Doctors Revision

Gastrointestinal & Hepatic System

Acute Cholecystitis / Cholangitis

Acute Cholecystitis is inflammation of the gallbladder, usually caused by cystic duct obstruction by a gallstone. Acute Cholangitis is inflammation/infection of the bile ducts, usually due to obstruction of the common bile duct (CBD) by a stone or stricture.

Also known as: Gallbladder Infection, Bile Duct Infection

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Referral and warning signs

When to refer

ALL cases of suspected Acute Cholecystitis or Cholangitis require URGENT hospital admission (H/RR) for diagnosis, IV antibiotics, and consideration for intervention (cholecystectomy or biliary drainage). Cholangitis, especially with signs of sepsis/organ dysfunction (Reynolds' pentad), is a medical emergency requiring immediate resuscitation and urgent biliary decompression (ERCP preferred).

Red flags

  • Charcot's Triad (RUQ Pain, Fever, Jaundice) -> Cholangitis
  • Reynolds' Pentad (Charcot's + Confusion + Shock) -> Suppurative Cholangitis
  • Positive Murphy's sign with fever/leucocytosis -> Cholecystitis
  • Signs of sepsis or organ dysfunction
  • Failure to improve on initial management

Signs and symptoms

  • Acute Cholecystitis:
  • - Persistent Right Upper Quadrant (RUQ) or epigastric pain (>6 hours).
  • - Fever, chills.
  • - Nausea, vomiting, anorexia.
  • - Positive Murphy's sign (inspiratory arrest on deep palpation of RUQ).
  • - Localized tenderness, guarding in RUQ.
  • - Mild jaundice may occur due to inflammation affecting CBD.
  • Acute Cholangitis:
  • - Charcot's Triad: RUQ pain, Fever (often high, with chills/rigors), Jaundice.
  • - Reynolds' Pentad (indicates severe/suppurative cholangitis): Charcot's Triad + Altered Mental Status + Shock (hypotension).
  • - Pruritus (itching).
  • - Dark urine, pale stools.

Risk factors

  • Gallstones (Cholelithiasis) - most common cause for both.
  • Biliary sludge.
  • Choledocholithiasis (stones in CBD - leads to cholangitis).
  • Bile duct strictures (post-surgical, PSC, tumour).
  • Biliary instrumentation (e.g., ERCP).
  • Tumours obstructing bile duct (pancreatic, cholangiocarcinoma).
  • Acalculous Cholecystitis (inflammation without stones): Severe illness, trauma, burns, prolonged TPN, immunosuppression, certain infections (CMV, Cryptosporidium in HIV).

Diagnosis

Clinical assessment

Suspect Cholecystitis with persistent RUQ pain, fever, positive Murphy's sign. Suspect Cholangitis with Charcot's triad (RUQ pain, fever, jaundice). Assess severity (presence of organ dysfunction, Reynolds' pentad). Differentiate from biliary colic, pancreatitis, PUD, hepatitis, appendicitis (high-lying), pneumonia.

Investigations

  • Abdominal Ultrasound: Initial imaging test. Cholecystitis: Shows gallstones, gallbladder wall thickening (>4mm), pericholecystic fluid, sonographic Murphy's sign. Cholangitis: May show CBD dilation (>6mm), stones in CBD (less sensitive).
  • Blood tests: CBC (leucocytosis), LFTs (Cholecystitis: may have mild elevation; Cholangitis: typically cholestatic pattern - elevated Bilirubin, ALP, GGT; ALT/AST may also be high), Amylase/Lipase (rule out pancreatitis).
  • Blood Cultures: Obtain in suspected cholangitis (often positive).
  • MRCP (Magnetic Resonance Cholangiopancreatography): Non-invasive imaging of biliary tree, good for detecting CBD stones/strictures.
  • ERCP (Endoscopic Retrograde Cholangiopancreatography): Diagnostic AND therapeutic for cholangitis/choledocholithiasis. Allows visualization, stone extraction, sphincterotomy, stenting.
  • HIDA Scan (Cholescintigraphy): Nuclear medicine scan, highly sensitive for acute cholecystitis if gallbladder doesn't visualize (indicates cystic duct obstruction). Used if ultrasound inconclusive.

Diagnostic criteria

Cholecystitis: Clinical picture + Ultrasound findings. Cholangitis: Clinical picture (esp. Charcot's triad) + Evidence of biliary obstruction (imaging - dilated ducts) and inflammation (fever, raised WBC/CRP).

Management

Non-pharmacological management

  • Hospital Admission.
  • NPO (Nil by mouth).
  • IV Fluid Resuscitation.
  • NG Tube insertion (if persistent vomiting).
  • Monitoring vital signs, urine output.
  • Acute Cholecystitis:
  • - Early Cholecystectomy (within ~72 hours of onset preferred if stable) is definitive treatment.
  • - Delayed cholecystectomy (after interval antibiotics) if presentation late or high surgical risk.
  • - Percutaneous Cholecystostomy (drainage tube in gallbladder): For patients unfit for surgery.
  • Acute Cholangitis:
  • - Urgent Biliary Drainage is crucial (usually via ERCP with sphincterotomy +/- stone extraction/stenting). Percutaneous transhepatic cholangiography (PTC) drainage or surgical drainage are alternatives if ERCP fails/unavailable.

Pharmacological treatment

  • Analgesia: Opioids (Pethidine, Morphine) or NSAIDs (Ketorolac).
  • Antiemetics.
  • IV Antibiotics: Start empirically, cover common biliary pathogens (Gram-negatives, Enterococcus, anaerobes).
  • - Mild/Moderate Cholecystitis/Cholangitis: e.g., Ceftriaxone +/- Metronidazole OR Piperacillin/Tazobactam OR Ciprofloxacin + Metronidazole.
  • - Severe Cholangitis/Healthcare-associated: Broader coverage (e.g., Piperacillin/Tazobactam, Carbapenem +/- Vancomycin depending on local resistance/patient factors).
  • - Tailor based on culture results if available. Duration varies (e.g., until cholecystectomy for cholecystitis, longer for cholangitis depending on drainage/response).

Monitoring

  • Monitor vital signs, clinical status, pain.
  • Monitor WBC count, LFTs, bilirubin.
  • Monitor response to antibiotics.
  • Monitor for signs of sepsis/organ dysfunction.

Complications

  • Cholecystitis: Gangrenous cholecystitis, Gallbladder perforation, Pericholecystic abscess, Cholecystoenteric fistula, Gallstone ileus.
  • Cholangitis: Sepsis/Septic shock, Liver abscess, Biliary cirrhosis (chronic obstruction), Pancreatitis.
  • Post-ERCP complications (pancreatitis, bleeding, perforation, cholangitis).

Prevention

  • Elective cholecystectomy for symptomatic gallstones prevents cholecystitis.
  • Prompt treatment of choledocholithiasis prevents cholangitis.

Patient education

  • Explain the condition (gallbladder/bile duct inflammation/infection).
  • Need for hospitalization, IV fluids, antibiotics.
  • Explain planned investigations (Ultrasound, blood tests).
  • Discuss definitive treatment (Cholecystectomy for cholecystitis; ERCP/drainage for cholangitis).
  • Post-procedure/operative care instructions.

Uganda-specific notes

Gallstone disease is increasing. Ultrasound is key initial test. Access to ERCP and laparoscopic cholecystectomy is limited to specialized centers. Management often involves IV antibiotics and referral for definitive treatment. Cholangitis carries high mortality if drainage delayed.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 6, Section 6.5.9

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