Critical Care Medicine
Cholecystitis and Cholangitis
1. Description of the problem
Acute inflammation of the gallbladder
Right upper quadrant or epigastric pain
Anorexia, nausea, vomiting, and intolerance to tube feedings
Fever and chills
Critically ill patients may not present with the usual symptoms and signs.
Laboratory tests are non-specific.
The best imaging study is ultrasound, though scintigraphy and computed tomography may be helpful.
Initial management includes antibiotics and bowel rest.
Definitive therapy includes cholecystectomy.
Precutaneous cholecystostomy may be indicated if the patient is too sick for cholecystectomy.
2. Emergency Management
Manage the airway.
Early goal-directed resuscitation for sepsis
Initiate antibiotic coverage for enterococcus and gram-negative rods.
Consider cholecystectomy or cholecystostomy.
White blood cell count.
Liver enzymes, bilirubin.
Ultrasound of the right upper quadrant.
Scintigraphy with iminodiacetic acid.
White blood cell count (nl 4,500-11,000 cells/ml) elevated.
Transaminases (aspartate aminotransferase, alanine aminotransferase, nl <35 units/liter) normal or mildly elevated.
Alkaline phosphatase (nl 30-120 units/liter) elevated with cholangitis, but not usually with cholecystitis.
Bilirubin (nl 0.3-1.0 mg/dl) elevated with cholangitis but not usually with cholecystitis.
Ultrasound demonstrates thickened gallbladder wall and pericholecystic fluid. Gallstones may or may not be present. With cholangitis, the gallbladder may appear normal, but there should be intrahepatic and extrahepatic biliary ductal dilatation.
Computed tomography may have similar findings.
Scintigraphy demonstrates the absence of filling of the gallbladder.
Ultrasound of the gallbladder demonstrating wall thickening (white arrow) and sludge (black arrow).
Computed tomography of the abdomen demonstrating thickening of the gallbladder wall and pericholecystic fluid (black arrow), as well as sludge (white arrow).
Scintigraphy of biliary tree, demonstrating concentration of tracer in the liver, followed by flow into biliary tree and small bowel. The gall bladder is not visualized.
Diagnosis is made by a combination of clinical findings and imaging.
Other diagnoses include peptic ulcer disease (with or without perforation), acute pancreatitis, and hepatitis.
The most definitive tests are aspiration of bile by percutaneous cholecystostomy or removal of the gallbladder.
4. Specific Treatment
Cholecystectomy or percutaneous cholecystostomy
Second- or third-generation cephalosporins
Refractory cases are unusual once a cholecystectomy has been performed. If patients do not respond well to cholecystostomy, gangrenous cholecystitis should be considered. The patient may require cholecystectomy.
5. Disease monitoring, follow-up and disposition
Typically, treatment with cholecystostomy or cholecystectomy leads to rapid improvement in the patient's condition. For critically ill patients who develop acalculous cholecystitis, prognosis may be more dependent upon the underlying disease processes than the management of the cholecystitis.
If the patient undergoes a cholecystectomy, the follow-up with the surgeon should be routine. Follow-up after placement of a cholecystostomy is controversial. A cholangiogram is usually performed through the catheter.
Acute cholecystitis most frequently occurs in outpatients with gallstones, often with impaction of a stone in the cystic duct. In critically ill patients, however, acute cholecystitis occurs without gallstones. The pathophysiology is thought to be a combination of hypoperfusion and increased luminal pressure in the gallbladder. Hypoperfusion may be caused by hypovolemia, heart failure, sepsis, or the use of vasopressors. Increased luminal pressure from biliary stasis is related to fasting and narcotics.
Acute cholecystitis in the ICU is very uncommon. Exact data on incidence are difficult to come by. For patients who develop cholecystitis in the ICU, at least half have acalculous disease. Identifying specific groups at highest risk is difficult because the disease is rare, yet the risk factors are common. Mortality is high, though it is not clear how much the cholecystitis directly increases mortality since the sickest patients tend to be the ones who develop this complication.
Overall mortality is around 30%. Complications such as gangrene or perforation of the gallbladder and abscess formation are much more common than in the non-ICU population. Patients who develop necrosis are at a significant risk for failure of percutaneous drainage. The risk for mortality is very dependent upon the underlying disease processes and comorbidities.
Special considerations for nursing and allied health professionals.
The only thing I might bring up is how to care for drains that might be placed, such as a cholecystostomy tube or a closed-suction drain (if the patient undergoes cholecystectomy).
What's the evidence?
Boland, GW, Slater, G, Lu, DS. "Prevalence and significance of gallbladder abnormalities seen on sonography in intensive care unit patients". Am J Roentgenol. vol. 174. 2000. pp. 973-7.(This paper gives an overview of the prevalence of certain sonographic findings in patients in the intensive care unit with or without possible cholecystitis.)
Helbich, TH, Mallek, R, Madl, C. "Sonomorphology of the gallbladder in critically ill patien". Value of a scoring system and follow-up examinations. Acta Radiol. vol. 38. 1997. pp. 129-34.(This group tried to quantify ultrasound findings, coupled with serial clinical examinations, to improve diagnostic accuracy of ultrasonography in critically ill patients.)
Jeffrey, RB, Sommer, FG. "Follow-up sonography in suspected acalculous cholecystitis: preliminary clinical experience". J Ultrasound Med. vol. 12. 1993. pp. 183-7.(This paper illustrates the utility of repeat ultrasonography in patients for whom the clinician has a high index of suspicion for cholecystitis, but the initial study is negative or equivocal.)
Flancbaum, L, Alden, SM, Trooskin, SZ. "Use of cholescintigraphy with morphine in critically ill patients with suspected cholecystitis". Surgery. vol. 106. 1989. pp. 668-73.(The addition of morphine to cholescintigraphy can improve the ability of this test to diagnose cholecystitis in critically ill patients.)
Prevot, N, Mariat, G, Mahul, P. "Contribution of cholescintigraphy to the early diagnosis of acute acalculous cholecystitis in intensive-care-unit patients". Eur J Nucl Med. vol. 26. 1999. pp. 1317-25.
Mariat, G, Mahul, P, Prevot, N. "Contribution of ultrasonography and cholescintigraphy to the diagnosis of acute acalculous cholecystitis in intensive care unit patients". Intensive Care Med. vol. 26. 2000. pp. 1658-63.(The papers by Prevot et al. and Mariat et al. bring into perspective the additional diagnostic information afforded by scintigraphy that complements the information obtained by ultrasound.)
Mirvis, SE, Whitley, NO, Miller, JW. "CT diagnosis of acalculous cholecystitis". J Comput Assist Tomogr. vol. 11. 1987. pp. 83-7.(CT of the abdomen can be used to diagnose acalculous cholecystitis, but its more important role may be to rule out other causes of an acute abdomen in the ICU.)
Boland, GW, Lee, MJ, Leung, J, Mueller, PR. "Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients". Am J Roentgenol. vol. 163. 1994. pp. 339-42.(This study demonstrates the diagnostic and therapeutic value of percutaneous cholecystostomy for patients with suspected acalculous cholecystitis.)
van Sonnenberg, E, D' Agostino, HB, Goodacre, BW. "Percutaneous gallbladder puncture and cholecystostomy: Results, complications, and caveats for safety". Radiology. vol. 183. 1992. pp. 167-70.(In a large series, this paper demonstrates that cholecystostomy has a high success rate with a small risk of complications.)
Yang, HK, Hodgson, WJ. "Laparoscopic cholecystostomy for acute acalculous cholecystitis". Surg Endosc. vol. 10. 1996. pp. 673-5.(For patients who can tolerate a general anesthetic but intra-operative findings preclude a cholecystectomy, an operative cholecystostomy is a viable option.)
Almeida, J, Sleeman, D, Sosa, JL. "Acalculous cholecystitis: the use of diagnostic laparoscopy". J Laparoendosc Surg. vol. 5. 1995. pp. 227-31.(When the diagnosis of acute cholecystitis is difficult to confirm and other life-threatening diagnoses have been considered, yet the patient may be too ill to tolerate transport to the operating room, diagnostic bedside laparoscopy may be considered.)
Thompson, JW, Ferris, DO, Beggenstoss, AH. "Acute cholecystitis complicating operation for other diseases". Ann Surg. vol. 155. 1962. pp. 489.(This paper postulated that the critical pathophysiologic mechanism for acalculous cholecystitis is hypoperfusion.)
Warren, BL, Carstens, CA, Falck, VG. "Acute acalculous cholecystitis–a clinical-pathological disease spectrum". S Afr J Surg. vol. 37. 1999. pp. 99-104.(This study found ischemia of the gallbladder in a significant number of patients with acalculous cholecystitis.)
Ryu, JK, Ryu, KH, Kim, KH. "Clinical features of acute acalculous cholecystitis". J Clin Gastroenterol.. vol. 36. 2003. pp. 166-9.(This paper describes the risk factors for acalculous cholecystitis in outpatients.)
Kalliafas, S, Ziegler, DW, Flancbaum, L, Choban, PS. "Acute acalculous cholecystitis: Incidence, risk factors, diagnosis, and outcome". Amer Surg. vol. 64. 1998. pp. 471-5.
Trowbridge, RL, Rutkowski, NK, Shojania, KG. "Does this patient have acute cholecystitis?". JAMA. vol. 289. 2003. pp. 80-6.
Fabian, TC, Hickerson, WL, Mangiante, EC. "Post-traumatic and postoperative acute cholecystitis". Am Surg. vol. 52. 1986. pp. 188-92.(This paper describes an association between trauma or surgery and the subsequent development of cholecystitis.)
Shapiro, MJ, Luchtefeld, WB, Kurzweil, S. "Acute acalculous cholecystitis in the critically ill". Am Surg. vol. 60. 1994. pp. 335-9.(This paper describes an association between critical illness, particularly sepsis, and the subsequent development of cholecystitis.)
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