Gallbladder disease (main)

DDX

1. Cholecystitis
2. Cholangitis
3. Symptomatic Cholelithiasis

Acute Cholecystitis

Diagnosis

1. RUQ pain + fever + leukocytosis associated with gallbladder inflammation
2. Ultrasound
   1. GB wall thickening (greater than 4-5mm) or edema (double wall sign)
   2. Sonographic Murphy's Sign

Treatment

1. Antibiotics
   1. Although clear evidence is lacking, assoc/ w/ decreased wnd infection and bacteremia
   2. CTX + metronidazole OR piperacillin/tazobactam (Zosyn) OR ampicillin-sulbactam (Unasyn)
2. Admit

Complications

1. Gangrene
   1. Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
   2. Consider if pt presents with sepsis in addition to cholecystitis
2. Perforation
   1. Occurs in 2% after development of gangrene
   2. Usually localized, leading to pericholecystic abscess
3. Gallstone Ileus
   1. Due to cholecystoenteric fistula
4. Emphysematous cholecystitis
   1. Due to secondary infection of GB by gas-forming organisms
   2. Presents like cholecystitis (crepitus in abdominal wall may rarely be detected)
   3. IV abx and cholecystectomy are essential
   4. Ultrasound report may mistake GB wall gas for bowel gas

Cholangitis

Diagnosis

1. Charcot's Triad: Fever + jaundice + RUQ pain
   1. Occurs in 50-75%
2. Reynold's Pentad: The triad + AMS + hypotension
   1. Hypotension may be the only presenting sign in elderly pts
3. Labs
   1. Leukocytosis with neutrophil predominance
   2. Elevated alk phos, conj. bilirubin
   3. Blood culture is indicated
4. Imaging
   1. Ultrasound
      1. Dilatation of CBD ( > 6mm) and presence of choledocholithiasis
      2. May miss small CBD stones and in acute cases CBD may not have had time to dilate
5. ERCP
   1. Should be obtained to confirm the diagnosis and to intervene

Treatment

1. Broad-spectrum parenteral Abx covering gram - and anerobes
   1. CTX + metronidazole OR piperacillin/tazobactam (Zosyn) OR ampicillin-sulbactam (Unasyn)

Symptomatic Cholelithiasis

Diagnosis

1. History
   1. RUQ pain that is usually constant, not colicky
   2. Usually does not occur during fasting
2. Physical Exam
   1. Often benign; as compared to cholecystitis, usually negative Murphy's Sign
3. Labs
   1. LFT, CBC normal
4. Ultrasound
   1. Sensitivity 84%, Specificity 99%

Treatment

1. IV/IM Ketorolac (as effective as meperidine) with Rx for Ibuprofen

Source

UpToDate