Understanding Cholecystitis: Diagnostic Procedures and Treatments

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Short recap about Cholecystitis

Cholecystitis is the inflammation of the gallbladder. It causes abdominal pain, tenderness, and
rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is
associated with nausea, vomiting, and the usual signs of an acute inflammation.

Two types:
● Calculous cholecystitis - is most common, occurs when gallstones become lodged in the
cystic duct, causing inflammation and infection in the gallbladder.
● Acalculous cholecystitis - is a less common form of cholecystitis, it has an acute
gallbladder inflammation in the absence of obstruction by gallstones. It is often caused by
other factors such as trauma, prolonged fasting, or infection.

Diagnostic Findings for Calculous Cholecystitis

● Ultrasonography - indicative of acute cholecystitis are thickening of the gallbladder wall
and pericholecystic fluid
○ “double wall sign,” representing edema of the gallbladder wall
○ “halo sign,” representing sloughed gallbladder mucosa
○ “sonographic Murphy’s sign,” demonstrating point tenderness over the gallbladder
● CT Scan and MRI - it could be observed that there is gallbladder wall thickening of greater
than 3 mm with mural/mucosal hyperenhancement of the liver adjacent to gallbladder.
● Hepatobiliary scintigraphy - Cholecystitis is diagnosed if the radioactive tracer is
visualized in the small bowel without visualization of the gallbladder within 4 hours,
suggesting occlusion of the cystic duct. Delayed visualization of the gallbladder may
represent chronic cholecystitis. The rate of false-positive tests is significant in fasting
patients, particularly those receiving parenteral nutrition. The use of intravenous morphine
to increase tone in the sphincter of Oddi and thereby increase pressure within the biliary
system can decrease the risk of a falsely positive test
● Laboratory Test
○ CBC - Leukocytosis with a left shift may be observed
○ Alkaline Phosphatase (ALP) Test - Alkaline phosphatase level may be elevated
○ Alanine Transaminase (ALT) Test - Alanine aminotransferase (ALT) and
aspartate aminotransferase (AST) levels may be elevated in cholecystitis
○ C-reactive Protein Test (CRP Test) - C-reactive Protein is elevated.
○ Amylase Test - Amylase may be mildly elevated in cholecystitis.
○ Urinalysis - For ruling out pyelonephritis and renal calculi.
Diagnostic Findings for Acalculous Cholecystitis

● Blood Tests - Obtain blood cultures in all patients with suspected acalculous
cholecystitis. If a pathogen is detected, it can be used to guide antibiotic therapy.
Confirmation of AAC typically requires imaging, most commonly abdominal ultrasound.
If the diagnosis remains unclear, cholescintigraphy can be obtained.
● Cholescintigraphy (HIDA scanning) - This can be performed in stable patients. Failure
to opacify the gallbladder is the most sensitive finding. Leakage into the pericholecystic
space suggests perforation. Cholescintigraphy is not recommended in critically ill
patients in whom a delay in therapy can be potentially fatal.
● Ultrasonography - Wall thickening is the most reliable finding. Nuclear
cholescintigraphy may be useful in cases in which the diagnosis remains uncertain after
ultrasonography.
● CT Scan - Findings suggestive of acalculous cholecystitis include: absence of gallstones
or sludge, gallbladder wall thickening, subserosal halo sign, pericholecystic infiltration of
fat, pericholecystic fluid, mucosal sloughing, intramural gas, and gallbladder distention
● MRCP - Magnetic resonance cholangiopancreatography (MRCP) is superior to
ultrasound for detecting stones in the cystic duct (sensitivity 100% vs. 14%) but is less
sensitive than ultrasound for detecting gallbladder wall thickening (sensitivity 69% vs.
96%)

Medical Management
 Fasting where the patient may not be allowed to drink or eat at first in order to take the
stress off the inflamed gallbladder.
 IV fluids are prescribed to provide temporary food for the cells.
 Supportive medical care where it includes restoration of hemodynamic stability and
antibiotic coverage for gram-negative enteric flora.
 Gallbladder stimulation with IV cholecystokinin may help prevent the formation of
gallbladder sludge in patients receiving TPN.
 Avoid high fat and fried foods, whole milk products, eggs, cream, pork, cheese, rich
dressings and gas forming foods
 Eat smaller meals more frequently to avoid upset in the digestive system and produce a
gallbladder or bile duct spasm
 Rest should be vital as it promotes less abdominal pain
 High protein, high carbohydrates (stirred into skim milk), low fat liquids should be given
such as cooked fruits, rice, lean meats, mashed potatoes, and non-gas-forming vegetables
 Avoid alcoholic food and beverages, and smoking
 One of the most nonsurgical approaches is lithotripsy - break a large stone into smaller
stones by sending focused ultrasonic energy or shock waves

Pharmacologic Treatment
The goals of pharmacotherapy are to reduce morbidity and prevent complications. Agents used in
patients with cholecystitis include antiemetics, analgesics, antibiotics, and IV hydration.
 ● Antiemetics - Patients with cholecystitis frequently experience nausea and vomiting.
Antiemetics can help make the patient more comfortable and can prevent fluid and
electrolyte abnormalities.
Example : Promethazine (Phenergan, Promethegan, Phenadoz)
● Analgesics - these can help control pain until the inflammation in your gallbladder is
relieved.
Example: Meperidine (Demerol) has been shown to provide adequate analgesia without
affecting the sphincter of Oddi and, therefore, is the drug of choice.
● Antibiotics - If the gallbladder is infected, antibiotics should provide coverage against the
most common organisms, including Escherichia coli and Bacteroides fragilis, as well as
Klebsiella,Pseudomonas, and Enterococcus species.
Example: Ciprofloxacin (Cipro), Levofloxacin (Levaquin), Metronidazole (Flagyl)

Surgical Treatment

● Cholecystectomy - a surgical procedure to remove gallbladder

○ Laparoscopic cholecystectomy - most commonly performed by using a
laparoscope by inserting a tiny video camera and special surgical tools through
four small incisions to see inside your abdomen and remove the gallbladder.
○ Open cholecystectomy - one large incision may be used to remove the
gallbladder.
● Endoscopic retrograde cholangiopancreatography (ERCP) - ERCP visualizes the
biliary tree by cannulation of the common bile duct through the duodenum.This helps
providers diagnose and treat gallstones, inflamed gallbladders, bile duct blockages,
pancreatitis, pancreatic cancer and other conditions.

In both types of cholecystitis, prevention is key. Eating a healthy diet that is low in fat and rich in
fiber can help prevent the formation of gallstones and reduce the risk of cholecystitis. Additionally,
maintaining a healthy weight, getting regular exercise, and avoiding smoking can help promote
overall health and reduce the risk of complications associated with cholecystitis.

Overall, early diagnosis and prompt treatment are critical in ensuring a successful outcome for
patients with calculous or acalculous cholecystitis. Healthcare providers should work closely with
patients to develop a comprehensive treatment plan that addresses their unique needs and promotes
optimal health and wellbeing.