Acute Cholecystitis Definition PE: Murphys sign, RUQ tender to palpation RUQ pain + fever + leukocytosis + GB inflammation CBC

CBC with differential: leukocytosis, left shift Usually related to gallstone disease Total BR, ALP: usually normal AST, ALT, amylase: elevated Pathogenesis US: supportive, not diagnostic Blockade of cystic duct + irritation of GB mucosa HIDA scan, MR cholangiography, CT scan Prostaglandins GB contraction, fluid absorption Infected bile: E coli, enteroccocus, Klebsiella, Treatment Enterobacter Supportive IVF, correct electrolyte abnormalities Signs and symptoms Ketorolac, butorphanol, NSAIDs RUQ and/or epigastric pain R shoulder, back NPO Steady, severe pain NG tube if patient is vomiting Nausea, vomiting, recent fatty food intake Antibiotics: >12,500 WBC/mm3, T>38.5 C, air in GB or 4-6 hours RUQ pain + fever r/o biliary colic GB wall, older patients with DM Patient in distress, tachycardic, guarding o Beta lactam + lactamase inhibitor, third Murphys sign (sensitive, not specific) generation cephalosporin + metronidazole Surgery Differential Immediate: suspected gangrene or perforation, Biliary colic: intermittent pain, no constitutional progressive fever, severe pain, arrhythmia symptoms Laparoscopic: no rectus abdominus cutting, less pain, Ascending cholangitis (Reynolds pentad) shorter hospital stay Acute pancreatitis High risk patients: drainage with antibiotics, endoscopic transpapillary GB drainage Appendicitis Medical Acute hepatitis Percutaneous gallstone extraction lithotripsy PUD Right renal disease Right sided pneumonia Cardiac ischemia

Workup and diagnosis Presence of gallstones not enough for diagnosis

Complications Gangrene: elderly, DM, delay in treatment Perforation pericholecystic abscess Cholecystoenteric fistula Gallstone ileus Emphysematous (Clostridium welchii, E coli, staph, strep, Pseudomonas, Klebsiella)