ACUTE CHOLECYSTITIS

Cholangitis

Inflammation of the gall bladder and/or of the biliary tract. It often requires surgical management.

Causes

  • Obstruction of gall bladder duct by gall stones (calculi)
  • May occur after major trauma, burns, or surgery
  • Occurs in HIV infected persons as acalculous cholecystitis

Clinical features

  • Sudden onset of pain and tenderness in the right upper quadrant of the abdomen; worsens on deep breathing
  • Jaundice (in cholangitis)
  • Fever (38-39°C) with chills

Severity of acute cholecystitis is classified into:

GRADE DEFINITION
Grade I
(mild acute
cholecystitis)
Associated with no organ dysfunction
and limited disease in the gallbladder,
making cholecystectomy a low-risk
procedure
Grade II
(moderate
acute
cholecystitis)
Associated with no organ dysfunction,
but with extensive disease in the
gallbladder, resulting in difficulty in
safely performing a cholecystectomy

Usually characterized by:

  • An elevated white blood cell count
  • A palpable, tender mass in the right
    upper abdominal quadrant
  • Disease duration of more than
    72 hours
  • Imaging studies indicating significant
    inflammatory changes in the
    gallbladder.
Grade III
(severe acute
cholecystitis)
Acute cholecystitis with organ
dysfunction (shock)

Differential diagnosis

  • Acute alcoholic hepatitis
  • Intestinal obstruction

Investigations

  • X-ray, abdominal ultrasound: findings are wall thickening ± stones pericholecystic fluid
  • Blood: Haemogram, liver tests, pancreatitis. Findings are: fever, elevated white blood cells
  • Enzymes and renal function tests

Management

  • Nil by mouth
  • Relieve pain: Pethidine 50–100 mg IM every 6 hours
  • Rehydrate with IV fluids and electrolytes e.g. Ringer’s lactate
  • Ceftriaxone 1-2 g daily

In cholecystitis:

  • Refer to hospital within 2–3 days for surgery (cholecystectomy)
  • In cholangitis, if not better refer for urgent surgical management