Cholecystitis - Hepatobiliary infections
Acute Cholecystitis is typically preceded by biliary colic associated with cholelithiasis and characteristically presents with fever, RUQ tenderness with Murphy's sign, and vomiting. Acalculous cholecystitis occurs in 5%-10% of cases. Organisms usually consist of normal gut flora. Leukocytosis and mild elevations of bilirubin, transaminases, and alkaline phosphatase are possible.
Ascending Cholangitis is a sometimes fulminant infectious complication of an obstructed common bile duct, often following pancreatitis or cholecystitis.
Dx: Clinical presentation is the Charcot triad of fever, RUQ, and jaundice; the additional sx of confusion and hypotension (Reynold's pentad) warrant rapid intervention. Bacteremia and shock are common.
Lab: Hepatic function panel abnormalities are usually severe.
Imaging: Imaging, with US being the primary modality. Technetium-99m-hydroxy iminodiacetic acid scanning and CT scanning may also be useful.
Dxtic procedures: ERCP allows for Dx as well as Tx intervention in the case of common bile duct obstruction and should be considered in patients with CBD dilation, jaundice, or LFT abnormalities.
Tx:
Management of acute cholecystitis includes parenteral fluids, restricted PO intake, analgesia, and surgery. Consider perioperative ABx in mild disease as they may reduce the risk of postsurgical infections, but advanced age, severe disease, or complications such as gallbladder ischemia or perforation, peritonitis, or bacteremia mandate broad-spectrum ABx. Immediate surgery is usually necessary for sever disease, but surgery can be otherwise delayed for up to 6 wks if there is an initial response to medical therapy.
The mainstay of therapy for ascending cholangitis is aggressive supportive care and surgical or endoscopic decompression and drainage. Broad-spectrum ABx are mandatory. Development of abscess is a complication requiring surgical drainage.
American Society of Anesthesiologists physical status scale
Adapted from Feigal, DW, Med Clin North Am 1979; 63:1131.
Empiric Tx for Cholangitis and Cholecystitis