Cholecystitis

You are the general surgery CT1 asked to see a 42-year old, overweight, caucasian lady complaining of right upper quadrant pain after a French fries and burger eating contest. It has been occurring on and off after meals over the past few months but never this bad. It is now coming in waves and makes her double over. She has vomited a few times and is passing wind. She is pyrexic at 38.4. How would you proceed? 

Example answer introduction

I suspect that this lady may have acute cholecystitis. I would take a focused history, perform a focused examination and request the relevant investigations depending on my clinical suspicions. I would then initiate treatment and escalate to my registrar for senior review. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, Trop I, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications 

  • Past medical history – Trauma, known gallstones, previous abdominal surgery, smoking, alcohol

  • Last meal

  • Events leading up to this point - nature of pain, nausea and vomiting, diarrhoea, constipation, weight loss, PR bleeding

Abdominal examination

  • Inspect – Jaundice, distention, surgical/traumatic scars

  • Auscultate – diminished or absent bowel sounds

  • Palpate – Tenderness, guarding, peritonism, Murphy’s sign, rebound tenderness

  • Percussion – Resonant or hyper-resonant

  • Digital rectal examination – I would ask for a chaperone –melena, masse

Example questions to progress the station

Q1 You suspect that this lady has acute cholecystitis. Which investigations would you order?

 

  • Urine dip – looking for blood, leukocytes, nitrites, Beta HCG, glucose, ketones

  • Abdominal x-ray – Evidence of bowel obstruction

  • Erect chest x-ray – Air under diaphragm signifying perforated viscus. 

  • Ultrasound abdomen – gallstones, bile duct dilatation

 

Q2 The ultrasound shows gallbladder wall thickening of 5mm and presence of multiple gallstones in the gallbladder. The biliary duct appears normal, suggesting uncomplicated acute cholecystitis. What would you do next?

Initial management

  • IV antibiotics according to local protocol 

  • Analgesia according to the WHO pain ladder

  • IV crystalloids to maintain urine output of 0.5ml/kg/hr 

  • Keep nil-by-mouth

  • Inform the surgical Registrar to review the patient

  • Prep for theatre – early laparoscopic cholecystectomy – within 1 week of diagnosis according to NICE guidelines

  • VTE Prophylaxis

  • Keep patient and any relatives informed

  • Document, document, document!!!

 Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct and arrange further imaging, 
Cholecystitis can be diagnosed and managed clinically but an USS can be useful to examine the ductal anatomy. In this case escalation to a radiologist will be required.
In centres which perform "hot gall bladders" then discussion with theatres and anaesthetics +/- ICU will be required. 
Useful Resources

NICE CKS Cholecystitis - acute

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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