Rosen & Barkin's 5-Minute Emergency Medicine Consult (156 page)

• All patients with acute cholangitis should be admitted with immediate surgical and gastroenterologic consultation.
  
• Admit patients with signs of septic shock to the ICU.
  

None

Surgery/GI consultation

Admission to hospital for IV antibiotic and possible biliary drainage procedure.

• Aggressively fluid resuscitate patients.
  
• Administer antibiotics.
  
• Obtain GI and surgical consultations.
  

• Jackson PG, Evans SR. Biliary system. In: Townsend CM Jr, ed.
  Sabiston Textbook of Surgery
  . 19th ed. Philadelphia, PA: WB Saunders; 2012:1476–1514.
  
• Kinney TP. Management of ascending cholangitis.
  Gastrointest Endosc Clin N Am
  . 2007;17:289–306.
  
• Silen W. Cholecystitis and other causes of acute pain in the right upper quadrant of the abdomen. In: Silen W, ed.
  Cope’s Early Diagnosis of the Acute Abdomen.
  22nd ed. Oxford, UK: Oxford University Press; 2010:131–141.
  
• Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections.
  Clin Infect Dis
  . 2010;50:997; 133–164.
  
• Yusuf TE, Baron TH, AIDS Cholangiopathy.
  Curr Treat Options Gastroenterol
  . 2004;7:111–117.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cholecystitis
  
• Cholelithiasis
  

CODES

576.1 Cholangitis

BASICS

Cholecystitis is defined as inflammation of the gallbladder.

• Acute calculous cholecystitis:
  
  • Owing to bile stasis secondary to prolonged obstruction by a gallstone (see “Cholelithiasis”) in the gallbladder neck, cystic duct, or common bile duct
    
  • Leads to increased intraluminal pressure and mucosal damage
    
  • Release of inflammatory mediators results in distention, edema, and increased vascularity.
    
  • Coliforms and anaerobes lead to infection—primary causal role is controversial.
    
• Acalculous cholecystitis:
  
  • 10% of cases
    
  • Underlying critical illness leads to biliary stasis and mucosal ischemia.
    
  • Subsequent mucosal inflammation and infection
    

• Acute calculous cholecystitis
  extremely rare in childhood (see “Cholelithiasis”)
  
• Acalculous cholecystitis
  more common than calculous form in children:
  
  • Associated with systemic bacterial infections, scarlet fever, Kawasaki disease, and parasitic infections
    

DIAGNOSIS

• Acute calculous cholecystitis:
  
  • Dull, aching, epigastric, or right upper quadrant (RUQ) pain
    
  • Radiation to tip of right scapula, acromion, or thoracic spine
    
  • Duration >6 hr more suggestive of cholecystitis than uncomplicated biliary colic
    
  • As inflammation progresses, parietal peritoneal irritation leads to sharp, localized pain.
    
  • Nausea, vomiting, fever, and chills often reported, but absent in most cases
    
  • Jaundice in 20%
    
  • History of prior attacks of biliary colic or known gallstones favors diagnosis.
    
• Acalculous cholecystitis:
  
  • Occurs in critically ill patients (burns, sepsis, trauma, or postoperative)
    
  • Localized pain and tenderness frequently absent
    
  • Often presents with symptoms of generalized sepsis of unknown source
    

• Localized parietal peritoneal signs:
  
  • Percussion tenderness
    
  • Rebound
    
  • Found as the disease progresses
    
• Murphy sign:
  
  • Inspiratory arrest with gentle palpation of RUQ owing to increased pain
    
  • Found in most cases
    

• ECG in patients at risk for coronary artery disease
  
• CBC
  
• LFT
  
• Amylase, lipase
  
• Urinalysis
  
• Human chorionic gonadotropin (hCG)
  
• Gallbladder US or HIDA scan
  

• CBC:
  
  • WBC >12,000 cells/mm
    ³
    supports diagnosis, but may be normal in more than half of cases
    
• LFTs:
  
  • Transaminases, bilirubin, amylase, and lipase may be minimally elevated, but are generally normal.
    
  • Disproportionate elevation of direct bilirubin and alkaline phosphatase compared with transaminases suspicious for common duct obstruction or cholangitis
    

• US:
  
  • Generally the 1st-line imaging procedure
    
  • Positive findings include gallbladder wall thickening (>5 mm) or pericolic fluid—sensitivity, 90%; specificity, 80%.
    
  • Optimal if patient NPO >8 hr
    
• Radionuclide scanning (HIDA):
  
  • Most useful when clinical suspicion remains high despite equivocal findings on US or when acalculous cholecystitis suspected
    
  • Positive when tracer seen in small bowel but inflamed gallbladder fails to visualize
    
  • Sensitivity, >95%; specificity, 90%
    
  • False-positive results increase in nonfasting state.
    
  • Addition of IV morphine induces Sphincter of Oddi contraction which improves gallbladder filling and reduces false-positive scan results.
    
• CT scanning:
  
  • Exclude intestinal perforation or obstruction
    
  • Air in the gallbladder wall consistent with emphysematous cholecystitis
    
  • Gallstones radiopaque in up to 20%
    

• Biliary colic
  
• Hepatitis or hepatic abscess
  
• Cholangitis
  
• AIDS sclerosing cholangitis
  
• Pancreatitis
  
• Intestinal perforation
  
• Peptic ulcer disease
  
• Gastritis
  
• Duodenal perforation
  
• Right lower lobe pneumonia, pleurisy, or pulmonary infarction
  
• MI
  
• Abdominal aortic aneurysm
  
• Appendicitis
  
• Fitz-Hugh and Curtis syndrome
  
• Pyelonephritis
  

TREATMENT

Establish IV access for patients with vomiting or severe pain.

• IV, oxygen, cardiac monitoring until myocardial ischemic cause excluded
  
• Initiate IV fluid therapy for dehydration, hemodynamic compromise, or sepsis.
  

• Broad-spectrum antibiotics for coliforms, anaerobes, and enterococcus:
  
  • Ampicillin/sulbactam
    
  • Piperacillin/tazobactam
    
  • Add aminoglycoside if sepsis or cholangitis suspected (see “Cholangitis”).
    
• Alternative antibiotics for penicillin allergic:
  
  • Adults: Levofloxacin (Levaquin) and metronidazole
    
  • Peds: Clindamycin with aminoglycoside
    
• NPO
  
• IV fluid replacement and maintenance
  
• Antiemetics (ondansetron) if vomiting
  
• Nasogastric (NG) suctioning if refractory vomiting or ileus
  
• Narcotic analgesics (hydromorphone) with antiemetic (ondansetron):
  
  • Administer for refractory pain once diagnosis is reasonably established.
    
  • Morphine sulfate may lead to spasm at sphincter of Oddi (clinical significance not well established).
    
• Anticholinergics (glycopyrrolate) of no proven benefit for acute biliary pain.
  
• Surgical consultation
  

• Ampicillin/sulbactam: 3 g (peds: 200 mg/kg/24h) IV piggyback (IVPB) q6h
  
• Clindamycin: 600–900 mg (peds: 25–40 mg/kg/24h) IVPB q6–q8h
  
• Gentamicin: 1.5–2 mg/kg (peds: 6–7 mg/kg/24h) IVPB q8h; follow levels
  
• Levaquin: 500 mg IVPB q24h; contraindicated in peds
  
• Hydromorphone: 0.5–2 mg IV (0.01–0.02 mg/kg), titrated to pain relief.
  
• Metronidazole: 500 mg (peds: 30 mg/kg/24h) IVPB q6h
  
• Piperacillin/tazobactam: 3.375 mg (peds: 300 mg/kg/24h) IVPB q6h
  
• Ondansetron: 4–8 mg IV (peds: 0.15–0.3 mg/kg) IV (not to exceed 8 mg/dose IV), q4h PRN vomiting