1. Acute cholecystitis
Diagnosis

2. History Triad of sudden onset Accompanying symptoms RUQ tenderness
Fever (low-grade)
Leukocystosis (10,000-15,000 cells/uL)
Accompanying symptoms
Nausea and vomiting
Abdominal pain (severe, persistent)

3. Physical Examination Vary with the severity
right hypochondrial tenderness
muscle guarding, rigidity, rebound tenderness
some degree of fever
tachycardia
Murphy’s sign: variable

4. Laboratory Laboratory finding: ALT/AST: mildly raised
Alkaline phosphate: mildly elevated
Bilirubin: variable, may rise to 85 mol/l
CBC/DC: elevated due to acute inflammation

5. Imaging studies Ultrasound Initial investigation of choice
Most useful diagnostic tool
Demonstrate calculi in 90-95% of cases
no intrahepatic or extrahepatic ducts dilatation
Useful in detection of gallbladder inflammation
Thickening of the wall
Pericholecystic fluid
Dilation of the bile duct
Sonographic Murphy’s sign
Color doppler scan to r/o ischemia condition

6. Imaging studies Computed tomography
Typical CT findings: wall thickening, pericholecystic stranding, and distension
Other findings: pericholecystic fluid, gallstones, luminal membranes and gas in the gallbladder wall
Findings of mural or luminal gas, intraluminal membranes, irregular wall or pericholecystic abscess are strongly suggestive of gangrenous cholecystitis
r/o other differential diagnosis

7. Imaging studies ERCP (Endoscopic retrograde cholangiopancreatography)
Diagnostic
Significantly dilated common bile duct
Therapeutic
ERCP is now rarely performed without therapeutic intent

8. Imaging studies Radionuclide (HIDA) biliary scan
Evaluate health and function of gallbladder
usually technetium-99m
HIDA scan (Hepatobillary imino-diacetic acid scan)
Sensitivity: 95%, specificity 93-96%
Positive predictive value: 92.1%, negative predictive value: 99%
Adequate filling of the gallbladder
Acute cholecystitis is effectively excluded
Cystic duct obstruction
Failure to visualize the gallbladder up to 4 hours

9. Acute cholecystitis
Treatment

10. Medical therapy In-hospital stabilization Oral intake is eliminated
Nasogastric suction may be indicated
Extracellular volume depletion
Electrolyte imbalance

11. Medical therapy Meperidine or NSAIDs Intravenous antibiotics
For analgesia
Produce less spasm of the sphincter of Oddi
Intravenous antibiotics
Severe acute cholecystitis
Piperacillin or mezlocillin, ampicillin sulbactam, ciprofloxacin, moxifloxacin and 3rd gen cephalosporins
Reduce postoperative complications of wound infection, abscess formation, or sepsis

12. Surgical therapy Open or laparoscopic cholecystectomy
Optimal timing of surgery – depends on stabilization of patient
Urgent (emergency) cholecystectomy or cholecystostomy – appropriate for suspected or confirmed complications such as empyema, emphysematous cholecystitis, or perforation
Delayed surgical intervention
Early cholecystectomy (usually within 72hrs of admission) – treatment of choice