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