Acute Cholecystitis/Cholangitis

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Inflammation of the gall bladder and/or of the biliary tract. It often requires surgical management.

Cause

• Obstruction of gall bladder duct by gall stones (calculi)
• May occur after major trauma, burns, or surgery
• Occurs in HIV infected persons as acalculous cholecystitis

Clinical features

• Sudden onset of pain and tenderness in the right upper quadrant of the abdomen; worsens on deep breathing
• Nausea and vomiting
• Jaundice (in cholangitis)
• Fever (38-39°C) with chills

Severity of acute cholecystitis is classified into:

GRADE	DEFINITION
Grade I (mild acute cholecystitis)	Associated with no organ dysfunction and limited disease in the gallbladder, making cholecystectomy a low-risk procedure
Grade II (moderate acute cholecystitis)	Associated with no organ dysfunction, but with extensive disease in the gallbladder, resulting in difficulty in safely performing a cholecystectomy Usually characterized by: An elevated white blood cell count A palpable, tender mass in the right upper abdominal quadrant Disease duration of more than 72 hours Imaging studies indicating significant inflammatory changes in the gallbladder.
Grade III (severe acute cholecystitis)	Acute cholecystitis with organ dysfunction (shock)

Differential diagnosis

• Acute alcoholic hepatitis
• Intestinal obstruction

Investigations

• X-ray, abdominal ultrasound: findings are wall thickening ± stones pericholecystic fluid
• Blood: Haemogram, liver tests, pancreatitis. Findings are: fever, elevated white blood cells
• Enzymes and renal function tests

ManagementTreatment

• Nil by mouth
• Relieve pain: Pethidine 50–100 mg IM every 6 hours
• Rehydrate with IV fluids and electrolytes e.g. Ringer’s lactate
• Ceftriaxone 1-2 g daily

In cholecystitis:

• Refer to hospital within 2–3 days for surgery (cholecystectomy)
• In cholangitis, if not better refer for urgent surgical management