Medical Student Clinical Pearl

Alana Jewell

M.D. Candidate, Class of 2022

Memorial University Faculty of Medicine

Reviewed & Edited by Dr. Mandy Peach

All case histories are illustrative and not based on any individual.

 

Case Presentation

A 70-year-old gentleman presented with four days of right upper abdominal pain radiating to the LUQ with nausea + vomiting, anorexia, flatulence, and bloating. Patient has PMHx of Crohn’s disease with a history of small bowel obstruction (SBO) and multiple surgeries. He felt these symptoms were like his SBO but he continued to have normal bowel movements. He had a similar episode a few months ago after eating fast food, but did not seek care for.

You suspect cholecystitis.

 

Differential Diagnosis

Can’t miss diagnoses for atraumatic abdominal pain ⁴:

ruptured AAA

pancreatitis

cholangitis

mesenteric ischemia

obstruction

perforated viscus

complicated diverticulitis

ruptured ectopic pregnancy

Differential for RUQ pain ⁴ :

hepatitis

biliary colic

cholecystitis

cholangitis

pancreatitis

pneumonia

pleural effusion

pulmonary embolism

 

There is no single exam finding or laboratory test that has the ability to rule out acute cholecystitis⁵.

 

A combination of clinical evaluation, laboratory values, and diagnostic imaging are key to differentiate abdominal pain and make a diagnosis.

 

Cholecystitis

Cholecystitis is defined as inflammation of the gallbladder, typically caused by persistent stone obstruction in the cystic duct.

Acute cholecystitis (AC): Stone obstruction leads to bile trapping, increased intraluminal pressure, and an acute inflammatory process, typically presenting with RUQ pain, leukocytosis, and fever¹.

Chronic cholecystitis: defined as recurrence of these events and is associated with fibrosis and mucosal atrophy².

Acalculous cholecystitis: consider in chronically debilitated patients, classically elderly patients in ICU on total parental nutrition after sustained trauma or significant burn injury¹¹.

Ascending (or acute) cholangitis: an important complication of cholecystitis – a serious bacterial infection of the common bile duct. It presents with Charcot’s triad of fever, jaundice, and abdominal pain².

 

Acute cholecystitis is diagnosed and graded on severity by using the Tokyo Guidelines³.

 

 

 

Gallstones (which cause 95% of acute cholecystitis) are common in Western society, with about 10% of people affected, and 80% of those affected being asymptomatic^1,3. The risk of pain or complications is 1-4% per year².

 

Risk factors for cholesterol gallstones (the most common type) ²:

increased age

female gender

pregnancy

parity

race

high calorie

low fibre diet

low activity

obesity

 

 

 Clinical Presentation and findings

Clinical presentation varies with severity.

On history, a patient may have anorexia, emesis, fever, nausea, and RUQ pain.  On examination, guarding, Murphy’s sign (pain upon deep inspiration while palpating RUQ), rebound tenderness, abdominal rigidity, and RUQ tenderness may be seen². Patients may describe a history of biliary colic, but with the presenting episode being more severe and longer in duration.

Mild-moderate cases have RUQ pain, fever, leukocytosis, and may have a palpable mass in the RUQ². The most severe patients may have jaundice and, if have a secondary bacterial infection, could have signs of sepsis.

 

Case Continued

 

Physical Exam

Patient was tender to light palpation over RUQ and epigastric region. No rigidity, rebound tenderness, or guarding was noted.

Bloodwork

• Elevated WBC with neutrophilic shift
• C reactive protein > 250
• Normal lipase, liver enzymes and renal function.

The most common laboratory findings in acute cholecystitis are an increased CRP and leukocytosis².

 

This patient requires imaging to confirm the suspected diagnosis.

 

Diagnostic Imaging

Ultrasound

Ultrasound is the first-choice modality for imaging of AC. It is easily available in any emergency department, cost-effective, and minimally invasive³. Ultrasound findings can include^5,6,9, as seen below ^6.

GB wall thickening > 3.5 mm

pericholecystic fluid

biliary sludge

gallstones

sonographic Murphy sign

 

If an ultrasound is positive, there is no need for further testing.

If negative, a CT should be ordered to exclude other diagnoses^2,7.

 

CT findings for AC may include ^3,6 as seen below ²:

thickening of GB wall

enlargement of GB

gallstones in GB neck or cystic duct

fluid accumulation around GB

pericholecystic fat stranding

 

Many gallstones are not radiopaque and may be missed on CT⁷. 

 

Management

Assessment with Tokyo Guideline diagnostic criteria can be used every 6-12 hours until a diagnosis is clear if initially uncertain, and to check severity until surgical management⁸.

In the Emergency Department, a patient is best managed with supportive care.

IV fluids,

NPO

Analgesia (NSAIDs are first-line treatment for AC. If ineffective, opioids are second line2. )

 

Secondary infection can result from bile stasis. Empiric antibiotics may be started against E. coli, Klebsiella, and Enterococcus⁵.

Definitive treatment for AC is cholecystectomy, with the gold standard being done laparoscopically (lap-C)^2,7. Having a lap-C within 24-72 hours of symptom onset is recommended to decrease complication rates. If left unoperated for more than 72 hours chronic inflammation may occur, potentially complicating the surgery¹. If a patient is ineligible for surgery, percutaneous cholecystostomy (gallbladder drainage) may be performed⁷.

 

Case Conclusion

Formal ultrasound found a hydropic gallbladder with pericholecystic fluid, thickened wall, and stranding. Cholecystitis was diagnosed. The patient was given analgesia and covered with ceftriaxone and metronidazole^10. He went on to have an uncomplicated lap cholecystectomy.

 

References

1. Indar, Adrian A, and Beckingham, Ian J. “Acute Cholecystitis.” BMJ, vol. 325, no. 7365, 2002, pp. 639–643.
2. Wilkins, Thad, MD, MBA, et al. “Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia.” Primary Care, vol. 44, no. 4, 2017, pp. 575–597.
3. Yokoe, Masamichi, et al. “Tokyo Guidelines 2018: Diagnostic Criteria and Severity Grading of Acute Cholecystitis (with Videos).” Journal of Hepato-Biliary-Pancreatic Sciences, vol. 25, no. 1, 2018, pp. 41–54.
4. Anjum, Omar, et al. “Ottawa’s Clerkship Guide to Emergency Medicine.” Department of Emergency Medicine, University of Ottawa, Mar. 2018.
5. Jain, Ashika, et al. “History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis.” Academic Emergency Medicine, vol. 24, no. 3, 2017, pp. 281–297.
6. Chawla, Ashish, et al. “Imaging of Acute Cholecystitis and Cholecystitis-Associated Complications in the Emergency Setting.” Singapore Medical Journal, vol. 56, no. 8, 2015, pp. 438–444.
7. Bagla, Prabhava, et al. “Management of Acute Cholecystitis.” Current Opinion in Infectious Diseases, vol. 29, no. 5, 2016, pp. 508–513.
8. Mayumi, Toshihiko, et al. “Tokyo Guidelines 2018: Management Bundles for Acute Cholangitis and Cholecystitis.” Journal of Hepato-Biliary-Pancreatic Sciences, vol. 25, no. 1, 2018, pp. 96–100.
9. Flemming, Lewis & Henneberry (2017). PoCUS – Measurements and Quick Reference https://sjrhem.ca/pocus-measurements-quick-reference/
10. Bugs & Drugs Medical App
11. Forsythe (2016). Cholecystitis. First Aid for the Emergency Medicine Boards, Third Edition: Abdominal and Gastrointestinal Emergencies. McGraw-Hill Education. China.