Rosen & Barkin's 5-Minute Emergency Medicine Consult (157 page)

FOLLOW-UP

• All cases of cholecystitis should be admitted for parenteral antibiotics, analgesia, fluid replacement, and cholecystectomy in 24–72 hr.
  
• Unstable patients (gallbladder perforation or sepsis) require immediate surgery.
  

None

General surgery consult for patients with cholecystitis. GI consult if choledocholisthiasis or cholangitis suspected.

Inpatient admission for antibiotics and surgical evaluation.

• US is the 1st-line imaging procedure.
  
• Perform a radionuclide scanning (HIDA) when clinical suspicion is high with equivocal US or when acalculous cholecystitis suspected.
  

• Barie PS, Eachempati SR. Acute acalculous cholecystitis.
  Gastroenterol Clin North Am
  . 2010;39:243–357.
  
• Silen W, ed. Cholecystitis and other causes of acute pain in the right upper quadrant of the abdomen.
  Cope’s Early Diagnosis of the Acute Abdomen.
  22nd ed. Oxford, UK: Oxford University Press; 2010:131–141.
  
• Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections.
  Clin Infect Dis
  . 2010;50:997; 133–164.
  
• Strasberg SM. Acute calculous cholecystitis.
  N Eng J Med
  . 2008;358:2804–2811.
  
• Yusuf TE, Baron TH, AIDS cholangiopathy.
  Curr Treat Options Gastroenterol
  . 2004;7:111–117.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cholangitis
  
• Cholelithiasis
  

CODES

• 574.00 Calculus of gallbladder with acute cholecystitis, without mention of obstruction
  
• 575.0 Acute cholecystitis
  
• 575.10 Cholecystitis, unspecified
  

BASICS

• Symptoms arise when gallstones pass through the cystic or common bile ducts leading to impedance of normal bile flow and gallbladder spasm.
  
• Biliary dyskinesia produces symptoms identical to biliary colic in the absence of stones.
  
• Choledocholithiasis (common bile duct stones), may lead to prolonged pain, elevated LFTs and bilirubin, and to more complications like cholangitis or pancreatitis.
  

• Cholesterol stones:
  
  • Most common type of gallstone
    
  • Form when solubility exceeded
    
• Pigment stones:
  
  • 20%
    
  • Composed of calcium bilirubinate
    
  • Associated with clinical conditions such as hemolytic anemias that lead to increased concentration of unconjugated bilirubin
    
• Incidence increases with age and favors females to males 2:1. Other risk factors include Hispanic ethnicity, obesity, pregnancy, rapid weight loss, and drugs that induce biliary stasis (e.g., ceftriaxone and oral contraceptives).
  
• Gallstones are exceedingly rare in childhood and are most commonly associated with sickle cell disease, hereditary spherocytosis, or other hemolytic anemias that result in pigment stone formation.
  
• Biliary sludge:
  
  • Nonstone, crystalline, granular matrix
    
  • Associated with rapid weight loss, pregnancy, ceftriaxone or octreotide therapy, and organ transplantation
    
  • May develop symptoms identical to cholelithiasis and its complications
    
• “Porcelain gallbladder” from mucosal precipitation of calcium salts owing to recurrent obstruction of cystic duct.
  

DIAGNOSIS

• Dull, aching epigastric or right upper quadrant (RUQ) pain:
  
  • Arising over 2–3 min, continuous (rather than colicky), and lasting from 30 min–6 hr before dissipating
    
  • May radiate to the tip of right scapula, acromion, or thoracic spine
    
  • Often correlated with ingestion of large, fatty meal
    
• Anorexia
  
• Nausea and vomiting
  
• Afebrile:
  
  • Fever and chills suggest cholecystitis or cholangitis
    

• Tenderness to deep palpation but without rebound
  
• Murphy sign (inspiratory arrest during deep palpation of the RUQ) may be present during the episode of colic, but should resolve when symptoms pass.
  

• Obtain ECG on those whose pain may be owing to myocardial ischemia.
  
• CBC
  
• LFTs
  
• Amylase, lipase
  
• Urinalysis
  
• Human chorionic gonadotropin (hCG)
  

• CBC:
  
  • WBC count usually normal, but may elevate after vomiting
    
  • Leukocytosis suggestive of cholecystitis or cholangitis
    
• LFTs:
  
  • Usually normal
    
  • Elevation suggests common duct obstruction, cholangitis, cholecystitis, or hepatitis.
    
• Amylase/lipase
  
  • Normal or minimally elevated with passage of gallstone
    
  • Elevation in context of severe persistent epigastric pain suggests pancreatitis.
    
• Urinalysis:
  
  • Exclude nephrolithiasis or pyelonephritis.
    
  • Bilirubinuria suggests common duct obstruction or hepatitis.
    

• US:
  
  • Detects gallstones with sensitivity and specificity >90%
    
  • Dilation of common bile duct >10 mm indicates obstruction, but no dilation may be present with acute obstruction.
    
  • Gallbladder wall thickening >5 mm or pericolic fluid 90% sensitive and 80% specific for cholecystitis
    
  • Accuracy enhanced in fasting patient (>6 hr) with noncontracted gallbladder
    
• Radionuclide scanning (HIDA):
  
  • Cannot detect gallstones
    
  • Passage of tracer into small intestine without visualization of gallbladder highly diagnostic of cystic duct obstruction and cholecystitis:
    
    • Sensitivity and specificity roughly 95%
      
  • Failure of tracer to pass into duodenum suggests common bile duct obstruction. Accuracy enhanced by morphine injection during scan causing sphincter of Oddi spasm and improving gallbladder filling.
    
• CT scanning:
  
  • Less sensitive than US to detect gallstones:
    
    • Only 20% radiopaque.
      
  • Most useful to exclude other causes of upper abdominal pain such as aortic aneurysm, perihepatic abscess, or pancreatic pseudocyst
    
  • Detects rare complications such as air in gallbladder wall in emphysematous cholecystitis, air-filled gallbladder in biliary-enteric fistula or a “Porcelain gallbladder.”
    
• Plain radiographs:
  
  • Most useful for diagnosis of intestinal obstruction or rare abnormalities such as air in gallbladder wall in emphysematous cholecystitis, air-filled gallbladder in biliary-enteric fistula or a “Porcelain gallbladder.”
    

• MI
  
• Abdominal aortic aneurysm
  
• Acute cholecystitis, cholangitis, or choledocholithiasis
  
• Renal colic or pyelonephritis
  
• Duodenal ulcer perforation
  
• Acute pancreatitis
  
• Intestinal obstruction
  
• Peptic ulcer disease, gastritis, or GERD
  
• Right lower lobe pneumonia, pleurisy, or pulmonary infarction
  
• Hepatitis or hepatic abscess
  
• Fitz-Hugh and Curtis syndrome
  

TREATMENT