lap chole has some surgical risk as late lap chole, but lower cost and lower morbidity by reducing recurrent Sx/readmission 2. High surgical risk patients  o Severe cardiovascular or pulmonary disease, or patients with sepsis o Conservative management  o If fail to improve   Percutaneous cholecystostomy to drain gallbladder plus continued antibiotics  Once inflammation resolved, elective cholecystectomy  If not surgical candidates   Gallstone dissolution therapy with ursodiol via cholecystostomy catheter 3. Contraindications for laparoscopic cholecystectomy  o Cirrhosis, coagulopathy, pancreatitis, pregnancy, morbid obesity, severe cardiorespiratory insufficiency, signs of gallbladder perforation  Prognosis (SOR:B) 1. Mortality for single episode of acute cholecystitis is 3%  o <1% mortality in young, otherwise healthy patients o 10% mortality in high-risk patients or those with complications  Prevention (SOR:C) 1. Prevention of gallstones 2. NSAIDs for biliary colic  o Single dose ketorolac 30-60 mg IM (adjusted for age and renal function) followed by ibuprofen 400 mg PO for subsequent attacks o Indomethacin and diclofenac have shown promise in some studies o May reduce progression to acute cholecystitis   References 1. Afdhal N. Approach to the patient with incidental gallstones. www.uptodate.com. June 14 2004.  2. Biliary Tract Disease. In Sabatine M Ed. Pocket Medicine. Philadelphia: Lippincott, 2002. 3. Biliary Tract Stones and Postcholecystectomy Syndrome. In Yamada T, Ed. Handbook of Gastroenterology. Philadelphia: Lippincott, 1998. 4. Gilbert D, Moellering R, Sande M. The Sanford Guide to Antimicrobial Therapy. www.sanfordguide.com.  5. Guidelines for the clinical application of laparoscopic biliary tract surgery. Surg Endosc 2000; 14: 771-772.  6. Horton J & Bilhartz L. Gallstone Disease and its Complications. In Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th Ed. 2002, Elsevier. 1065-1074.  7. Indar A & Beckingham I. Acute cholecystitis. BMJ 2002; 325: 639-643.  Biliary Infections:  Cholecystitis Page 6 of 6    9.9.09 8. Raijman I. Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy. www.uptodate.com. May 21 2004.  9. Zakko S & Afdhal N. Clinical features and diagnosis of acute cholecystitis. www.uptodate.com. Nov 9 2004. 10. Zakko S & Afdhal N. Treatment of acute cholecystitis. www.uptodate.com. Oct 18 2004. 11. Disease of Gallbladder and Bile Ducts. In Kasper et al, Eds. Harrison's Principles of Internal Medicine, 16th Ed. www.Harrisonsonline.com.    Author:  Abhishake Kaapuraala, MD, Hennepin County FP, MN  Editor:  Robert Marshall, MD, MPH, Capt MC USN, Puget Sound Family Medicine Residence Naval Hospital, Bremerton, WA 

Biliary infections: cholecystitis

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