Makindo Medical Notes

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

⚠️ Mortality: Acute calculous cholecystitis has a mortality of <10% with prompt treatment. However, 🔥 Acute Acalculous Cholecystitis (more common in the critically ill) carries a mortality rate of up to 50% 🚨 and requires urgent recognition and intervention.

ℹ️ About

• 📊 Prevalence: Gallstones affect ~10% of the population; 10–20% become symptomatic.
• 🧪 Pathophysiology: Gallstone obstructs cystic duct → ↑ pressure, bile stasis, gallbladder wall inflammation.
• 👩 Demographics: More common in women; incidence rises with age (♀24%, ♂15% by age 70).
• 🔪 Treatment: Symptomatic patients usually require laparoscopic cholecystectomy after excluding CBD stones.

🧪 Aetiology

• 💧 Lithogenic bile: ↑ cholesterol, ↓ bile salts → stone formation.
• 🚪 Cystic duct obstruction: Main trigger → inflammation.
• 🦠 Secondary infection: Often E. coli, Klebsiella, Enterococcus.
• ⚠️ Empyema: Severe complication = pus-filled gallbladder needing urgent surgery.

⚠️ Risk Factors

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

💎 Types of Gallstones

🩺 Clinical Features

• ⚡ Typical: Sudden, severe RUQ pain → radiates to right shoulder/scapula.
• 🤮 Nausea, vomiting, anorexia, fever.
• 🖐️ Murphy’s Sign: Arrest of inspiration on RUQ palpation → highly suggestive.
• 🟡 Jaundice: Consider CBD stone or cholangitis.

🔎 Investigations

• 🧪 Bloods: Leukocytosis, ↑ CRP, mildly deranged LFTs. ↑ bilirubin = CBD involvement.
• 🖥️ USS: 1st-line → gallstones, wall thickening, pericholecystic fluid, sonographic Murphy’s sign.
• 🩻 CT: For complications (abscess, perforation).
• 💿 MRCP: Best for CBD stones.
• 🛠️ ERCP: Diagnostic + therapeutic → CBD stone extraction.

📐 Calot’s Triangle: Bound by cystic duct, common hepatic duct, cystic artery. Must be clearly identified during laparoscopic cholecystectomy to avoid bile duct injury.

🚨 Complications

🎭 Differentials

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

💊 Management

• 💉 Analgesia (e.g. IV morphine), NBM.
• 🧪 IV antibiotics (cefuroxime + metronidazole / per protocol).
• 🔪 Laparoscopic cholecystectomy = definitive treatment (within 5 days ideally).
• ⏳ Delayed cholecystectomy (≈6 wks) if high-risk or unstable.
• 🛠️ ERCP for CBD stones before surgery.

📚 References

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

Case – Acute cholecystitis

A 46-year-old woman presents with right upper quadrant pain radiating to the back, fever, and nausea after a fatty meal. She is tender with a positive Murphy’s sign; WBC and CRP are raised, LFTs largely normal or mildly cholestatic. Bedside US shows gallstones, gallbladder wall thickening, and pericholecystic fluid. Diagnose acute calculous cholecystitis. Manage with ABCDE, IV fluids, analgesia, keep NBM, and start IV antibiotics per local policy (e.g., co-amoxiclav or cefuroxime + metronidazole in penicillin allergy). Plan early laparoscopic cholecystectomy (ideally within 24–72 h); if unfit or severe sepsis, consider percutaneous cholecystostomy. Watch for complications: empyema, gangrene/perforation, and bile duct stones; differentials include biliary colic, ascending cholangitis (fever, jaundice), and gallstone pancreatitis (↑amylase/lipase).