Cholecystitis Types

Cholecystitis

• May be associated with nausea and/or vomiting
• Patient is usually systemically well

Acute Cholecystitis

• Prolonged gallbladder outlet obstruction leading to inflammation due to concentrated bile
• May be complicated by infection, pus (empyema), or mucus (mucocele)
• Often a history of previous biliary colic
• RUQ/epigastric pain that becomes more severe, constant, and localized after a day or two
• Associated fever, ↑ WCC, may be rigors and other features of sepsis
• Tenderness and guarding in the RUQ on examination
• Murphy's sign positive

Chronic Cholecystitis

• Repeated episodes of inflammation resulting in chronic fibrosis and thickening of the entire gallbladder wall
• Recurrent episodes of pain with or without fever

Diagnosis

• Inflammatory markers (WCC, CRP) usually elevated in acute cholecystitis, cholangitis, and pancreatitis
• LFTs may show an obstructed picture
• Serial measurements of LFTs should be taken if obstructive jaundice is present
• Ultrasound scan (USS) used to visualise the gallbladder and biliary tree
• Plain abdominal x-ray useful in gallstone ileus, showing evidence of small bowel obstruction, often with pneumobilia
• MRCP allows better visualisation of the biliary tree and demonstrates any gallstones within the CBD that may be causing obstruction
• ERCP is diagnostic for biliary tree dilatation and CBD stones, and is used therapeutically to remove obstructing CBD stones, insert stents, and perform sphincterotomy

Management

• Antibiotics required in patients with acute cholecystitis, cholangitis, and acute severe pancreatitis
• Vitamin K used to correct coagulopathy caused by obstructive jaundice
• ERCP may be used therapeutically in the presence of CBD obstruction
• Percutaneous transhepatic cholangiography (PTC) used in patients with severe biliary obstruction and sepsis who are unsuitable for ERCP or where it has been unsuccessful
• Complications of PTC include bleeding, infection (cholangitis), pancreatitis, and perforation

Cholecystectomy

• Indications: acute or chronic cholecystitis, recurrent biliary colic, gallstone-induced pancreatitis, biliary peritonitis due to perforation of the gallbladder or previous CBD obstruction
• Usually performed laparoscopically
• Conversion to open procedure is rare and should occur in exceptional circumstances