CHOLECYSTITIS

CASE REVIEW

A 71-year-old man presented to the ED with right upper quadrantpain of two day’s duration.The pain began as a dull ache in the midepigastrium and thenmoved to the right upper quadrant and right flank. He vomitedseveral times and was unable to eat. The emesis was a waterybrown material. He had a small bowel movement earlier thatday.He had a history of diabetes and hypertension and was takingglyburide and lisinopril.He had not had prior abdominal surgery.On examination, he was overweight and in mild distress dueto abdominal discomfort. His blood pressure was 148/100 mm Hg,pulse 110 beats/min, respiratory rate 24 breaths/min, temperature100.4°F (rectal).He was alert and oriented. His oral mucosa was dry and sclera was anicteric. His lungs were clear and his heart wasr apid and regular without a murmur

Abdominal examination revealed diminished bowel sounds,moderate tenderness in the right upper quadrant, and a Murphy’ssign. There was no tenderness on rectal examination andstool was guiac negative.An intravenous line was started and blood specimens wereobtained. Intravenous fluids, insulin, and ampicillin/sulbactamwere administered

Blood test results (units for electrolytes, mEq/L and chemistryvalues, mg/dL, except where noted):WBC 19,700/mm3, hematocrit 49%, platelets 246,000/mm3.Na 132, K 4.1, Cl 101, CO2 22, BUN 24, creatinine1.4, glucose 406.ALT 100 U/L (normal: 7–37), AST 65 U/L, alkaline phosphatase61 U/L (normal: 39–117), total bilirubin 1.6(normal: 0.2–1.2), lipase 110 U/L (normal).A bedside sonogram was performed and the gallbladder couldnot be confidently identified. The patient was sent to the radiologydepartment for another abdominal ultrasound study. Selectedultrasound images, including the right upper quadrant,are shown in Figure 1.

TYPICAL SONOGRAPHIC APPEARANCE OF

GALLSTONE

UNDER WHAT CIRCUMSTANCES WOULD THE GALLBLADDER

NOT HAVE ITS TYPICAL APPEARANCE?

• When patient has recently eaten.• Multiple episodes of cholecystitis (scarred and

shrunken)• Filled w/stones or contracted around

gallstones• Air filled gallblader (empysematouse

cholecystitis)

WALL-ECHO-SHADOW (WES) OR DOUBLE ARC

EMPHYSEMATOUS CHOLECYSTITIS

• Emphysematous cholecystitis < 1%• ATC: elderly, male, dbt• Mortality rate: 15% (1.4 cholecystitis)• TTO: CX because of perforation• Test of choice: Abdominal RX

• Air in the biliary system also occurs w/ enteric-biliary fistula (gallstone ileus or surgical anastomosis)– Gallbladder is collpased rather than distended

GAS IN THE GALLBLADDER WALL IS PATHOGNOMONIC FOR EMPHYSEMATOUS CHOLECYSTITIS

BEST INITIAL TEST?

• ULTRASONOGRAPHY : bright echogenic crescent in the gallbladder fossa with dirty shadowing and ring down artifacts.– Similar:

• Contracted stone-filled gallbladder (WES)• Porcelain gallbladder w/ calcified wall due to chronic

cholecystitis

• CONFIRMATION:– Abdominal rx or CT

IMAGING DIAGNOSIS OF ACUTE CHOLECYSTITIS

• Abdominal rx: 15% stones calcified• Ultrasound : > sensitive• Symptomatic:

– 80% without

DIAGNOSIS OF ACUTE CHOLECYSTITIS

• CLINICAL PRESENTATION• SIGNS OF GALLBLADDER INFLAMATION ON

SONOGRAPHY OR CT– GALLBLADDER WALL THICKENING (>3 TO 5MM)– PERICHOLECYSTIC FLUID– SONOGRPHIC MURPHY’S SIGN

CLINICAL PRESENTATION!

Persitant painFocal tendernessMurphy signLeukocytosisFever