• Virtual Rounds Session 6: Acute Calculous Cholecystitis (Premed Shadowing)

Virtual Rounds Session 6: Acute Calculous Cholecystitis (Premed Shadowing)

Throughout each premed virtual shadowing session, you will actively participate by answering and asking questions about the week’s proposed case. Like an in-person shadowing experience, we strive to stimulate students intellectually and ultimately reaffirm their interest in medicine.

 

Introduction –Acute  calculous cholecystitis

This is an extremely common diagnosis, and perhaps one of the most commonly performed procedures in General Surgery. With this, however, comes many more serious illnesses that must be identified to decrease the risk of mortality and postoperative complications. Through this case, we will discuss the most common presentation of cholelithiasis while taking into account other etiologies that may present as abdominal pain. 

Case Highlights 

A 45-year-old female with a pmhx of HTN and hypercholesterolemia presents with a complaint of abdominal pain for the past 3 days with associated nausea. She states the pain is diffuse but increased in the upper abdomen. She notes that it became markedly worse after eating dinner last night. Pain is described as being sharp, waxing, and waning, and improved with rest. Pain is stated to be a 10/10 at its worst and 5/10 when at rest. States that she has had about 4 episodes of this pain in the past but cannot recall any specific diagnosis given for the pain. Additionally notes that she started having a dull aching pain in her right shoulder and mid-back. She is status post a total abdominal hysterectomy 1 year ago. She does not smoke, drink alcohol, or use drugs.

Pathology 

Cholelithiasis can be caused a number of different diseases, but the four main risk factors for this can be easily remembered by the 4F’s: Female, Fat, Forty, Fertile. There are two types of stones that can be found in the gallbladder, cholesterol or pigmented, and while the underlying cause for each to occur differs the treatment of the acute illness does not change. It is important to remember that you might find patients that have cholelithiasis for years but do not have any intervention to treat them. This is because having Cholethiasis itself doesn’t warrant surgical intervention and many people are asymptomatic. Intervention is needed when the patient develops cholecystitis as a result of the stones. This is what we will discuss below

Presentation:

Patients will present with intermittent abdominal pain that is worse in the RUQ, and worse right after eating. Some patients may have shoulder or back pain due to referred pain. They may or may not have a fever, nausea, vomiting.

Physical: 

  • RUQ pain, especially Murphy’s sign. This is when the physician palpates under the right costal margin and has the patient take a deep breath in. If the patient has to abruptly stop breathing because of sharp pain this is a + Murphys sign.

Work Up: 

CBC: To look at the WBC level. 

Liver Function Test: to look to see if there are any signs of the patient having a biliary tree obstruction. 

RUQ US: This is the gold standard for visualizing the gallbladder. Looking for signs of a stone, bile sludge, edema around the gallbladder as well as gallbladder wall thickening. 

Treatment: 

In most cases, if this is a repeated instance of cholecystitis, the patient will be recommended to have an elective cholecystectomy. In cases where the patient is not a surgical candidate at the present moment they can return for an elective cholecystectomy at a later date, and for patients will more severe comorbidities the use of cholecystostomy tubes or ursodiol can be done to decrease the symptoms and likelihood of another attack in the future.

 Take home points

    1. Gallstones may be asymptomatic but can be a nidus for infection leading to cholecystitis. 
    2. Always have a large differential list, because abdominal pain can present differently in patients so this will help you look for everything without getting tunnel vision. 
    3. 4 F’s: Female, Fat, Forty, Fertile are the most common risk factors for cholelithiasis. 
    4. Cholecystectomy is not an emergent surgery, but due to the high likelihood of a repeat episode, it is commonly removed to prevent further attacks. 
    5. Always think of Choledocholithiasis (CBD obstruction due to a stone) as this can lead to Cholangitis which needs to be treated medically first.  
    6. RUQ US is the gold standard diagnostic test for Cholecystitis.

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