Cholecystitis Acute - developinganaesthesia



ACUTE CHOLECYSTITIS

Introduction

Acute cholecystitis is infection of the gallbladder.

Note that for cases of persistent RUQ pain, (greater than 4 - 6 hours) there must be a high index of suspicion for early cholecystitis.

All cases will require IV antibiotics and admission to hospital under the surgical unit.

Emphysematous cholecystitis is the most serious presentation and all cases will require operation.

History

Murphy’s sign is named after the American physician John Benjamin Murphy (1857–1916) who was the first to describe the tenderness to deep palpation in the subcostal area when a patient with gallbladder disease takes a deep inspiration.

Laparoscopic cholecystectomy was introduced in 1985 and markedly reduced the need for open cholecystectomy and its attendant complications. The procedure has become the standard treatment for symptomatic cholelithiasis and mild-to-moderate acute cholecystitis.

Pathophysiology

Organisms:

Causative organisms of acute cholecystitis include:

● Aerobic bowel flora (eg Escherichia coli, Klebsiella species and, less commonly, Enterococcus faecalis).

● Anaerobes are found infrequently, unless obstruction is present.

Less commonly:

● Salmonella species, (including typhi)

● Gas forming organisms, such as clostridia species are responsible for emphysematous cholecystitis

Classification:

There are 3 types of acute cholecystitis:

1. Acute calculus cholycystitis:

● This is due to cholecystitis in association with gallstones.

● It is by far the commonest cause, (around 90-95 % of cases).

2. Acute acalculus cholecystitis:

This is cholecystitis, which occurs in the absence of gallstones.

It is less common than acute calculus cholecystitis, (only 5-10 % of cases of all acute cholecystitis).

It may be due to increased bile viscosity, secondary to poor oral intake and fever with subsequent dehydration.

It is associated with greater morbidity and mortality than gallstone cholecystitis.

Predisposing factors include:

● Obstructed bile ducts (other than that due to gallstones eg biliary sludge)

● Major stress reactions:

♥ Trauma, burns, major surgery.

♥ Any severe illness in general. It may be seen as a complication in very unwell ICU patients.

● The immunosuppressed in particular:

♥ Diabetics, HIV patients, the elderly.

● De novo bacterial infection:

♥ Salmonella typhi or that due to gas forming clostridial organisms, seen in elderly, diabetics or again in major illness.

3. Emphysematous cholecystitis:

● Emphysematous cholecystitis (also known as “gangrenous”) may occur in association with gallstones or without gallstones.

● There is distension of the gall bladder with gas forming organisms, (usually clostridial). Evidence of gas may be seen on plain x-ray (see below)

● This condition is relatively rare.

● It is a surgical emergency with high mortality and requires urgent operation.

Complications:

1. Associated pancreatitis:

● Especially with calculus cholecystitis.

2. Ascending cholangitis:

● Associated with impacted gallstones

3. Generalized septicaemia.

4. Gangrene and perforation:

● More common in cases of acalculus and emphysematous cholecystitis with subsequent peritonitis.

5. Fistula formation into bowel.

6. Adjacent lung atelectasis.

Clinical Features

There may be a history of previous attacks of biliary colic or of documented gallstones.

Clinical features include:

1. Fever:

● Although fever may not be present, especially in the initial stages of cholecystitis.

2. GIT upset:

● Nausea, vomiting and anorexia

3. Right upper quadrant pain:

● There may be some radiation to the back.

● In distinction to uncomplicated attacks of biliary colic, the patient tends to remain still, due to inflammatory “peritonism”.

● Biliary colic pain that has been prolonged, (4-6 hours or longer) is likely to have some degree of cholecystitis.

● Although the “classic” presentation is RUQ pain, many patients will present with diffuse epigastric pain without specific localization to the RUQ.

4. Right upper quadrant tenderness:

● There may be some associated voluntary / involuntary guarding.

● A positive “Murphy’s sign” may be seen.

♥ Tenderness to palpation over the RUQ on inspiration.

● Note however that for cases of persistent RUQ pain, (greater than 4 - 6 hours) there must be a high index of suspicion for early cholecystitis, even if blood tests are normal and there is no significant tenderness.

The absence of physical findings does not necessarily rule out the diagnosis of early cholecystitis. Many patients present with diffuse epigastric pain without localization to the RUQ.

5. Jaundice:

● The presence of jaundice/ hyperbilirubinemia, suggests a common bile duct obstruction.

Diagnostic criteria: 6

The Tokyo 2013 diagnostic criteria for the diagnosis of acute cholecystitis are:

1. Local signs of inflammation:

● Murphy’s sign

● Mass, pain, or tenderness in right upper quadrant

2. Systemic signs of inflammation:

● Fever

● Elevated levels of C-reactive protein

● Leukocytosis

3. Findings on imaging characteristic of acute cholecystitis:

● Gallbladder wall thickness ≥ 5 mm.

● Pericholecystic fluid,

● Direct tenderness when probe is pushed against gallbladder (i.e. an ultrasonographic Murphy’s sign)

For suspected cholecystitis:

● Positivity for one item in local signs of inflammation and one item in systemic signs of inflammation.

Definitive cholecystitis:

● Positivity for one item in local signs of inflammation, one item in systemic signs of inflammation, and findings on imaging characteristic of acute cholecystitis.

Severity assessment: 6

Disease severity of acute cholecystitis can also be assessed according to the Tokyo 2013 criteria:

Grade I (Mild):

● Acute cholecystitis in otherwise healthy patient with mild local inflammatory changes and without organ dysfunction.

● Criteria for grade II or III not met

Grade II (Moderate):

Any one of the following characteristics:

● Leukocytosis (> 18,000 cells per mm3)

● Palpable, tender mass in right upper quadrant

● Symptom duration >72 hours

Marked local inflammation (gangrenous or emphysematous cholecystitis, pericholecystic or hepatic abscess, biliary peritonitis.

Grade III (Severe):

Organ dysfunction in any one of the following systems:

● Cardiovascular

♥ Hypotension requiring administration of norepinephrine.

● Neurologic

♥ Decreased level of consciousness

● Respiratory

♥ PaO2 / FiO2 < 300

● Renal

♥ Oliguria

♥ Creatinine >177 μmol/liter.

● Hepatic

♥ International normalized ratio >1.5

● Hematologic

♥ Platelet count < 100,000 / mm3

Investigations

Blood tests:

1. FBE:

● Elevated WCC, but this is not always present in early stages.

2. CRP

3. U&Es and glucose

4. Lipase:

● It is always important to rule out associated pancreatitis.

5. LFTs

● Elevated bilirubin and ALP are not common in uncomplicated cholecystitis, (since biliary obstruction is usually limited to the level of the gall bladder) - if present suspicion should be raised for choledocholithiasis/ cholangitis.

6. Blood cultures if the patient is significantly unwell.

ECG:

● Help rule out possible cardiac conditions (as a differential diagnosis).

FWT:

● To help rule out pyelonephritis (as a differential diagnosis)

CXR / AXR (erect and supine):

● Useful for ruling out other causes of lower chest, or abdominal pain.

● There may be indirect indicators of cholecystitis, including:

♥ Sentinel bowel loops.

♥ Basal lung atelectasis.

♥ Gall stones, (the majority will be radiolucent, however).

● In cases of emphysematous cholecystitis radiological signs may be detectable on the plain x-ray film, (see appendix 1 below)

Upper abdominal ultrasound:

This should be done in all cases of suspected acute cholecystitis.

It will confirm the diagnosis and detect the presence of gallstones.

Ultrasonic signs of cholecystitis include:

● Thickened gallbladder wall, (greater than 3 mm)

● Positive ultrasonic Murphy’s sign, (tenderness on direct probe pressure).

● The presence of pericholecystic fluid, (from exudate or perforation).

● Air in the gall bladder wall suggests the serious condition of emphysematous (or gangrenous) cholecystitis.

See appendix 1 below.

Radionuclide Scan:

● This has superior diagnostic accuracy and specificity compared to ultrasound, however is rarely needed.

● It can be used to clarify a negative, equivocal or technically difficult ultrasound in the presence of continued clinical suspicion of acute cholecystitis.

CT Scan:

● This is not the first line investigation of choice for biliary tract disease. It is less reliable in detecting gallstones than is ultrasound, because up to 20% of gallstones may be of the same radiodensity as bile. 4

● It is more useful when the diagnosis is unclear and a range of important intra-abdominal conditions need to be ruled out.

● It may be done if ultrasound results are equivocal. It is sensitive in detecting emphysematous cholecystitis.

ERCP:

● This provides both endoscopic and radiographic visualization of the biliary tract.

● It can be diagnostic as well as therapeutic (by direct removal of common bile duct stones).

Management

1. ABC as required

2. Analgesia:

● Titrated IV opioid analgesia as required.

3. Keep the patient fasted.

4. IV fluids.

5. IV antibiotics: 1

● Cefotaxime / ceftriaxone

And

● Metronidazole (should be added if there is evidence of obstruction)

Alternatively:

● Tazocin (piperacillin + tazobactam) or Timentin (ticarcillin + clavulanate)

Ciprofloxacin is an alternative for those who are allergic to penicillin.

See latest Antibiotic Guidelines for full prescribing details.

6. Surgery:

Options include:

Laparoscopic cholecystectomy:

This is the current procedure of choice.

● Minimally invasive cholecystectomy is usually undertaken within 7 days for cases of acute cholecystitis, to prevent recurrence or other complications.

● Most uncomplicated cases of cholecystitis are treated with antibiotics in the first instance before surgery is contemplated.

Open cholecystectomy:

It is an option for patients able to tolerate the procedure and where a laparoscopic technique is not appropriate.

Contraindications to laparoscopic cholecystectomy include the following:

● High risk for general anesthesia

● Morbid obesity

● Signs of gallbladder perforation, such as abscess, peritonitis, or fistula

● Giant gallstones

● Suspected malignancy

● End-stage liver disease with portal hypertension and severe coagulopathy

● Emphysematous/ gangrenous cholecystitis

Open cholecystectomy is also done in cases of failed laparoscopic cholecystectomy.

Percutaneous cholecystostomy:

For patients at high surgical risk, placement of a sonographically guided, percutaneous, cholecystostomy drainage tube together with the administration of antibiotics may provide definitive therapy or at least act as a temporizing measure, until a patient is well enough for cholecystectomy.

Endoscopic drainage techniques:

These can also be effective for acute cholecystitis in patients who are poor surgical candidates.

Options include:

● Endoscopic transpapillary gallbladder stenting

● Endoscopic ultrasound-guided transmural gallbladder drainage

Disposition

Septic and unwell patients, including cases of emphysematous cholecystitis should also be referred to HDU/ICU.

Appendix 1

Emphysematous cholecystitis on plain radiograph.

A plain film obtained while the patient was upright shows an air-fluid level in the lumen of the gallbladder (arrow) and gas in its wall (black arrowheads.) There is diffusion of gas around the gallbladder and beneath the liver (white arrowheads). Emergency cholecystectomy was performed. Laparotomy showed emphysematous cholecystitis, with perforation of the gallbladder into the right side of the retroperitoneal space in association with an obstructing stone. 2

Impacted gallstone in the gallbladder neck with evidence of cholecystitis. 6

Ultrasound showing a grossly thickened gallbladder wall of 12.8mm measured between the callipers, (normally up to 3mm) with calculi (yellow arrow) within the gallbladder and pericholecystic fluid. 3

Appendix 2

Peroral Endoscopic Approaches to Gallbladder Drainage:

Transpapillary and transmural (transduodenal) gallbladder drainage.

References:

1. eTG - July 2015

● Therapeutic Antibiotic Guidelines, 14th ed 2010.

2. Danse E and Laterre P Emphysematous Cholecystitis Images in Clinical Medicine NEJM 341: 1126 Oct 7 1999

3. Biliary Tract Disease in Textbook of Adult Emergency Medicine, Cameron et al 4th ed 2015.

4. K.C Chan & E. Seow. Abdominal Pain in Textbook of Adult Emergency Medicine, Cameron et al 4th ed 2015.

5. Todd H. Baron et al. Interventional Approaches to Gallbladder Disease. NEJM 373: 4, July 23, 2015.

6. Yokoe M, Takada T, Strasberg SM, et al. TG13 (Tokyo Guidelines, 2013) diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci 2013; 20: 35 - 46.

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