Cholecystitis

The gallbladder is the quintessential British organ, storing bile that is produced in the liver and releasing it after a good meal to help with digestion. Its Britishness has nothing to do with its function and all to do with the fact that you can shorten it to GB. Rule Britannia. Go Team GB! You can do it. Release the bile! Release the bile!

Of course, this is all in my head. I’m extremely professional in real life 🙂


Cholecystitis

Image result for anatomy of biliary treeDefinition: inflammation of the gallbladder (GB)

Aetiology/risk factors:

-Acute Cholecystitis follows stone or sludge (viscous mixture of small particles derived from bile)  impaction in the neck of the gallbladder or cystic duct.

-gallstones (bile pigment, cholesterol or mixed stones)obstruct neck of GB or cystic duct → inflammation of mucosa due to chemical injury from bile salts → reactive mucus production →  increased intraluminal pressure & distension →  restricted blood flow to GB wall →  increasing wall thickness from oedema & inflammatory change →  secondary bacterial infection in ~66% patients

R/F for gallstones: Female, Fat, Forty (do not say this to a patient!)

Also-parenteral nutrition, drugs (OCP, octreotide), FHx, interruption of enterohepatic circulation of bile salts (e.g. Crohn’s disease), terminal ileal resection. Pigment stones: haemolytic disorders (e.g. Sickle cell), liver cirrhosis

R/F for stones becoming symptomatic: smoking, parity (previously carried pregnancies to viable gestational age).

Epidemiology:

-Gallstones very common- prevalence = 8% of those over 40 years. 90% remain asymptomatic.  -3 x more females in younger population but equal sex ration after 65 years

~ 50,000 cholecystectomies (GB removals) performed in UK per year

-Acute cholecystitis develops in up to 10% of patients with symptomatic gallstones.

Symptoms:

Acute Cholecystitis:

-Continuous epigastric or Right Upper Quadrant (RUQ) abdominal pain. Pain may be referred to the right shoulder (irritation of underside of diaphragm via phrenic nerve- C3-5 dermatomes)

-often a history of previous biliary colic

Nausea, anorexia, vomiting (uncommon)

Fever, tachycardia

Chronic Cholecystitis:

-Chronic inflammation +/- colic

-Flatulent dyspepsia: vague abdominal discomfort, distention, nausea, flatulence, fat intolerance

Signs:

Acute Cholecystitis:

Murphy’s sign positive: press down on the RUQ at the subcostal margin (mid-clavicular line) and ask them to take a deep breath in. As they breath in, their breath will catch and they’ll feel pain, as the as the inflamed GB descends and contacts the palpating hand. Only positive if test on opposite side does not cause pain.

Local peritonism (localised abdominal pain, tenderness & guarding-contraction of abdo muscles when palpating area- exacerbated by moving peritoneum e.g. by coughing, rebound tenderness– hurts more when you take hand away from area.)

Abdominal mass-distended, tender GB may be palpable as a distinct mass in 30-40% cases.

Pyrexia

Less common:

Obstructive Jaundice may occur if stone moves to the common bile duct (may cause cholangitis- inflammation of bile duct)

-Phlegmon- RUQ mass of inflamed adherent omentum and bowel, may be palpable

-The main difference from biliary colic (colicky pain from the presence of gallstones) is the inflammatory component- peritonsim, fever, raised WCC 

Investigations:

FBC: raised white cell count

CRP: Raised

LFTs: In acute cholecystitis, elevated Alkaline Phosphatase, bilirubin (typically mild) and gamma-GT

Ultrasound of the gallbladder: thick walled, shrunken GB, pericholecystic fluid, stones, common bile duct may be dilated (> 6mm). – in both acute and chronic disease

May consider:

Image result for hida scan acute cholecystitisHIDA Cholescintigraphy may be useful if diagnosis uncertain after U/S. It is a nuclear medicine procedure. A radioactive tracer is injected through a vein, circulates to the liver, excreted into the bile ducts and stored by the GB until released into the duodenum. GB visualised within 1 hr in absence of disease. If not visualised within 4hrs, this indicates cholecystitis or cystic duct obstruction e.g. by gallstones.

MRCP/Magnetic resonance cholangiopancreatography  is used to find common bile duct stones (e.g. in chronic disease)

 

MRCP Choledocholithiasis.jpg

MRCP image. A) GB with stones. B) Stones in common bile duct. C) Pancreatic duct. D) Duodenum

-Abdominal CT, Abdominal MRI
-Plain Abdominal X-ray: only shows ~10% of gallstones. Rarely, may identify a  calcified ‘porcelain’ GB (15% association with cancer).

 

 

Porcelain gallbladder.png

Porcelain GB

 

Management:

Acute cholecystitis:

-Nil By Mouth

-Analgesia

-IV fluids

-IV antibiotics (e.g. Cefuroxime)

Laparoscopic Cholecystectomy (i.e. take the thing out)- either acutely or delayed (within 6 weeks) for all patients that are fit for surgery. Open surgery required if there is GB perforation. Consider percutaneous cholecystostomy (tube from GB to skin) for elderly/ high risk/ unsuitable for surgery patients. Cholecystectomy can still be done at a later date.Image result for cholecystostomy

Chronic cholecystitis:

-Cholecystectomy is also indicated in Chronic Cholecystitis. If U/S shows a dilated common bile duct with stones, ERCP (Endoscopic retrograde cholangiopancreatography = endoscopic camera goes in and images biliary tree, magic wire can pull out the stones or insert stents) + sphincterotomy (cut Sphincter of Oddi so stones can come out) before surgery.

Complications:

GB mucocoele (full of mucus) or GB empyema (full of pus), GB perforation with peritonitis, porcelain GB (calcification), gangrenous cholecystitis, predisposition to GB cancer (rare)

Cholecystectomy- bleeding, infection, bile leak, bile duct injury, post-cholecystectomy syndrome (persistent dyspeptic symptoms), hernias

Prognosis:

Surgery is a pretty good effective treatment.

Untreated, there is a up to 50% mortality

References: Cheese & Onion, Rapid Surgery, Radiopaedia.org, BMJ Best Practice
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