Acute Cholecystitis Case Study

This assignment delves into a case study of acute cholecystitis. It outlines typical symptoms like right hypochondriac pain, vomiting, fever, and anorexia. The importance of history, including previous episodes of biliary colic, is emphasized. Diagnosis often involves ultrasound, but other imaging modalities may be necessary. Complications such as gallbladder perforation are discussed, along with conservative treatment approaches and the eventual need for cholecystectomy. The case study highlights the significance of recognizing acute cholecystitis, particularly in critically ill patients.

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Case Discussion of Acute Cholecystitis
Student’s name
Institution
Course
Date

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Case Discussion of Acute Cholecystitis
Cholecystitis is an inflammation of the gall bladder. Let us first revise the basic anatomy and
physiology of the biliary system.
Bile is produced by cells of the liver. It drains in common hepatic duct. Gall bladder is a
fibromuscular sac located below the surface of the right lobe of liver. [5] It stores the bile
produced by the liver and releases it when required for digestion. It drains via the cystic duct,
which joins the common hepatic duct and forms the common bile duct [CBD]. CBD opens in
Ampulla of Vater along with main pancteatic duct . The ampulla opens in the second part of
duodenum[5]. Thus the bile produced in the liver reaches small intestine for the purpose of
digestion.
If the cholecystitis develops acutely it is called acute cholecystitis. It is most often associated
with gallstones and is called calculous cholecystitis. It may also develop over time, and then it is
called chronic cholecystitis. There is infiltration of gall bladder with chronic inflammatory cells
seen on histopathology examination of the surgical specimen.
Why Does One Get Cholecystitis?
Most often, it is due to blockage of cystic duct due to a gallstone. The bile produced cannot be
emptied and accumulates. This increases the pressure inside the gall bladder. Irritants like
lysolecithins are released which cause chemical inflammation of the gall bladder mucosa. A
bacterial infection adds to the problem and worsens the inflammation. [5]
Occasionally cholecystitis can develop without impaction of a stone or blockade of the cystic
duct. It is called acalculous cholecystitis.. It can occur in the setting of infections like Leptospira,

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Salmonella, prolonged fasting, burns etc [6]. One should be watch out for it in patients admitted
in critical care units. The signs and symptoms can be subtle and go unnoticed till the gall bladder
perforates or develops gangrene. It probably occurs secondary to multiple factors including
ischemia of the gall bladder, atherosclerosis and decreased tissue perfusion secondary to the
critical illness from which the patient is suffering [7]
However our case study patient is not a likely candidate to have acalculous cholecystitis.
With this background knowledge, let us study the case of Mr. Kasim [name changed], a 49 year
old man
He presented to emergency department, with an illness of two days duration
His chief complaints were abdominal pain in the right upper quadrant, fever, vomiting and pain
at the shoulder tip
Let us see the positive findings in the clinical examination.
He had fever, tachycardia, hypotension, dryness of mucosal membranes and pallor
The findings of his examination of abdomen, respiratory and cardiovascular system are not given
in the case summary
Let us start with the basics of signs and symptoms. Knowing these basics will be helpful in
evaluation of any patient
Normal average oral body temperature is 36.8 degree C [1]. When it is above 37.2 [in morning]
and 37.7 [in evening], we call it fever. [1]

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Tachycardia is faster than normal heart rate, generally used when it is more than 100/ minute in
an adult [2]
Hypotension is a blood pressure reading below the expected normal for a person [3]
Dryness, which can be seen in oral mucosa and lips, is observed in our patient, because he is
dehydrated, secondary to repeated vomiting and fever.
What is the difference between a sign and a symptom?
A symptom is a subjective [that is, perceived by the patient] evidence of disease. [2] Abdominal
pain and pain at shoulder tip are the symptoms of our patient
A sign is any objective evidence of disease which is perceptible to the examining physician {2]
Fever, tachycardia, pallor and low blood pressure are the signs present in our patient
In a patient of acute cholecystitis, what should we expect in the examination of abdomen?
When you inspect, you may see reduced movements of the abdomen with breathing.
On palpation, right hypochondriac area will have guarding and tenderness. Occasionally you
may get a vague lumpish feeling below the edge of the liver. [4]
How to look for Murphy’s sign, which is characteristic of acute inflammation of the gall
bladder? Keep your hand in the gall bladder fossa below right costal arch and ask the patient to
take a deep breath. He will suddenly take a halt during inspiration as the inflamed gall bladder
which descends on deep inspiration presses against your fingers causing discomfort to the patient
[2]

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Why is our patient getting pain at shoulder tip when the pathology is in the abdomen? A referred
pain is a pain that is perceived away from its source. [4] Inflammation of diaphragm will cause a
referred pain at the shoulder tip.
Now we have done basic evaluation of our patient. What should be done next?
This patient definitely needs to be hospitalised
An intravenous cannula should be inserted and laboratory tests should be sent. We know that he
is dehydrated and in pain. So appropriate analgesics and intravenous fluids should be given.
Patient should be kept nil by mouth.
Antibiotics should be given. The chosen antibiotic should cover Gram negative rods like
Klebsiella and E. coli. [8] In patients with emphysematous cholecystitis, in which gas is seen in
the wall of the gall bladder, antibiotic regimen should also cover gas forming anerobic
organisms[8]
For example, in mild to moderately ill patients cefuroxime or ceftriaxone can be used. In more
seriously ill patients, imipenem- cilastatin, meropenem, piperacillin- tazobactum and
metronidazole can be used.
A general surgeon’s consultation should be obtained soon
Cholecystectomy is the definitive treatment. Multiple factors like the fitness of the patient for
anesthesia, hemodynamic stability, risk of impending rupture or gangrene of the gall bladder or
development of any complication decide the timing of the surgery. It may be done on emergency
basis or after stabilization of the patient with conservative treatment.

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Percutaneous cholecystostomy is an option for seriously ill patients who are not in a condition to
tolerate general anesthesia [8] In this under ultrasound or CT guidance, a pigtail catheter is
inserted over a guide wire in the gall bladder for external drainage. [8]
Basic laboratory evaluation should include
CBC- complete blood count
LFT- Liver function tests
Renal function tests- serum Urea, Creatinine and Electrolytes
Random blood sugar
We expect a rise in the total white blood cell count [leucocytosis] with shilft to left, which is
increase in the number of band forms.
Liver function tests [serum bilirubin, ALP, AST, alkaline phosphatase] may or may not show
some derangement in a typical case of acute calculous cholecystitis
Imaging studies- Ultrasonography of the abdomen can be readily done.
It often shows thickening of the gall bladder wall and collection of fluid around gall bladder.
There are many other features which point towards the diagnosis, like distension of the gall
bladder, presence of gas in the gall bladder wall and double wall sign [ due to edema of the gall
bladder wall] [8].

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Additionally , while doing ultrasonography, when the radiologist places the transducer on the
gall bladder area, patient may get tenderness when the probe presses on the inflamed gall
bladder[sonographic Murphy’s sign] [8].
What can be done if the ultrasound is inconclusive?
Other imaging modalities like Cholescintigraphy [HIDA scan], CT [Computed Tomography]
scan and MRCP- Magnetic resonance cholangiopancreaticography can be used then.
The advantages of ultrasound are that it is easily done, can also be done bedside in a sick patient,
is non invasive with no side effects or radiation exposure and can be repeated often easily.
One should always consider other illnesses which may mimic cholecystitis. Any illness in organs
in vicinity of gall bladder like hepatitis, peptic ulcer disease, pancreatitis, right lower zone
pneumonia etc should be considered.
What are the complications that can occur in a case of acute cholecystitis?
Perforation or gangrene of the gall bladder, abscess formation, and empyema of the gall bladder
are some of the serious complications. [8]
They are more common in critically ill population than in a typical case of otherwise healthy
adult with acute calculous cholecystitis.
Let us now summarise the important points which we learned in the case study of acute
cholecystitis
1. The typical presentation is with right hypochondriac pain, vomiting, fever and anorexia in
a sick looking patient

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2. One should try to find out history of gall stones and previous episodes of right sided
abdominal pain, which may indicate biliary colic [ a sudden onset of steady pain in
epigastric or right hypochondriac area, often preceded by a meal and radiating to right
scapula] [6].
3. Patient should be hospitalised
4. A positive Ultrasound of the abdomen , in a patient with the typical symptoms and signs
of cholecystitis often confirms the diagnosis but other imaging modalities like HIDA
scan, CT scan or MRCP may be needed
5. Intensive care specialist should look for and should have a high index of suspicion for
diagnosis of acalculous cholecystitis in all critically ill patients, irrespective of the
primary diagnosis
6. Antibiotics, intravenous fluids, analgesics are important parts of conservative treatment,
which is generally followed by definitive treatment of cholecystectomy.

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Bibliography
1. Murtagh , J. 2011. Murtagh’s general practice, companion handbook, 5th edition, pp, 240,
McGraw-Hill Medical.
2. Dorlands.com. 2014. Dorland’s Illustrated Medical Dictionary, 30th edition, USA: Elsevier.
3. WebMD, Inc. 2017. Medical Definition of Hypotension, Available
at<http://www.emedicinehealth.com/script/main/art.asp?articlekey=3864>[Accessed 26 Apr.
2017]
4. Browse, N. et al. 2005. An Introduction to the Symptoms and Signs of Surgical Disease,
Hodder Arnold, pp. 496.
5. SInnatamby, S. 1999. Anatomy, Regional and Applied, by R J Last, Churchill Livingstone.
6. Kasper, D. L., et al. 2016. Harrisons Manual of Medicine, 19th edition, McGraw-Hill
Education / Medical.
7. Bersten. 2014. Oh’s Intensive Care Manual, 7th edition, UK: Elsevier Health.
8. Vincent , J. L., e t al., 2011. Textbook Of Critical Care, 5th edition, Saunders, pp. 1744.