Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)
Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.
A 41-year-old obese female presents for evaluation of severe right upper quadrant pain and nausea without emesis. The patient reports post-prandial pain of one months duration, acutely worsening prior to presentation following the consumption of a bacon cheeseburger. ROS is negative for sick contacts, foreign travel, and changes in bowel habits. The patient denies a surgical history.
Triage VS: T101.6°F Oral, HR 134, BP 147/99, RR 24, SpO2 98% on room air
What is the patient’s diagnosis? What’s the next step in your evaluation and treatment?
Answer: Acute Cholecystitis1-4
- Risk Factors: oral contraceptives or estrogen replacement therapy (alters cholesterol and bile salt metabolism leading to gallstone formation and gallbladder hypomotility1), diseases of the terminal ileum (e.g. Crohns; secondary to poor bile salt reabsorption), cirrhosis (decreased bile acid secretion), hemolytic diseases (pigmented gallstones), pregnancy, obesity, TPN
- Presentation: RUQ or epigastric pain, postprandial pain, nausea +/- emesis, +Murphy’s sign (+LR: 2.8; 95% CI, 0.8-8.62), +/- fever
- US (Sensitivity 95%, Specificity 98%3): sonographic Murphy’s, pericholecystic fluid, gallstones/biliary sludge, gallbladder wall thickening > 3mm.
- CBC, LFTs
- CBC: often demonstrates leukocytosis
- LFTs: transaminitis; allows for evaluation of choledocolithiasis
- Mildly ill: ciprofloxacin 400 mg IV + metronidazole 500 mg IV
- Critically ill: vancomycin 20 mg/kg (up to 2 g) IV + piperacillin/tazobactam 4.5 g IV
- Fluid Resuscitation
- Pain control
- Anti-emetic PRN
- Surgical Consultation – cholecystectomy
- Diabetes is a risk factor for emphysematous cholecystitis:3 initiate antibiotic therapy directed against Gram-negative rods and anaerobes, and consult surgery.
- Include acalculous cholecystitis in your differential diagnosis of the critically ill: RUQ pain, epigastric pain, and nausea are absent upon initial evaluation in up to 75% of these patients.1
- Welch J, Chike V, Bowens N, Arnell T, Ferri F. Acute Cholecystitis. First Consult. 2011. Elsevier, Philadelphia, PA.
- Trowbridge R, Rutkowski N, Shojania K. Does this patient have acute cholecystitis? JAMA. 2003; 289(1): 80-86.
- Glasgow R, Mulvihill S. Treatment of Gallstone Disease. In: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. Philadelphia: Saunders Elsevier, 2016:1134-1151.e5.
- Senturk S, Miroglu T, Cilici A, Gumua H, Tekin R, et al. Diameters of the common bile duct in adults and postcholecystectomy patients: a study with 64-slice CT. Eur J Radiol. 2012; 81(1): 39-42.