Cholecystitis: Clinical sciences

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Introduction0:00–0:43

Acute cholecystitis is a sudden inflammation of the gallbladder, usually caused by conditions that impair the outflow of bile.
Think of the biliary tree as one of the many plumbing systems in the body! Disrupted bile outflow increases the pressure within the gallbladder, leading to bile stasis.
This in turn can lead to complications such as inflammation, infection, gangrene, and perforation. Acute cholecystitis is most commonly related to a stone, which is called calculous cholecystitis.
However, gallbladder inflammation can also occur without stones, which is known as acalculous cholecystitis.When assessing a patient with suspected acute cholecystitis, first you should determine if your patient is stable or unstable by doing an ABCDE assessment.

Unstable branch0:43–4:06

If the patient is unstable, you should stabilize them first, which means that you might need to intubate the patient, establish IV access, or administer fluids before continuing with your assessment.After completing those important steps, you should obtain a history and physical exam, as well as labs such as CBC, ESR, CRP, and CMP, which includes ALP, GGT, ALT, AST, and total bilirubin; also obtain lactate, and blood cultures, as well as amylase and lipase to rule out pancreatic involvement.
The history usually reveals symptoms like nausea, vomiting, and right upper quadrant or epigastric abdominal pain that might radiate to the shoulder or scapula; symptoms typically occur after eating a high fat meal.
On a physical exam, you might find signs such as tenderness to palpation in the right upper quadrant, with a positive Murphy sign.
You can elicit Murphy sign by palpating the right upper quadrant while asking the patient to take a deep breath. If the pain stops inspiration, Murphy sign is considered positive.
Additional findings on physical exam include jaundice, fever, and signs of hemodynamic instability like tachycardia and hypotension.
These systemic signs are more common in those with severe disease. Finally, labs might reveal leukocytosis and elevated ESR and CRP, which are signs of inflammation; elevated ALP and GGT, which are associated with liver and bile duct injury; and elevated lactate, which indicates tissue hypoxia and points to severe disease.
Some patients may also have mildly elevated ALT, AST, and total bilirubin, while severe elevations might indicate the development of more extensive involvement leading to obstruction of the biliary system.
Although blood cultures are usually drawn in these patients, they are not immediately available and cannot aid in making the diagnosis, but they are used to help with the direction of antibiotic coverage.
The next step is to start them on supportive care, which involves continuing IV fluids, administering empiric antibiotics, pain medications, and bowel rest.Then, you can move on to diagnostic imaging, which usually means a bedside ultrasound in a critically ill patient, or possibly a CT scan.
On ultrasound, these patients typically have signs of complicated cholecystitis, like gangrene, which is seen as irregular gallbladder mucosal outlines and possibly delamination.
Additionally, the ultrasound might show signs of gallbladder perforation, like gas within the gallbladder or abdomen, and possibly large pericholecystic fluid collections.
In an acutely ill patient that is unable to give a good history, a CT of the abdomen and pelvis can be done to help identify the source of instability.
Now, if imaging shows signs of gangrene or gallbladder perforation, consult the surgical team for an emergent cholecystectomy or percutaneous drainage.
However, if there are no signs of gallbladder disease, you should consider an alternative diagnosis.Now that we’re done with unstable patients, let’s move on to the stable ones.

Stable branch4:06–5:54

When it comes to stable individuals, there is less urgency, so you have more time to obtain the history and physical exam, and draw labs, including CBC, ESR, CRP, CMP, lactate, and amylase and lipase.
History will often reveal the onset of symptoms after eating a high fat meal. The patient might report a right upper quadrant or epigastric abdominal pain that may radiate to the shoulder or scapula, as well as nausea or vomiting.
Here are some high-yield facts to keep in mind! While taking the history, be on the lookout for predisposing risk factors for gallbladder disease.
These include biologically female individuals, individuals with obesity or who have had rapid weight loss, as well as those over the age of 40.
Lastly, there are some pathophysiologic states and illnesses that can predispose patients to gallbladder disease, like pregnancy, or viral infections like HIV/AIDS.When it comes to the physical exam, it usually reveals tenderness on palpation in the right upper quadrant with a positive Murphy sign.
Other possible exam findings include jaundice, fever, and tachycardia. Finally, labs might reveal leukocytosis, elevated ESR and CRP, as well as elevated liver function tests.
If the patient has an elevated lactate, that might be an indication that they have a complication like a gangrenous gallbladder or more severe condition like ascending cholangitis.
Some patients may also have elevated ALT, AST, and total bilirubin.If, based on history and physical exam, you suspect cholecystitis, start supportive care before doing any diagnostic tests.

Supportive care5:54–6:14

This includes bowel rest, IV fluids, empiric antibiotics, and pain management. Additionally, perform serial abdominal exams to assess if the patient is worsening.
Your next step is to order imaging. When you suspect gallbladder pathology, an ultrasound is the first choice of imaging.

Imaging6:14–8:26

Ultrasound findings of cholecystitis include gallbladder wall thickening of more than 3 millimeters, pericholecystic fluid, and a sonographic Murphy sign.
This means that the patient feels pain when the ultrasonographer pushes in the right upper quadrant. Now, if you see stones in the gallbladder or cystic duct, we are talking about calculous cholecystitis.
However, if there are no stones here, it’s important to also measure the common bile duct to determine if it is dilated, which would indicate that the stone has been ejected from the gallbladder and gotten stuck downstream.
If ultrasound doesn’t show a stone here either, then this is acalculous cholecystitis. Alternatively, if the ultrasound is nondiagnostic, you can order Hepatobiliary Iminodiacetic Acid Scan or HIDA for short.
HIDA is a nuclear medicine study that uses an IV radiotracer with an affinity for the liver cells that produce bile. After the radiotracer is given, a series of images are taken to see how it travels through the hepatobiliary tree.
Normally, the radiotracer reaches the liver and bile-producing cells. It is excreted with the bile, and travels to the gallbladder and then through digestion.
If there is an obstruction, the radiotracer won’t be able to reach the gallbladder, so it won’t be visualized on the scan.
Keep in mind that, when calculous cholecystitis is suspected, the HIDA scan should be ordered with no CCK injection. CCK, or cholecystokinin, is a hormone that normally causes the gallbladder to contract and release bile.
In patients with suspected biliary dyskinesia, CCK is injected during a HIDA scan to reproduce symptoms, which is diagnostic.
On the other hand, in patients with suspected calculous cholecystitis, CCK injection is contraindicated because it can force the stone out, causing choledocholithiasis.
Alright, now that we’re done with imaging, let’s talk about calculous cholecystitis. So, if you saw signs of cholecystitis and stones on imaging, the patient has calculous cholecystitis.

Calculous cholecystitis8:26–9:42

The next step involves continuing supportive care, while the surgeon will determine the timing of surgery depending on several factors.
If the patient improves after a short trial of supportive care alone, the surgeon may recommend having a cholecystectomy while in the hospital, or electively as an outpatient.
Some may choose to try diet modifications and medications and wait to see if the inflammation recurs. However, if the patient has repetitive episodes or “gallbladder attacks,” the surgical team might inform them that cholecystectomy is their best option.
On the flip side, if the patient doesn’t improve with supportive care alone, or even has worsening signs and symptoms like fever, increased pain, or worsening lab findings, it might indicate complicated cholecystitis.
In this case, the surgical team will move forward with an urgent cholecystectomy. Keep in mind though, if the patient has comorbidities that prevent surgery, you should consult interventional radiologists for possible percutaneous drainage of the gallbladder.
Okay, let’s go back to imaging. If there are all signs of cholecystitis, but no signs of stones anywhere on imaging, we are talking about acalculous cholecystitis.

Acalculous cholecystitis9:42–10:20

As before, you should continue the supportive care, but don’t wait to see if the patient improves or not. These patients usually require a cholecystectomy on their first presentation due to the higher risk of complications.
Now, if surgery isn’t possible because the patient has comorbidities, you should consult interventional radiologists for possible percutaneous drainage of the gallbladder.
Alright, as a quick recap… patients with acute cholecystitis can present as unstable or stable. Unstable patients require bedside ultrasound to diagnose the condition.

Review10:20–11:15

They should be treated with emergent cholecystectomy or percutaneous drainage of the gallbladder. On the other hand, stable patients should be started on supportive care with IV fluids, empiric antibiotics, and pain medications; and evaluated using ultrasound or HIDA.
If there are signs of stones, this is called calculous cholecystitis. In this case, continue supportive treatment and assess for a response.
Patients that improve can be treated by elective cholecystectomy, while those that don’t improve on supportive care need urgent cholecystectomy.
When it comes to patients with acalculous cholecystitis, they are treated with supportive care, and cholecystectomy or percutaneous drainage of the gallbladder.