A 36-year-old woman, a known case of
symptomatic gallstone for at least three years.
She was admitted to the emergency department
with a 2-day history of progressive increasing
abdominal pain in the right upper quadrant with
the radiation of pain to the epigastric area. The
patient also had nausea, vomiting, and anorexia.
She had 3 times previous admissions for the
same problem last year, in which she did not
give consent for operation and she did not use
any medications.
A 36-year-old woman, a known case of
symptomatic gallstone for at least three years.
She was admitted to the emergency department
with a 2-day history of progressive increasing
abdominal pain in the right upper quadrant with
the radiation of pain to the epigastric area. The
patient also had nausea, vomiting, and anorexia.
She had 3 times previous admissions for the
same problem last year, in which she did not
give consent for operation and she did not use
any medications.
What are the possible differential diagnosis
on this case?
• Right Renal Colic (Kidney Stone)
4. Renal Causes
• Pyelonephritis
•Choledocholithiasis (Common Bile Duct
Stones)
1. Biliary Causes •Cholangitis
•Cholecystitis
•Biliary Dyskinesia
5. Cardiac Causes • Acute Myocardial Infarction (MI)
2. •Peptic Ulcer Disease (PUD)
Gastrointestinal •Duodenal Perforation
Causes •Right-Sided Colitis
6. Pulmonary • Right Lower Lobe Pneumonia or
Causes Empyema
3. Pancreatic
•Acute Pancreatitis
Causes
Past Medical History:
• Known symptomatic gallstone disease for at least three years.
• Three previous admissions for similar complaints within the last year.
• The patient declined surgical intervention and did not adhere to medical management.
Family History: No significant medical
history.
Lifestyle: Non-smoker, no alcohol use.
Ø General Condition:
• Hemodynamically stable and afebrile.
• No jaundice.
Ø Abdominal Examination:
• Positive Murphy’s sign.
• RUQ tenderness and palpable
gallbladder.
Lab findings Results
WBC count 9300/mm³ (mildly elevated).
Total bilirubin 1.24 mg/dL (mildly elevated).
Direct bilirubin 0.68 mg/dL (mildly elevated).
AST 36 U/L (mildly elevated).
ESR 58.4 mm/hr (elevated).
CRP 58.4 mg/dL (elevated).
ALT Normal
Alkaline phosphatase Normal
amylase,lipase Normal
Urinalysis Normal
Abdominal Ultrasonography:
• Dilated, edematous gallbladder with wall thickening >10 mm.
• Numerous small stones and sludge; the largest stone measured 25 mm.
• No evidence of bile duct dilation or pathology.
Diagnosis
Acute calculous
cholecystitis with a giant,
inflamed, and
overdistended gallbladder.
Initial Management:
Ø The patient was admitted and prepared for surgery.
Ø IV fluids, antibiotics (broad-spectrum), and analgesics were
administered.
Surgical Intervention:
Procedure: Open cholecystectomy via midline laparotomy.
Intraoperative Findings:
ü Severely inflamed, overdistended gallbladder adherent to
adjacent organs.
ü Gallbladder measured 22 cm in length, 6 cm in width, with a
wall thickness of 1 cm.
ü A large impacted stone (25 mm) in the neck of the gallbladder.
Steps Taken:
Ø Needle decompression to reduce the size of the gallbladder
for easier dissection.
Ø Complete cholecystectomy performed successfully.
Conclusions
Early surgical intervention in acute
cholecystitis is crucial to prevent
complications such as perforation or sepsis.
This case emphasizes the role of clinical
judgment and timely open cholecystectomy in
managing severe and atypical
presentations.Open cholecystectomy was
preferred due to the severity of inflammation,
gallbladder size, and adhesions to adjacent
structures. The successful use of
decompression to facilitate dissection
highlights the importance of operative
adaptability in managing complex gallbladder
cases.
By,
SHAHANA SUNIJA
Group 18,6th year
Ø Gallbladder is a small, pear-shaped organ that stores and releases bile. It is located in the upper right part
of your abdomen (belly).
Ø Its main function is to store bile.
Bile Flow Pathway:
• Liver: Produces bile that flows through the left
and right hepatic ducts.
• Common Hepatic Duct: Formed by the left and
right hepatic ducts.
• Cystic Duct: Connects the gallbladder to the
common hepatic duct, allowing bile storage and
release.
• Common Bile Duct (CBD): Formed by the cystic
duct and common hepatic duct, leading to the
duodenum.
ü Cholecystitis is a redness and swelling
(inflammation) of the gallbladder. It
happens when a digestive juice called
bile gets trapped in your gallbladder.
ü Cholecystitis can be sudden (acute) or
long-term (chronic).
ü Of all people with stones, 1–4% have
biliary colic each year. If untreated,
about 20% of people with biliary colic
develop acute cholecystitis.
Gallbladder inflammation can be:
• Acute (sudden and urgent).
• Chronic (slow and longstanding).
• Calculous (related to gallstones).
• Acalculous (not related to
gallstones).
Ø Cholecystitis accounts for 3–10% of cases of abdominal pain worldwide.
Ø The frequency of cholecystitis is highest in people age 50–69 years old.
Ø Acute cholecystitis cases account for 3%–10% of all patients with abdominal pain.
Ø The incidence is higher in the intensive-care population, particularly in patients in
burn and trauma units.
Ø The mortality rate of acute cholecystitis is approximately 0.6%.
Ø Acute cholecystitis usually affects individuals of the North American Indian race.
Ø Gallstones(Acute calculous
cholecystitis) blocking your
bile ducts are the most
common cause of cholecystitis,
both chronic and acute.
• Biliary stricture.
• Biliary dyskinesia.
• Tumors
• Infection.
• Ischemia.
• Acalculous cholecystitis
History
Ø Right upper quadrant (RUQ) pain
• Prolonged (> 6 hours)
• After a fatty meal
• Radiation to the right scapula (Boas’s sign)
Ø Fever.
Ø Anorexia.
Ø nausea.
Ø vomiting.
Examination
§ Positive Murphy’s sign:
causing pain/discomfort and abrupt
cessation of the breath.
§ Abdominal guarding, rebound: local peritoneal
inflammation
Physical examination:
• Tenderness to palpation in RUQ/epigastric area
• Murphy’s sign
• Fever, tachycardia
Laboratory tests:
• Liver function tests (LFTs):
- Elevation of bilirubin and alkaline phosphatase (but
can be normal in uncomplicated cases)
-Mild elevation of alanine aminotransferase (ALT)
and aspartate aminotransferase (AST)
• CBC: leukocytosis (with left shift)
Imaging:
• GB wall thickening > 4 mm
• GB wall edema (double-wall sign)
• Sonographic Murphy’s sign (elicited with US probe pressing on the abdomen)
• Pericholecystic fluid
• Presence of gallstones
• Performed if US reveals equivocal results
• Intravenous injection of radioactive tracer that gets excreted in the bile
• If the cystic duct is not obstructed, the tracer will be seen in the gallbladder.
• Abnormal if gallbladder not visualized within 30–60 minutes
• Not a first-choice test for suspected cholecystitis as most gallstones will not be visualized on CT
• Will show GB inflammation
• Used if patient presents with peritonitis, bowel obstruction, or sepsis.
: utilized if choledocholithiasis is suspected
Ultrasound of a patient with acute
cholecystitis: A very large gallstone
with significant surrounding
edema can be seen.
In patients with severe acute cholecystitis who are at risk of complications like
gallbladder perforation or cholangitis (infection of the bile ducts), ERCP can help
in diagnosing and managing any obstructive or infectious component (by
clearing the bile ducts).
A. Local signs of inflammation :
(1) Murphy’s sign, (2) RUQ Definite diagnosis
mass/pain/tenderness (1) One item in A and one item in B are
positive
(2) C confirms the diagnosis when acute
cholecystitis is suspected clinically
B. Systemic signs of inflammation :
(1) Fever, (2) elevated CRP, (3)
elevated WBC count
C. Imaging findings:
imaging findings characteristic of
acute cholecystitis
Supportive therapy:
• Correct dehydration and electrolyte imbalances.
• IV acetaminophen or NSAIDs for pain relief. Avoid opioids if possible, but they may be used for severe pain.
• To control nausea and vomiting (e.g., ondansetron).
Broad-spectrum antibiotics are started to cover gram-negative, gram-positive, and anaerobic bacteria
commonly involved in biliary infections:
• Piperacillin-tazobactam.
• Ceftriaxone + Metronidazole.
• Ampicillin-sulbactam.
• Carbapenems (e.g., meropenem).
• Fluoroquinolone + Metronidazole (if beta-lactam allergy).
• For most people with acute cholecystitis, the treatment of choice is surgical removal of
the gallbladder,
• Approach:Laparoscopic is the standard of care (lower risk of infection, shorter hospital
stay).
• Open surgery: reserved for complicated cases
ü GB is drained/decompressed with a tube placed percutaneously under radiologic guidance.
Ø For patients with:
• Contraindications to surgery
• Cholecystitis not resolving with antibiotics/supportive management
• Acalculous cholecystitis (especially the severely ill)
• (ERCP) prior to surgery if US showed that common bile duct (CBD) stones are present
Laparoscopic
cholecystectomy
Special surgical tools and a
tiny video camera are put
through cuts, called incisions,
in the belly during
laparoscopic cholecystectomy.
Carbon dioxide gas inflates
the belly to make room for the
surgeon to work with surgical
tools.
• Make small incisions (2–3 cm near the belly button, 1 cm in the upper right
abdomen).
• Inflate the abdomen with carbon dioxide gas to improve visibility.
• Insert a laparoscope (camera) through one incision and surgical tools through
others.
• Remove the gallbladder using the video monitor for guidance.
• Release the gas and close the incisions with stitches.
• Make a single larger incision (4–6 inches) under the right rib.
• Use surgical tools to remove the gallbladder.
• Insert a drain (e.g., Jackson Pratt) to manage excess fluids.
• Close the incision with stitches, leaving the drain in place.
Peptic Ulcer Disease (PUD):
Choledocholithiasis (Bile Duct Stones) Acute Myocardial Infarction (Inferior
Acute Pancreatitis: Wall):
Ascending Cholangitis:
Hepatitis (Acute or Chronic):
Gallbladder Empyema: Pneumonia (Right Lower Lobe):
Gastritis:
Gallbladder Perforation: Pulmonary Embolism:
Small Bowel Obstruction (SBO):
Appendicitis (Retrocecal): Biliary Dyskinesia:
Kidney Stones (Right-Sided): Referred Pain from Spine or
Pyelonephritis: Chest Wall:
§ It describes the presence of abdominal symptoms after a cholecystectomy
(gallbladder removal).
§ Symptoms occur in about 5 to 40 percent of patients who undergo
cholecystectomy, and can be transient, persistent or lifelong.
§ The chronic condition is diagnosed in approximately 10% of
postcholecystectomy cases.
ü Dyspepsia, nausea and vomiting.
ü Flatulence, bloating and diarrhea.
ü Persistent pain in the upper right abdomen
Postcholecystectomy syndrome (PCS)
Ø Medications:
• Antispasmodics for bile duct spasms.
• Bile acid sequestrants (e.g., cholestyramine) for diarrhea.
• Pain relievers or antacids for gastrointestinal issues.
Ø Endoscopic Procedures: ERCP to remove retained stones or address bile duct strictures.
Ø Dietary Changes: Avoid fatty foods and eat smaller, frequent meals.
Ø Surgery: Rarely needed for complications like adhesions.
1. Gallbladder-Related Complications
• Empyema of the Gallbladder:
• Gallbladder Perforation:(Localized Perforation,Free Perforation)
• Gangrenous Cholecystitis:
• Cholecystoenteric Fistula:
• Risk of gallstone ileus (intestinal obstruction by a large gallstone).
2. Biliary Tract Complications
• Choledocholithiasis:
• Cholangitis.
3. Systemic Complications
• Sepsis:
• Peritonitis:
• https://www.hopkinsmedicine.org/health/conditions-and-
diseases/cholecystitis#:~:text=What%20is%20cholecystitis%3F,gets%20trapped%20in%20your%20g
allbladder.
• https://en.wikipedia.org/wiki/Cholecystitis#Differential_diagnosis
• https://my.clevelandclinic.org/health/diseases/15265-gallbladder-swelling--inflammation-cholecystitis
• https://www.ncbi.nlm.nih.gov/books/NBK459171/
• https://app.lecturio.com/#/article/2644?return=__app__%2Fsearch%2FCholecystitis
• https://onlinelibrary.wiley.com/doi/full/10.1002/jhbp.515
• https://my.clevelandclinic.org/health/procedures/21614-gallbladder-removal
• https://onlinelibrary.wiley.com/doi/10.1155/2020/8825167
