#Cholecystitis

***acute gallbladder inflammation associated with obstruction of cystic duct by gallstones of biliary sludge. >90% due to gallstones or biliary sludge

***cholecystitis w/o gallstones: critically ill patients s/p severe trauma burns, major surgery, long0term fasting, TPN, sepsis, DM2, systemic vasculitis, acute renal failure

***Risk factors: female, obese, hormone replacement therapy, severe TAGs, sickle cell disease, obesity surgery, sudden/significant weight loss, gallbladder cancer

-Dx:

>1 local sign of inflammation (murphy sign or RUQ mass/pain/tenderness)

>1 sign of systemic inflammation--fevers, WBC count, CRP

>Definitive dx: US findings (enlarged gallbladder, gallbladder wall thickening, gallbladder stones, debris echo, dilated common bile duct, pericholecystic cystic fluid), US murphy sign, HIDA (absence of gallbladder filling within 60 minutes), CT findings (gallbladder distention, pericholecystic fat stranding, gallbladder wall thickening, sub-serosal edema, mucosal enhancement, transient focal enhancement of liver adjacent to gallbladder, pericholecystic fluid collection, pericholecystic abscess, gas collection in gallbladder), MRCP

-RUQ pain, epigastric pain, fever, Murphy's sign (jaundice, mental status changes, hypotension)

-occurs after food/at night

-Classification:

>Mild: mild inflammation, no organ dysfunction, not meeting moderate/severe criterua

>Moderate (warrants immediate cholecystectomy or biliary drainage):

-WBC>18k

-Palpable tender mass in RUQ

-Complaints > 72 hours

-Marked local inflammation including: biliary peritonitis, pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, emphysematous cholecystitis

>Severe (ICU)

-hypotension requiring Dopamine/Levophed

-Decreased consciousness/AMS

-PaO2/FiO2 < 300

-oliguria

-Cr >2

-INR > 1.5

-Plt<100k

-WBC: ***, ALP: ***, AST/ALT: ***

-CRP: ***

-RUQ US: ***

Plan:

Ddx: PUD, acute pancreatitis, IBS, acute hepatitis, acute pyelonephritis, STEMI, PNA right sided, sickle cell disease acute crisis, Herpes Zoster

-f/up RUQUS

-f/up CT A/P if RUQUS unclear (NOT IF PREGNANT)

-f/up CRP

-f/up lipase

-f/up lactate

-NPO

-IV fluids

-pain control with ***

-plan for cholecystectomy inpatient, within 72-hours for mild cholecystitis

-discontinue antibiotics 24-hours post cholecystectomy unless s/s of sepsis persist

***Mild/moderate cholecystitis--Ceftriaxone, Cefuroxime, Cefazolin

***Severe/Healthcare Associated--Flagyl + Ciprofloxacin, Ceftazidime, Cefepime OR monotherapy with Zosyn vs. Meropenem. If healthcare-associated then add Vancomycin

***-if febrile, blood cx

***elevated liver function tests (AST, ALT, alkaline phosphatase, bilirubin) are NOT diagnostic of acute cholecystitis, but may suggest choledocholithiasis or other complications