QuestionSBA
QuestionChoice
NICE guidelines states that any patient with suspected acute cholecystitis should be urgently admitted to hospital. This patient has signs and symptoms highly suspicious of acute cholecystitis. They have a positive Murphy's sign (the patient stops in their inspiration due to tenderness over the right upper quadrant when palpated by the GP)
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Urgent admission
QuestionChoice
Liver Function Tests may be useful in aiding the diagnosis. However, there is high clinical suspicion of acute cholecystitis. Therefore, the patient requires urgent admission as they may need an urgent cholecystectomy
32981
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Urgent Liver Function Tests
QuestionChoice
This patient has signs and symptoms highly suspicious of acute cholecystitis. They have a positive Murphy's sign (the patient stops in their inspiration due to tenderness over the right upper quadrant when palpated by the GP). Although abdominal ultrasound is highly sensitive and specific for gallstones, the patient requires urgent admission for possible surgical treatment
32979
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Urgent outpatient abdominal ultrasound
QuestionChoice
This patient has signs and symptoms highly suspicious of acute cholecystitis. Although they do require antibiotic therapy and analgesia, the antibiotics will need to be intravenous and accompanied by intravenous fluids. The patient may also require urgent surgery. Therefore, this cannot be treated in the outpatient environment
32982
e
Oral antibiotics, analgesia and urgent outpatient abdominal ultrasound
QuestionChoice
This patient has signs and symptoms highly suspicious of acute cholecystitis. Although they do require antibiotic therapy and analgesia, the antibiotics will need to be intravenous and accompanied by intravenous fluids. The patient may also require urgent surgery. Therefore, they require urgent admission
32980
c
Oral antibiotics and analgesia
QuestionComment
Take the green thing out too!!
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# Summary

Cholecystitis is the inflammation of the gallbladder, typically caused by cholelithiasis, and can present as acute or chronic. The characteristic symptoms are right upper quadrant or epigastric pain, fever, nausea, vomiting, and right upper quadrant tenderness. Murphy's sign is commonly positive. Diagnosis is primarily made with an abdominal ultrasound. Management strategies depend on the severity of the condition, with supportive care and early laparoscopic surgery being the definitive treatment. More severe cases may require intensive treatment unit (ITU) admission and urgent cholecystostomy.

# Definition

Cholecystitis refers to the acute or chronic inflammation of the gallbladder, which is commonly precipitated by cholelithiasis, or gallstones. 
Cholecystitis can be categorised into acute or chronic forms based on the duration and progression of inflammation, and into calculous or acalculous types based on the presence or absence of gallstones. 

# Epidemiology

Cholecystitis is a common gastrointestinal disease and one of the major causes of hospital admissions related to gastrointestinal disorders worldwide. It affects women more than men, with an estimated ratio of 2:1. Age is a significant risk factor, with incidence rising in individuals over 40 years of age. Other risk factors include obesity, ethnicity (higher prevalence in Hispanic and Native American populations), rapid weight loss, diabetes, pregnancy, and a family history of gallstones.

# Pathophysiology

Cholecystitis predominantly results from the obstruction of the cystic duct by gallstones. This obstruction can lead to an infection in the gallbladder caused by organisms including:

-   E.coli (most common)
-   Klebsiella
-   Enterococcus

# Classification

Cholecystitis  can be classified into two main categories: acute and chronic. Additionally, cholecystitis can be further categorised based on the presence or absence of gallstones.

1. **Acute Cholecystitis:** This is characterised by the sudden onset of inflammation in the gallbladder. It is often associated with the presence of gallstones, particularly when one of these stones obstructs the cystic duct, leading to a buildup of bile and subsequent inflammation. 

2. **Chronic Cholecystitis:** This is a long-term, smoldering inflammation of the gallbladder, usually caused by the repeated irritation of gallstones. Over time, chronic cholecystitis can lead to thickening of the gallbladder wall and a decrease in its overall function. Unlike acute cholecystitis, chronic cholecystitis may have milder and more intermittent symptoms, including recurrent abdominal discomfort after meals.

3. **Calculous Cholecystitis:** This type of cholecystitis occurs when gallstones are present in the gallbladder. These stones can obstruct the cystic duct, impair bile flow, and trigger an inflammatory response. Calculous cholecystitis is the most common form of cholecystitis.

4. **Acalculous Cholecystitis:** In contrast, acalculous cholecystitis develops without the presence of gallstones. It is often associated with other underlying medical conditions, such as critical illness, severe trauma, or prolonged fasting, which can lead to gallbladder stasis or ischaemia. Acalculous cholecystitis is less common but can be more severe and challenging to diagnose, as it may not present with the typical gallstone-related symptoms.


# Signs and Symptoms

Patients with acute cholecystitis present with:

-   Right upper quadrant/epigastric pain, which can radiate to the right shoulder tip if the diaphragm is irritated
-   Fever
-   Nausea and vomiting
-   Right upper quadrant tenderness
-   Positive Murphy's sign

In cases with associated biliary obstruction, patients may exhibit jaundice, dark urine, and pale stools. However, these are not key features of cholecystitis.

# Differential Diagnosis

The differential diagnoses for cholecystitis primarily include other conditions that cause right upper quadrant pain. The key signs and symptoms for these conditions are:

-   **Acute pancreatitis**: Epigastric pain radiating to the back, nausea and vomiting, tenderness of the abdomen.
-   **Peptic ulcer disease**: Epigastric pain that may be relieved by eating, dark stool (melena), nausea and vomiting.
-   **Hepatitis**: Jaundice, fatigue, pale stools, dark urine, and flu-like symptoms.
-   **Right lower lobe pneumonia**: Cough, fever, shortness of breath, and right-sided abdominal pain.

# Investigations

* The first line investigation for suspected cholecystitis is an ultrasound examination of the abdomen, which can identify gallstones, gallbladder wall thickening, and pericholecystic fluid. 
* Alongside this, blood tests including FBC, U+Es, CRP and LFTs will help reveal if there is an underlying infection/evidence of sepsis, as well as any cholestasis
* CT abdomen-pelvis (rarely MRI) is helpful to look for complications e.g. perforation, collections

# Management

The management of cholecystitis varies depending on its subtype and the clinical circumstances. Here's a summary of management for each subtype of cholecystitis:

**Acute Calculous Cholecystitis:**

- **Conservative Management:** In mild cases, patients may be managed conservatively with bowel rest, fasting, and intravenous fluids to relieve symptoms.
- **Antibiotics:** Antibiotics, often covering common pathogens like Escherichia coli and Klebsiella pneumoniae, are typically prescribed.
- **Cholecystectomy:** The definitive treatment for acute calculous cholecystitis is laparoscopic cholecystectomy, which is recommended during the same hospital admission or within a week.

**Acalculous Cholecystitis:**

- **Prompt Surgery:** Acalculous cholecystitis is considered a surgical emergency, and prompt cholecystectomy is typically recommended.

**Chronic Cholecystitis:**

- **Elective Cholecystectomy:** For patients with chronic cholecystitis, an elective laparoscopic cholecystectomy may be performed to prevent recurrent episodes and complications.
- **Symptomatic Management:** In some cases, patients may initially receive symptomatic management and dietary modifications, but surgery is eventually recommended.

Further research now focuses on timing of intervention, resulting in what is now known as 'hot' vs 'cold' laparoscopic cholecstectomies:

**Hot Elective Cholecystectomy:**

- In cases of acute cholecystitis where the patient's condition has improved with conservative management, but the inflammation is still present, an elective ("hot") laparoscopic cholecystectomy should be performed within 6 weeks of the acute episode.
- This approach balances the need to address the underlying cause with allowing the patient's condition to stabilise.

**Cold Elective Cholecystectomy:**

- In cases of chronic cholecystitis or asymptomatic gallstones, where there is no acute inflammation or infection, an elective ("cold") laparoscopic cholecystectomy can be scheduled based on the patient's convenience and availability.
- This approach avoids the urgency associated with acute inflammation.

In summary, the management of cholecystitis includes conservative measures, antibiotics, and surgical intervention, depending on the subtype and clinical circumstances. Elective laparoscopic cholecystectomy is recommended for both acute calculous cholecystitis (after symptom resolution) and chronic cholecystitis. The timing of surgery may vary, with "hot" cholecystectomy addressing acute inflammation and "cold" cholecystectomy focusing on non-urgent cases.

### Complications of Laparoscopic Cholecystectomies

While the exact prevalence can vary, complications occur in a small but significant proportion of patients undergoing cholecystectomy. Post-cholecystectomy syndrome is seen in approximately 10-15% of patients.

-   **Haemorrhage:** Rapid hypotension or development of a retroperitoneal haematoma. May require surgical intervention if severe.
-   **Post-cholecystectomy syndrome:** Symptoms include colicky abdominal pain, diarrhea, vague abdominal pain, and jaundice. Management is symptomatic with e.g. anti-spasmodics for pain and nausea.
-   **Bile duct injury:** Presents with dark-colored urine and stools, potentially progressing to chemical peritonitis, causing abdominal pain and distension. Sometimes this requires surgical intervention.
-   **Pneumoperitoneum:** Trapped air in the subcutaneous space can lead to subcutaneous emphysema, pneumothorax, or air embolism.

# Complications


1. **Empyema:** This occurs when the gallbladder becomes filled with pus due to a severe infection. It can lead to systemic infection and sepsis if not treated promptly.

2. **Gangrenous Cholecystitis:** In severe cases of cholecystitis, the gallbladder tissue may become necrotic (dead) due to impaired blood flow. This condition is known as gangrenous cholecystitis and can lead to tissue perforation, abscess formation, or peritonitis.

3. **Perforation:** Prolonged inflammation can cause the gallbladder to rupture or perforate, leading to bile leakage into the abdominal cavity. This is a life-threatening emergency requiring immediate surgery.

4. **Abscess Formation:** A collection of pus can develop within or around the gallbladder, leading to an abscess. Abscesses may require drainage and antibiotic therapy.

5. **Bile Duct Obstruction:** Inflammation or gallstones can cause blockage of the common bile duct, leading to jaundice, pancreatitis, or cholangitis (bile duct infection).

6. **Chronic Cholecystitis Complications:** Long-term inflammation of the gallbladder may lead to scarring, thickening of the gallbladder walls, and impaired gallbladder function. This can result in chronic abdominal pain and discomfort.


# NICE Guidelines

[Click here to see the NICE guidelines on cholecystitis](https://cks.nice.org.uk/topics/cholecystitis-acute/)
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A 55-year-old female attends her GP due to right upper quadrant pain. She has been vomiting and feels feverish. She has a past medical history of gallstones, hyperlipidaemia and obesity. On examination there is rebound tenderness over the right upper quadrant. Furthermore, when the GP rests two fingers over the right upper quadrant and asks the patient to inspire, this leads to acute tenderness and patient stopping her inspiration.

What is the most appropriate management?
a