Acute cholecystitis

Clinical features:

The symptoms are similar to biliary colic but:

• Pain is more severe and persistent
• Nausea/vomiting
• Fever
• Tenderness/guarding in the RUQ
• Murphy’s sign:
• Lay a hand lightly on the upper right abdomen and ask the pt to take a deep breath in. A positive sign will be revealed by the pt ‘catching their breath’ caused by the inflamed gallbladder impacting on the examining hand.

Investigations:

Blood tests:

• Leucocytosis
• Raised Bilirubin
• Moderately elevated serum amylase

Imaging:

• Ultrasound shows an enlarged gallbladder with:
• Stone(s)
• Thickened wall
• Surrounding rim of fluid from local oedema

Mx:

Conservative (the initial rx):

• Analgesia
• Systemic A/Bs
• IV fluids

Operative (if conservative rx fails):

• Cholecystectomy is curative and must be performed if initial rx fails to work due to the risk of perforation or the formation of an empyema.

Perforation:

• This is caused by a progressive rise in tension in the gallbladder
• The blood supply of the wall becomes reduced and gangrene occurs (usually at the fundus)
• Abdominal pain becomes increasingly severe and more generalised
• Perforation may lead to diffuse peritonitis
• A variant is local perforation with abscess formation

Empyema and pericholecystic abscess:

• The infection remains localised, with the accumulation of pus within the gallbladder.
• Swinging fever
• Tachycardia
• Tender mass in the RUQ