Acute Cholecystitis

Pathophysiology

1) inflammation of gallbladder 2) causes are obstructing calculi in cystic duct (95%) and bile stasis (occurs in critically ill patients in the ICU) 3) pathologic process involves distention of gallbladder, edema, inflammation, venous and lymphatic obstruction, ishcemia, ulceration, and necrosis

Signs and Symptoms

1) abdominal, epigastric, right upper quadrant pain (sometimes radiates to scapula) 2) positive Murphy’s sign 3) anorexia, vomiting, diarrhea 4) fever 5) light-colored stools

Characteristic Test Findings

Ultrasound – 1) calculi 2) gallbladder wall thickening 3) cystic duct dilatation 4) pericholecystic fluid HIDA scan – 5) nonvisualization of gallbladder Laboratory – 6) leukocytosis 7) increased transaminases 8) increased bilirubin 9) increased amylase

Histology/Gross Pathology

1) leukocyte infiltration of mucosa 2) positive bile cultures in 50-70% of cases

Associated Conditions

1) high fat diet 2) pancreatitis 3) cholangitis 4) perforation and bile peritonitis 5) abscess formation 6) emphysematous gallbladder

Inheritance/Epidemiology

1) female to male, 3:1 2) more common in whites

Treatment

1) intravenous antibiotics to cover E. Coli, Klebsiella, Strep, Clostridium, Proteus (e.g., metronidazole and cefoxitin or Unasyn) 2) nothing by mouth 3) surgical removal, or if patient is critically ill, surgical drainage (cholecystectomy) with later resection

Tips for USMLE

1) if gallstones are found incidentally and are asymptomatic, cholecystectomy is not performed in non-diabetics 2) Murphy’s sign is inspiratory arrest with deep palpation of right upper quadrant (edge of inflammed gallbladder contacts fingertips causing pain) 3) pain classically occurs after a fatty meal or wakes the patient up at night 4) classic mnenomic is female, fat, fertile, forty

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