Let’s shift gears now to talk about cholecystitis
or inflammation of the gallbladder.
Here’s a 15-year-old girl who’s coming
in with fever and severe abdominal pain.
She’s been losing weight despite
noticing abdominal bloating.
And she’s rushed into the OR.
Notice she has a very high BMI.
She has acute sharp right upper quadrant
pain that radiates to here back
and they found gallstones and
a thickened gallbladder wall.
This patient has cholecystitis.
So cholecystitis is an inflammation and
often infection of the gallbladder itself.
It’s strongly associated with the present
of the gallstones inside the gallbladder.
90% of cases are associated
It is a common indication
for abdominal surgery.
It is more common in older
women than in younger women,
but we absolutely see this
in adolescents as well.
There are some rare causes of
inflammation of the gallbladder wall
that are associated with other systemic
diseases like Kawasaki’s disease,
which can cause
But most of cholecystitis is a result
of the obstruction of the neck
or a cystic duct usually from a stone and
like I said, that’s about 90% of cases.
The most common reason for emergent
cholecystectomy is cholecystitis.
And we see it typically in children
with predisposing risk factors.
Examples would be sickle cell disease where
they have a higher red blood cell turnover.
So let’s look at some risk
factors for gallstones.
are at higher risk.
Obesity is more common.
Pregnancy is a risk
factor for cholecystitis.
Patients with hemolysis such as
patients with hemoglobinopathies,
hereditary spherocytosis or red
blood cell membrane fragility.
Patients with infection
are at increased risk.
A patient with hemolytic
uremic syndrome for example
is going to have a high rate
of red blood cell breakdown,
which could result in a gallstone
formation and subsequent cholecystitis.
This is true for patients with red blood
cell breakdown for sepsis as well.
Other examples, patients with TPN
or total parenteral nutrition.
These patients are at
increased risk for gallbladders.
Patients with ileal and resection may
also be at increased risk for gallstones.
Because of that problems with enterohepatic
circulation and it can just be idiopathic.
Some kids just get them
and we don’t know why.
Classic symptoms will include abdominal
pain, which is acute, sharp and colicky.
These patients may have epigastric
or right upper quadrant pain
around the gallbladder site.
It can also radiate
around to the back,
especially in the right
scapular region on the back.
These patients typically will have fever
and they may develop nausea
and vomiting as well.
Usually they have anorexia
and they have some
bloating of their
intestinal wall from edema.
It’s key to understand that
nausea and vomiting is common.
Anorexia is common
and their nausea and vomiting is often
slightly delayed from when they eat.
If they are forced to eat or if
they decide they have to eat,
they’ll have significant pain, maybe a
half hour to 45 minutes to an hour later
as they have that delay before their
gallbladder tries to constrict
to extrude the juices
necessary for food digestion.
Physical exam findings, you will
note fever and dehydration,
right upper quadrant
tenderness with guarding
and they may have Murphy’s sign.
Let’s go over Murphy’s sign carefully.
Basically, what you’ll do is
as shown in this picture,
you will push down
underneath the rib cage
on that right side in the
right upper quadrant.
Before you ask the patient to –
Before you push down on the
patient’s abdominal wall,
you will ask the patient to
breathe all the way out.
So that their lungs are collapsed.
Then you will push in and ask
them to take a deep breath.
That deep breath will push
down on the gallbladder
as the lungs expand and the gallbladder
will be pushed into your hand.
This is Murphy’s sign.
And this will be painful as they inhale
against that hand which is pressed
into the right upper quadrant.
If you suspect this disease, ultrasound
has a high specificity for illness.
Here, you can see an inflamed
gallbladder wall on ultrasound
and some biliary sludging.
So these patients will have
findings on ultrasound
that are very likely
to be diagnostic.
Treatment is simply surgical removal.
We have to mitigate risk factors
in individuals who are at risk
in terms of should we remove their
gallbladder prior to having any episodes.
But generally what’s going to happen is
patients will come in with
an acute cholecystectomy
and it will have to be removed.