Acute Abdominal Pain
Acute Cholecystitis/Biliary Colic - Diagnostic Features/Management Choices
- RUQ pain and tenderness may be similar to previous episodes.
- Nausea is common, vomiting less so
- Murphy's sign (increased tenderness during inspiration with RUQ palpation).
- Abdominal findings range from mild to severe RUQ pain and tenderness.
- Gallbladder palpable 1/3 cases; jaundice (serum bilirubin usually < 4 mg % unless choledocholithiasis)
- Low grade fever (38- F), modest elevated WBC (10,000-16,000)
- Mild-moderate elevated SGOT/SGPT usually present.
- Ascending cholangitis – jaundice with sepsis picture; urgent need to decompress biliary tree (ERCP, PTC, cholecystectomy)
- Acalculous cholecystitis, usually occurring in critically ill patients with abdominal pain, can be diagnosed clinically by an ultrasound showing a thickened
gall bladder wall and pericholecystocolic fluid.
- Gallstones seen plain film abdomen 15% cases.
- Ultrasound may suggest Dx if gallstones clearly demonstrated (95% sensitive
for gall stones):
- stones with acoustic shadows; sludge representing microlithiasis may also be present.
- dilated biliary ducts
- GB wall thickening in acute cholecystitis
- common duct stones difficult to see with U/S
- PIPIDA/HIDA scans positive in 90% of cases; infrequent false positive.
Differential Diagnosis: -
Acute appendicitis Acute pancreatitis - Serum amylase increased 20-30% patients.
Alcoholic hepatitis - 10% patients with acute cholecystitis have SGOT/SGPT >
300. Gonococcal perihepatitis Pneumonitis Hepatic tumors.
Perforated peptic ulcer - usually produces more striking findings.
Management (Stepped Care) :
- Start appropriate antibiotics* and I.V. fluids.
- At 24 hours assess response to Rx: -
- presence or absence of fever, tachycardia, leucocytosis, peritoneal signs,
and liver tests.
- The presence of all of the above features should also raise the question of
choledocholithiasis and ascending cholangitis.
- If patient not improved, early surgery must be considered.
Recall that the gallbladder can be palpable in up to one third cases of
Follow-up in Recurring/Chronic Cholecystitis:-
porcelain gallbladder (high incidence of carcinoma)
- 1% will become symptomatic per year
- most will develop symptoms before complications
- indicators for surgery in an asymptomatic patient (rare):
- access to medical care
- Native American women and from Chile : increased incidence of GB cancer (up
to 5% of cases).
- diabetics - controversial - diabetics have a 3 - 5 times increased mortality
if they do develop cholecystitis.
Surgery is still the treatment of choice.
most cholecystectomies ( > 95%) are performed laparoscopically
quicker recovery compared to cholecystectomy
success rate is proportional to the experience of the laparoscopic surgeon.
Complications of Surgery:
bile duct injury fistula stricture transection
papillary dysfunction post cholecystectomy diarrhoea.
not usually done, expensive
high chance of recurrence
occasionally needed for particularly large stones
Solvents: ursodiol lowers cholesterol secretion - increases solubility
only effective for small (1cm) stones in functioning GB
60% effective at 6 months 50% will recur by 5 years
may be effective in prevention for high risk patients (diabetes, pregnant
women, post-delivery); indicated in bile duct stricture after cholecystectomy.
Solvent side effects:- diarrhea increased aminotransferases
* Antibiotic choices : vary with local preferences - see also:
IDSA Practice Guidelines (http://www.idsociety.org/)
(on Palm PDA) - ePocrates RX Pro (http://www.epocrates.com)
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