Cholecystitis: Clinical sciences

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. 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. 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.