Case Study of the Week: Acute Cholecystitis

'Slam-dunk' diagnoses are my favorite kind.  Listening to a patient describe their symptoms and identifying their problem is gratifying.  Often these diagnoses are rashes, visual clues as to what is going on inside the body.  Other 'slam-dunk' diagnoses affect a predictable type of patient and are easily identified by their telltale symptoms.  Acute cholecystitis is one if these conditions.

"Fair, fat, female and forty" describes the typical patient affected by acute cholecystitis.  This disease occurs most commonly in women and risk increases with age.  Acute cholecystitis occurs when a stone obstructs the common bile duct resulting in thickening of bile, bile stasis and secondary infection by gut organisms.  

Case Presentation

A forty two year-old woman presents to the emergency department complaining of abdominal pain, nausea and vomiting.  She notes she has had prior similar episodes which resolved spontaneously however the pain today has persisted for five hours and is much more severe.  She appears uncomfortable and is clutching her abdomen.  The pain is located in the right upper quadrant of her abdomen and radiates to her upper back.  She describes the pain as dull and cramping.  The patient's vital signs are as follows: BP 148/96, P108, R18, T99.9.  She has a history of hypertension and is overweight.  

On exam, you note the patient has right upper quadrant abdominal tenderness and guarding.  Murphy's Sign (a pause with inspiration on palpation of the right upper quadrant) is positive.  Based on the patient's symptoms you order labs including a CBC, CMP, amylase, lipase, urinalysis, urine Hcg as well as an ultrasound of the patient's gallbladder.

Management and Outcome

White blood cell count will likely be elevated in acute cholecystitis with 61% of patients having a white count of greater than 11,000.  WBC greater than 15,000 may indicate gallbladder perforation or gangrene.  Liver enzymes including AST, ALT and ALP may also be elevated in acute cholecystitis especially in the case of a common bile duct stone.

Ultrasound is the preferred imaging technique in cases of suspected cholecystitis.  Ultrasound in cholecystitis will show gallbladder wall thickening, gallbladder distention and pericholecystic fluid.  Murphy's sign is also evaluated with ultrasound and will likely be positive in patients with acute cholecystitis.  Abdominal CT scan can also be used in diagnosis but is less reliable than ultrasound.  HIDA scan assesses gallbladder function and is useful when ultrasound results are negative but gallbladder disease is suspected.

Upon diagnosing acute cholecystitis, a surgeon should be consulted and the condition treated on either an inpatient or outpatient basis depending on severity.  Antiemetics, pain control and antibiotics are the mainstay of treatment.  30% of patients will not improve with conservative treatment and require cholecystectomy.  Typically, this procedure is preformed laparoscopically with few complications.

Discussion

Although common and relatively easy to diagnose, acute cholecystitis can lead to complications including gangrene of the gallbladder and peritonitis and therefore must be properly diagnosed and treated.  Encourage your patients with biliary colic (pain associated with gallstones, a precursor to cholecystitis) to consume a low fat diet to prevent developing acute cholecystitis.  Warn them of the symptoms of acute cholecystitis so they know to seek treatment should they develop this painful condition. 

 

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Comments

great work

ali

Great review! Thank you!

Dedra hayden, A...