Acute cholecystitis and ischemic colitis

ACUTE CHOLECYSTITIS

GENERAL FEATURES


• Cholecystitis is most commonly associated with cholelithiasis but may be related to biliary stasis.


• Risk factors include female sex, overweight, rapid weight loss, and concomitant malabsorption or sickle cell disease.


• There appears to be a genetic predisposition to biliary tract disease.


CLINICAL ASSESSMENT


• History


– Right upper quadrant (RUQ) or epigastric pain that is colicky or constant is the most common symptom. Pain is usually postprandial and may radiate to the right shoulder.


– Patients may recall similar, less severe past episodes, often associated with ingestion of fatty foods.


– Fever, anorexia, and vomiting are usually present.


– The combination of fever, RUQ pain, and jaundice (Charcot triad) should alert the provider to possible ascending cholangitis.


• Physical examination


– RUQ tenderness is most common sign; interruption of deep inspiration with firm palpation beneath right costal arch below hepatic margin (positive Murphy sign) may be present.


– Patients may be febrile and tachycardic and may appear ill and obviously uncomfortable.


– In longstanding chronic biliary disease, jaundice may be noted, but it is not common in acute uncomplicated disease.


– Charcot triad plus hypotension and altered mental status indicates potential septic cholangitis. 


DIAGNOSIS 


• Laboratory findings may include leukocytosis with a left shift, elevated aminotransferases, and mild hyperbilirubinemia. Amylase may be mildly elevated; more pronounced elevation may be noted when acute cholecystitis occurs with acute pancreatitis due to a stone in the common bile duct.


• Ultrasound, the imaging modality of choice, may show thickened 
gallbladder wall, stones in the gallbladder, or pericholecystic fluid.


• If ductal obstruction is suspected, a hepatobiliary iminodiacetic acid (HIDA) scan may show contrast filling a portion of the common bile duct and small bowel but not the gallbladder.


TREATMENT


• Depends on severity of disease and health of patient. If patient is stable, pain-free, and tolerating food, may discharge and plan for elective surgery.


• If unstable, not tolerating food, or having uncontrolled pain, admission 
with planned cholecystectomy is standard. If a common bile duct stone is suspected, an intraoperative common bile duct exploration may be performed. 


• IV fluids and pain medicine should be administered to admitted patients. There is debate over appropriateness of morphine for pain control because of the potential for sphincter of Oddi spasm; the literature is split, and clinician preference generally dictates use.


• Broad-spectrum IV antibiotics, such as piperacillin/tazobactam or third-generation cephalosporins, may be used if infection is suspected.


• In nonsurgical candidates, lithotripsy or use of bile acids, such as chenodeoxycholic acid or ursodeoxycholic acid, may be an option.