EM@3AM – Acute Cholecystitis

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 41-year-old obese female presents for evaluation of severe right upper quadrant pain and nausea without emesis. The patient reports post-prandial pain of one months duration, acutely worsening prior to presentation following the consumption of a bacon cheeseburger. ROS is negative for sick contacts, foreign travel, and changes in bowel habits. The patient denies a surgical history.

Triage VS: T101.6°F Oral, HR 134, BP 147/99, RR 24, SpO2 98% on room air

What is the patient’s diagnosis? What’s the next step in your evaluation and treatment?

Answer: Acute Cholecystitis^1-4

• Risk Factors: oral contraceptives or estrogen replacement therapy (alters cholesterol and bile salt metabolism leading to gallstone formation and gallbladder hypomotility¹), diseases of the terminal ileum (e.g. Crohns; secondary to poor bile salt reabsorption), cirrhosis (decreased bile acid secretion), hemolytic diseases (pigmented gallstones), pregnancy, obesity, TPN
• Presentation: RUQ or epigastric pain, postprandial pain, nausea +/- emesis, +Murphy’s sign (+LR: 2.8; 95% CI, 0.8-8.6²), +/- fever

• Evaluation:
  • US (Sensitivity 95%, Specificity 98%³): sonographic Murphy’s, pericholecystic fluid, gallstones/biliary sludge, gallbladder wall thickening > 3mm
    • Note: gallbladder wall thickness increases with age; an upper limit of 8mm for patients > age 50 is commonly cited⁴
  • CBC, LFTs
    • CBC: often demonstrates leukocytosis
    • LFTs: transaminitis; allows for evaluation of choledocolithiasis

• Treatment:
  • Antimicrobials:
    • Mildly ill: ciprofloxacin 400 mg IV + metronidazole 500 mg IV
    • Critically ill: vancomycin 20 mg/kg (up to 2 g) IV + piperacillin/tazobactam 4.5 g IV
  • Fluid Resuscitation
  • Pain control
  • Anti-emetic PRN
  • Surgical Consultation – cholecystectomy
• Pearls:
  • Diabetes is a risk factor for emphysematous cholecystitis:³ initiate antibiotic therapy directed against Gram-negative rods and anaerobes, and consult surgery.
  • Include acalculous cholecystitis in your differential diagnosis of the critically ill: RUQ pain, epigastric pain, and nausea are absent upon initial evaluation in up to 75% of these patients.¹

References:

1. Welch J, Chike V, Bowens N, Arnell T, Ferri F. Acute Cholecystitis. First Consult. 2011. Elsevier, Philadelphia, PA.
2. Trowbridge R, Rutkowski N, Shojania K. Does this patient have acute cholecystitis? JAMA. 2003; 289(1): 80-86.
3. Glasgow R, Mulvihill S. Treatment of Gallstone Disease. In: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. Philadelphia: Saunders Elsevier, 2016:1134-1151.e5.
4. Senturk S, Miroglu T, Cilici A, Gumua H, Tekin R, et al. Diameters of the common bile duct in adults and postcholecystectomy patients: a study with 64-slice CT. Eur J Radiol. 2012; 81(1): 39-42.