Acute Cholecystitis ✅

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

⚠️ Mortality: Acute calculous cholecystitis has <10% mortality with prompt hospital management. However, 🔥 Acute Acalculous Cholecystitis (more common in critically ill/ICU patients) carries a mortality up to 50% 🚨 and requires urgent recognition and intervention. 💡 Teaching Tip: Always distinguish calculous from acalculous; high mortality in ICU means early suspicion is lifesaving.

ℹ️ About

• 📊 Prevalence: Gallstones affect ~10% of the population; 10–20% symptomatic.
• 🧪 Pathophysiology: Cystic duct obstruction → ↑ intraluminal pressure → bile stasis → gallbladder wall inflammation. 💡 Tip: Remember Charcot’s triad for cholangitis differs from Murphy’s sign for cholecystitis.
• 👩 Demographics: More common in women; incidence rises with age (♀ 24%, ♂ 15% by 70 years).
• 🔪 Treatment: Symptomatic patients usually require laparoscopic cholecystectomy after CBD stones excluded.

🧪 Aetiology

• 💧 Lithogenic bile: ↑ cholesterol, ↓ bile salts → stone formation.
• 🚪 Cystic duct obstruction: Primary trigger → gallbladder inflammation.
• 🦠 Secondary infection: Often E. coli, Klebsiella, Enterococcus.
• ⚠️ Empyema: Pus-filled gallbladder → urgent surgery. 💡 Exam Tip: Empyema = sepsis risk; do not delay surgery for antibiotics alone.

⚠️ Risk Factors

• 👵 Age >50, 👩 Female, Caucasian
• 🍔 Obesity, rapid weight loss, diabetes, metabolic syndrome
• 🧬 Crohn’s (terminal ileum), cholestyramine therapy
• 🤰 Pregnancy, cystic fibrosis

💎 Types of Gallstones

Cholecystitis Imaging (USS & CT)

Oblique coronal US: thickened GB wall, pericholecystic fluid, impacted calculus in GB neck. LI = liver.

CT axial/coronal: thickened GB wall, pericholecystic fat stranding (white arrow), reactive hyperaemia in adjacent liver (black arrow); large calculus visible.

🩺 Clinical Features

• ⚡ Sudden, severe RUQ pain → radiates to right shoulder/scapula
• 🤮 Nausea, vomiting, anorexia, fever
• 🖐️ Murphy’s sign: Inspiratory arrest on RUQ palpation
• 🟡 Jaundice → consider CBD stone/cholangitis
💡 Teaching Tip: Pain + Murphy’s sign is classic; jaundice suggests a different pathology or complication.

🔎 Investigations

• 🧪 Bloods: leukocytosis, ↑ CRP, mildly deranged LFTs; ↑ bilirubin if CBD involved
• 🖥️ USS: 1st-line → stones, wall thickening, pericholecystic fluid, sonographic Murphy’s sign
• 🩻 CT: complications (abscess, perforation)
• 💿 MRCP: best for CBD stones
• 🛠️ ERCP: diagnostic + therapeutic for CBD stones

📐 Calot’s Triangle: Cystic duct, common hepatic duct, cystic artery. Identify clearly to avoid bile duct injury during surgery. 💡 Exam Tip: Knowledge of anatomy reduces iatrogenic injury risk.

🚨 Complications

🎭 Differentials

• Peptic ulcer disease, liver abscess
• Acute pancreatitis
• MI (atypical pain), pneumonia (referred pain)

💊 Management

• 💉 Analgesia (IV morphine/alternative), NBM
• 🧪 IV antibiotics (cefuroxime + metronidazole / local protocol)
• 🔪 Laparoscopic cholecystectomy = definitive treatment (ideally 24–72 h)
• ⏳ Delayed surgery (~6 weeks) if high-risk/unstable
• 🛠️ ERCP for CBD stones prior to surgery
💡 Teaching Tip: Definitive surgery is key; antibiotics alone are not curative.

👵 Frail / Elderly Patients

⚠️ Atypical Presentation: In frail or elderly patients, acute cholecystitis often presents without classic signs. Fever and Murphy’s sign may be absent, and confusion, lethargy, or reduced oral intake may be the main features. 💡 Teaching Tip: Always consider acute cholecystitis in frail patients with unexplained delirium or functional decline. 🩺 Management Considerations: Careful ABC assessment, IV fluids, analgesia, and IV antibiotics remain first-line.💡 Surgical decisions require MDT input (geriatrician + surgeon) considering comorbidities and physiological reserve and patient choice. Failure to settle conservatively then INR to place a percutaneous cholecystostomy is often preferred if operative risk is high, with delayed elective cholecystectomy once stabilized. Some very frail patients may not be fit for either.

📚 References

• NICE Guidelines: Acute Cholecystitis
• Acute Cholecystitis: Diagnosis & Management

Case – Acute Cholecystitis

46-year-old woman presents with RUQ pain radiating to back, fever, nausea after fatty meal. Positive Murphy’s sign, raised WBC/CRP, mildly cholestatic LFTs. USS: gallstones, wall thickening, pericholecystic fluid. Managed with ABCDE, IV fluids, analgesia, NBM, IV antibiotics (co-amoxiclav or cefuroxime + metronidazole if penicillin allergy), and early laparoscopic cholecystectomy (24–72 h). Consider percutaneous cholecystostomy if unstable. Monitor for complications: empyema, gangrene/perforation, CBD stones. Differentials: biliary colic, ascending cholangitis, gallstone pancreatitis. 💡 Exam Tip: Always link clinical features, labs, imaging, and management when answering short-answer or OSCE questions.