Let's move to our next case.
A 31-year-old man with no past
medical history presents to the ED
with two days of right upper quadrant pain
accompanied by fever, nausea and vomiting.
Over the last few months, he has had
intermittent abdominal pain after eating.
These episodes last for a
few minutes then resolve.
Vitals are notable for temperature
of 38.2 C and heart rate of 115 bpm.
On abdominal exam, he has tenderness to palpation in
the right upper quadrant but no rebound or guarding.
Labs show mild elevation in
AST, ALT and the total bilirubin
His abdominal ultrasound shows pericholecystic
fluid and gallbladder wall thickening.
So what is the recommended
management for this patient?
So we'll review this case.
He has right upper quadrant pain with fever,
nausea and vomiting lasting for more than 6 hours
and he also has a history of
what sounds like biliary colic.
He has fever and tachycardia.
On his exam and labs, this helps us
localize something to the biliary system
And his ultrasound
findings are quite concerning.
So before we answer that question,
let's talk about the difference between
cholelithiasis or just the
presence of gallstones
versus acute cholecystitis, which
is inflammation of the gallbladder
So in cholelithiasis, patients
usually present with just biliary colic
that tends to be
intermittent and self-limited.
On the other hand, those with inflammation of
the gallbladder or cholecystitis will present with
persistent pain in the area, fever and
may have elevated liver chemistry studies.
So again, patients with acute
cholecystitis tend to present with
right upper quadrant pain,
fever, nausea and vomiting.
On physical exam, they will have
tenderness in the right upper quadrant
and they may have a particular
exam finding called "Murphy's sign"
This is when you press in on the right upper
quadrant and as they inspire or breathe in,
this causes the gallbladder to come in
contact or move closer to the examiner's fingers,
and they will stop breathing
in because they experience pain
Most cases of of cholecystitis are
from obstruction of the cystic duct,
which directly drains the
gallbladder, via gallstone.
The diagnosis is made by
right upper quadrant ultrasound.
So some common features
that we can discuss here are,
you may have fluid
surrounding the gallbladder.
What you would see is a dark or black
structure around the surface of the gallbladder
You may see gallbladder wall
thickening as shown here in that image,
the wall is slightly thicker than normal.
You may see the presence of gallstones
or biliary sludge within the gallbladder,
as shown here the echogenic or white
material within the lumen of the gallbladder.
And you may also find a
sonographic Murphy's sign.
This is simply the same physical
exam finding that we did earlier
by pressing on the right upper
quadrant and having the patient inspire
but in this case is done with the ultrasound
probe pressing in on the right upper quadrant.
So, as a quick aside, we mentioned that 90% of
patients with acute cholecystitis are from gallstones.
But patients may also have no
gallstones and develop cholecystitis
This is what's called "acalculous
cholecystitis", so the absence of stones.
This usually requires a type of drainage called
percutaneous cholecystostomy which we will discuss later.
So there are some cases when
the diagnosis is difficult to make.
For instance, when you have a high clinical
suspicion that your patient has acute cholecystitis
based on their presentation but your ultrasound
doesn't show those typical findings we discussed.
In these cases, you may do a
special type of scan called a HIDA scan
This is also known as cholescintigraphy
It is done by injecting a radiotracer
that is then taken up by the liver,
and then secreted into the biliary tract.
When we do this, we can look for an obstruction or
a blockage anywhere along this path of drainage.
If after 4 hours, we don't see the gallbladder,
then you can suspect either cholecystitis
or some type of
obstruction of the cystic duct.
So here's an example shown
here where you see the liver light up
and eventual drainage into the rest of the
system but no gallbladder is seen
So, the treatment of acute
cholecystitis first involves supportive care
so giving IV fluids.
You then also want to give IV antibiotics
to cover your gastrointestinal bacterial flora -
so these are gram negative
organisms and anaerobes.
So some choices you may choose are
beta-lactam and beta-lactamase inhibitors
or a 3rd-generation
cephalosporin with metronidazole.
Next, the patient should undergo a
laparoscopic or an open cholecystectomy,
so removal of the gallbladder
during that same hospital stay.
If the risk of surgery is too high, you
may also do a cholecystostomy drain.
This is shown here on the right
so this involves inserting a needle
and then a catheter to drain
directly from the skin into the gallbladder.
So now, we can return to our case.
We have a 31-year-old man who now
has persistent right upper quadrant pain,
fever, lasting for longer than 6 hours.
He has fever and tachycardia.
His ultrasound findings are concerning and now
we know that the presence of pericholecystic fluid
and gallbladder wall thickening
show us that he has acute cholecystitis.
So, the recommended management
for this patient is to start IV fluids,
since he does meet the sepsis criteria.
Give IV antibiotics and consult
surgery for a cholecystectomy.