Infection with C trachomatis is the most frequently reported sexually transmitted infection in the United States. Chlamydia can be passed from person to person by vaginal, anal, or oral intercourse. Infections are frequently asymptomatic, making screening necessary to identification. The United States Preventive Services Task Force (USPSTF) recommends screening for Chlamydia in all sexually active women age 24 or younger and in older women who are at increased risk for infection. Risk factors for infection include having multiple sexual partners, young age, history of other STI, and non-Hispanic Black race. The risk of transmission can be reduced by the proper use of latex condoms with every sexual encounter. Untreated Chlamydia infections in women can lead to ascending infections (ie, pelvic inflammatory disease [PID]), with an increased risk of ectopic pregnancy or infertility. Chlamydia can also cause cervicitis in women and epididymitis in men. It can cause urethritis and pharyngitis in men and women.

Testing for Chlamydia can be performed by collecting samples directly from the cervix, pharynx, or urethra, or by C trachomatis nucleic acid amplification testing of properly collected urine samples. Patients diagnosed with Chlamydia and their sexual partner(s) should be treated to reduce the risk of complications and to prevent further spread of the disease. Common treatment regimens for uncomplicated infection include azithromycin 1 g single dose PO or doxycycline 100 mg PO twice a day for a week. Doxycycline should not be used in a pregnant woman.

 

 

 

A. History Part I: Pattern Recognition:

• Constant RUQ pain or epigastric pain - often lasting hours or more. Pain may begin after a fatty meal (about an hour later).

• Fever

• Nausea/vomiting

• Patients often give a history of previous biliary colic (RUQ pain, nausea/vomiting lasting up to several hours after a fatty meal, which resolves spontaneously)

B. History Part 2: Prevalence:

The classically described patient at high risk for acute cholecystitis is: female, forty, fat, and fertile. Family history plays a role. Rapid weight loss is a risk factor. However, this is a common disease and risk increases simply with age. Another type of cholecystitis, acalculous cholecystitis, is generally a disease of the critically ill.

C. History Part 3: Competing diagnoses that can mimic cholecystitis.

• Biliary colic: Should be self limited, colicky. Should not have fever/leukocytosis.

• Acute cholangitis: Patients are often severely ill, appear septic, jaundiced, with rigors. Significant liver function test abnormalities. Inevitably associated with bacterial infection.

• Peptic ulcer disease: No fever. Gastrointestinal (GI) bleeding.

• Acute gastritis: No fever. GI bleeding. Typically epigastric tenderness. Risk factors like non-steroidal anti-inflammatory drugs (NSAIDs), alcohol use.

• Acute hepatitis: Typical transaminitis. Jaundice. Subacute onset. Constitutional symptoms.

• Myocardial infarction/acute coronary syndrome: electrocardiogram (EKG) changes. Positive troponins. Associated symptoms such as dyspnea. Associated with exertion. History of coronary artery disease.

• Pulmonary embolus: Dyspnea. Wells score can help. Signs/symptoms of deep vein thrombosis.

• Acute pancreatitis: Can co-exist with cholecystitis. Elevated lipase and/or amylase.

• Pleurisy/pneumonia: Pleuritic pain (though cholecystitis pain can be pleuritic). Dyspnea. Cough.

• Liver Abscess: High fevers. Subacute onset. Weight loss. Pain.

• Fitz-Hugh-Curtis syndrome: Associated PID/vaginal discharge, isolate Chlamydia trachomatis or Neisseria gonorrhoeae from cervical swab.

• Pleurisy/pneumonia

D. Physical Examination Findings.

• Patients appear uncomfortable at rest

• Febrile

• May have mild jaundice

• RUQ or epigastric tenderness with normal sized liver (in absence of other liver disease)

• Murphy's sign (arrest of inspiration with palpation of the gallbladder)

• Radiologic Murphy's sign

E. What diagnostic tests should be performed?

N/A

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Complete blood count usually reveals leukocytosis. LFTs may or may not be abnormal. Signs of obstruction (mildly elevated direct bilirubin, elevated alkaline phosphatase out of proportion to transaminases) and mildly elevated transaminases can be present. Lipase can be abnormal if there is common bile duct obstruction distal to the pancreatic duct though this is uncommon.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Right upper quadrant ultrasound

The presence of gallstones does not make the diagnosis. Findings of acute cholecystitis include the following: gallstones with signs of inflammation, gallbladder wall thickening or edema and pericholecystic fluid. If common bile duct (CBD) obstruction exists, dilation of the CBD will be seen. In a patient with the appropriate clinical syndrome, RUQ ultrasound (US) can make the diagnosis.

Hepatobiliary iminodiacetic acid scan

If RUQ US does not reveal the typical findings of gallbladder inflammation and clinical suspicion remains high, hepatobiliary iminodiacetic acid (HIDA) scan can reveal cystic duct obstruction that would not be seen on ultrasound. Patients with cystic duct obstruction will have no filling of the gallbladder on HIDA scan. Patients with previous sphincterotomy or on total parenteral nutrition may have false positive tests as these conditions which favor flow of bile directly from the liver to the duodenum (bypassing the gallbladder).

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

A computed tomography (CT) scan is generally unnecessary to make the diagnosis. It can show gallbladder wall thickening, stones and signs of inflammation but generally is more expensive and has a higher risk of complications (dye) than either HIDA or US.

III. Default Management.

N/A

A. Immediate management.

• Nil per os (NPO)

• Pain control often with intravenous (IV) narcotics. NSAIDs may work as well.

• Antiemetics

• IV fluids as patients have often been unable to hold down food or fluids for some time

• IV antibiotics to cover enteric gram-negative bacilli and possibly Enterococcus. Rates of bacterial infection range from 22-46% in studies.

• Consult a surgeon for probable cholecystectomy

B. Physical Examination Tips to Guide Management.

Watch for increasing jaundice, which may be a sign of ongoing CBD obstruction or acute cholangitis. Crepitus in the RUQ can be a sign of emphysematous cholecystitis (infection with gas producing organisms), which should prompt broadening of antibiotic coverage and urgent to emergent cholecystectomy. It is more common in elderly male diabetics.

Signs of sepsis or peritonitis imply gangrene and/or perforation, which would require urgent/emergent surgical intervention.

Signs of small bowel obstruction can be due to "gallstone ileus" - obstruction at the terminal ileum by a gallstone that reaches the small bowel through an enteric fistula.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

• Checking white blood cell (WBC) count daily would be reasonable to watch for trend down.

• Checking LFTs can be helpful if CBD obstruction is suspected, since this would change management (clearance of CBD prior to or during surgery depending on specialist support available), or if cholangitis is suspected.

D. Long-term management.

Cholecystectomy, preferably laparoscopic, is the long-term treatment of choice. If there is low surgical risk, the patient should get laparoscopic cholecystectomy during the initial hospitalization which may reduce cost, length of stay, and conversion to open cholecystectomy as compared to a delayed (> 6 weeks) strategy.

If there is high surgical risk and if symptoms and signs of cholecystitis resolve during hospitalization with conservative medical measures, patients can be referred for future cholecystectomy.

If there is high surgical risk, with ongoing signs of acute cholecystitis, a cholecystostomy tube can be placed to drain the gallbladder until the patient is well enough to undergo cholecystectomy.

Other treatments such as extracorporeal shock wave lithotripsy and oral bile acid therapy have lower rates of success, higher recurrence rates and may cost more, but can be used in patients who remain high risk for surgery or refuse surgical intervention.

E. Common Pitfalls and Side-Effects of Management.

N/A

IV. Management with Co-Morbidities.

A. Renal Insufficiency.

No change in standard management.

B. Liver Insufficiency.

In severe liver disease, HIDA scan can be falsely positive if biliary excretion is not normal.

C. Systolic and Diastolic Heart Failure.

No change in standard management.

D. Coronary Artery Disease or Peripheral Vascular Disease.

No change in standard management.

E. Diabetes or other Endocrine issues.

Diabetics are at higher risk of emphysematous cholecystitis.

F. Malignancy.

No change in standard management.

G. Immunosuppression (HIV, chronic steroids, etc).

No change in standard management.

H. Primary Lung Disease (COPD, Asthma, ILD).

No change in standard management.

I. Gastrointestinal or Nutrition Issues.

No change in standard management.

J. Hematologic or Coagulation Issues.

No change in standard management.

K. Dementia or Psychiatric Illness/Treatment.

No change in standard management.

V. Transitions of Care.

A. Sign-out considerations While Hospitalized.

If there is evidence of increasing jaundice, check LFTs and consider GI consultation for possible endoscopic retrograde cholangiopancreatography (ERCP).

B. Anticipated Length of Stay.

There is a spectrum of disease severity. In an otherwise healthy patient with mild acute cholecystitis, length of stay might be 3 days (enough to get the patient on the operating room schedule and discharge within 12-24 hours). In older, sicker patients with comorbid disease, length of stay could last more than a week.

C. When is the Patient Ready for Discharge.

In patients who are stabilized and undergo cholecystectomy, discharge is based on usual post surgical criteria (eating, drinking, bowel movement).

In patients who will undergo deferred cholecystectomy, discharge can occur when fever has resolved, WBC count is not rising, pain/nausea/vomiting is resolved, and the patient is eating and drinking, i.e. when cholecystitis has resolved clinically.

In patients with a cholecystostomy tube, discharge, either to home or to an alternate level of care, can occur when fever has resolved, WBC count is decreasing and pain/nausea/vomiting are under control.

D. Arranging for Clinic Follow-up.

N/A

1. When should clinic follow up be arranged and with whom.

Follow-up with surgeon within 1 week if post cholecystectomy. Patients with a cholecystostomy tube who are discharged will need follow-up, often in about 4-6 weeks, to determine if laparoscopic cholecystectomy can be performed.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

None

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

None

E. Placement Considerations.

N/A

F. Prognosis and Patient Counseling.

N/A

VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.

N/A

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

N/A

Sexually Transmitted Infection	First-Line Treatment	Alternative(s)	Pregnancy/Lactation
Chlamydia (treat for Neisseria gonorrhoeae concurrently)	Azithromycin, 1 gram PO single dose	Erythromycin base, 500 milligrams PO four times daily × 7 d	Azithromycin, 1 gram PO single dose
	or	or	or
	Doxycycline, 100 milligrams PO two times daily × 7 d	Erythromycin ethylsuccinate, 800 milligrams PO four times daily × 7 d	Amoxicillin, 500 milligrams PO three times daily × 7 d
		or	or
		Levofloxacin, 500 milligrams PO once daily × 7 d	Erythromycin base, 500 milligrams PO four times a day for 7 d
		or	or
		Ofloxacin, 300 milligrams PO twice daily × 7 d	Erythromycin base, 250 milligrams PO four times a day for 14 d
			or
			Erythromycin ethylsuccinate, 800 mg orally four times a day for 7 d
			or
			Erythromycin ethylsuccinate, 400 mg orally four times a day for 14 d

 

 

 

Chlamydial infections in men can cause urethritis, epididymitis, proctitis, or Reiter's syndrome (urethritis, conjunctivitis, and rash). Women generally have asymptomatic cervicitis when infected with Chlamydia, although if present, symptoms include vaginal discharge, bleeding between menses, and dysuria. The discharge may be mucopurulent (Figure 149-1) when Neisseria gonorrhoeae is a co-infectant. Consider urethral chlamydial infection in the differential diagnosis of sterile pyuria. Complications in women include pelvic inflammatory disease, ectopic pregnancy, and infertility.

 

In the United States and the United Kingdom, C. trachomatis infection is the most frequently reported STI. It is one of the causes of nongonococcal urethritis and commonly coexists with gonorrhea infections. It is most prevalent in people <25 years of age and is frequently asymptomatic, especially in women.1

 

Complications of Injecting Drug Use

• Local problems—Abscess (Figures 240-2 
  

  A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

  and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
  • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
  • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
• IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
  • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.

Chlamydial cervicitis with ectopy, mucoid discharge, and bleeding. The cervix is inflamed and friable. (Courtesy of Connie Celum and Walter Stamm, Seattle STD/HIV Prevention Training Center, University of Washington.)