Acute Cholecystitis and Complications

40 y/o Native American F with h/o DM, HLD, grand multiparity presents with acute on chronic abdominal pain. H/o similar relapsing/remitting pain x2 years. Now experiencing sudden onset, steady RUQ pain that started s/p consuming a fatty meal, has lasted >6 hours, and was not relieved by a bowel movement. Endorses chills and initially tried NSAIDs for pain relief with positive effect. PMH includes rapid weight cycling. Medications include OCPs. Fever, obesity, and positive Murphy’s sign on exam.

  • CBC shows leukocytosis

  • Obtain CMP, amylase, lipase, and total bilirubin levels

  • Imaging

    • Initial U/S shows bile duct dilation

    • Equivocal U/S with suspicion for acute cholecystitis: Obtain CT with contrast to confirm diagnosis and rule out complications, e.g. perforation

    • CT contraindicated: Consider HIDA vs. magnetic resonance cholangiopancreatography (MRCP)

  • Ketorolac 10 mg q4 hours as needed for pain; maximum duration of therapy = 5 days

  • Surgery c/s recommends laparoscopic cholecystectomy (CCY) within 72 hours of admission

Choledocolithiasis with suspected cholangitis +/- gallstone pancreatitis:

  • Development of jaundice, hypotension, and altered mental status since admission

  • NS at 125 cc/hr while NPO

  • Start metronidazole 500 mg IV q8 hours and ceftriaxone 2g IV qd

  • Suspect pt will benefit from endoscopic retrograde cholangiopancreatography (ERCP); consult GI

Notes

  • Risk factors for gall stones include ethnicity, female gender, and medical history including pregnancies (fat, female, forty, fertile and from the Americas)

  • Murphy’s sign: Pain that causes pt to stop inhaling while examiner palpates RUQ

  • Biliary colic

    • Pain due to intermittent impaction of gallstones against gallbladder neck; usually resolves after 1-5 hours

    • Two-thirds of patients will progress to acute cholecystitis within 2 years

    • Elective cholecystectomy should be considered after more than one occurrence

    • Antibiotic ppx is not required in low risk patients undergoing elective CCY

  • Choledocolithiasis

    • Obstruction of bile duct by gallstone → bacterial infection → complications

    • Bacterial infection within bile duct (cholangitis) may present with

      • Charcot’s triad: Fever, abdominal pain, jaundice

      • Renaud’s pentad: Charcot’s triad + hypotension and altered mental status