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