Cholecystitis 

mechanism

• inflammation of gallbladder resulting from sustained obstruction of cystic duct by gallstone (80%)
• no cholelithiasis in 20% (acalculous – see below)

signs and symptoms

• often have history of biliary colic
• severe constant epigastric or RUQ pain
• anorexia, nausea and vomiting are common
• systemic signs – low grade fever (<38.5 ºC), tachycardia
• focal peritoneal findings – Murphy’s sign (sudden cessation of inspiration with deep RUQ palpation)
• palpable gallbladder in one third of patients

differential diagnosis 

• perforated or penetrating peptic ulcer
• MI
• Pancreatitis
• hiatus hernia
• right lower lobe pneumonia
• appendicitis
• hepatitis
• herpes zoster

diagnostic investigation

• elevated WBC, left shift
• mildly elevated bilirubin, ALP
• sometimes slight elevation AST, ALT
• U/S shows distended, edematous gallbladder, pericholecystic fluid, large stone stuck in gallbladder neck, sonographic Murphy’s sign (maximum tenderness elicited by probe over site of gallbladder)

complications

• hydrops: mucus accumulation in gallbladder; may lead to necrosis
• gangrene and perforation: may cause localized abscess or generalized peritonitis (can occur 3 days after onset)
• empyema of gallbladder (suppurative cholangitis) – gallbladder contains frank pus
• cholecystoenteric fistula from repeated attacks of cholecystitis
• gallstone ileus
• choledocholithiasis – 15% of patients with gallstones
• emphasematous gallbladder

treatment

• admit, hydrate, NPO, NG tube, analgesics once diagnosis is made, antibiotics if high risk (elderly, immunosuppressed)
• E.coli, Klebsiella, Enterococcus and, Enterobacter account for > 80% of infections, 1st and 2nd generation cephalosporins are first choice antobiotic coverage
• lack of improvement with conservative treatment ––> operate within 24-48 hours (cholecystectomy)
• earlier O.R. if high risk (DM, steroids) or severe disease

post cholecystectomy advice

1. Gradual Reintroduction of Fat: Initially, stick to a low-fat diet. Gradually reintroduce fats to allow the digestive system to adapt. High-fat meals can cause diarrhea or indigestion.
2. Small, Frequent Meals: Eating smaller, more frequent meals can help in managing symptoms and aid digestion.
3. Avoid Certain Foods: Initially, avoid spicy foods, fatty meats, fried foods, full-fat dairy products, and gas-producing foods like beans, cabbage, and carbonated drinks.
4. Increase Fiber Intake: Gradually increase fiber intake to help manage diarrhea but be cautious as too much fiber too soon can cause gas and cramping.
5. Bile acid binders like cholestyramine can be effective in treating post-cholecystectomy diarrhea