A 56-year-old woman presents to the emergency department complaining of abdominal
pain. Twenty-four hours previously she developed a continuous pain in the upper
abdomen which has become progressively more severe. The pain radiates into the back.
She feels nauseated and alternately hot and cold. Her past medical history is notable for a
duodenal ulcer which was successfully treated with Helicobacter eradication therapy
5 years earlier. She smokes 15 cigarettes a day, and shares a bottle of wine each evening
with her husband.
Examination
The patient looks unwell and dehydrated. She weighs 115 kg. She is febrile, 38.5°C, her
pulse is 108/min and blood pressure 124/76 mmHg. Cardiovascular and respiratory system
examination is normal. She is tender in the right upper quadrant and epigastrium, with
guarding and rebound tenderness. Bowel sounds are sparse.
ANSWER 5
This woman has acute cholecystitis. Cholecystitis is most common in obese, middle-aged
women, and classically is triggered by eating a fatty meal. Cholecystitis is usually caused
by a gallstone impacting in the cystic duct. Continued secretion by the gallbladder leads
to increased pressure and inflammation of the gallbladder wall. Bacterial infection is usually
by Gram-negative organisms and anaerobes. Ischaemia in the distended gallbladder
can lead to perforation causing either generalized peritonitis or formation of a localized
abscess. Alternatively the stone can spontaneously disimpact and the symptoms spontaneously
improve. Gallstones can get stuck in the common bile duct leading to cholangitis
or pancreatitis. Rarely, gallstones can perforate through the inflamed gallbladder wall into
the small intestine and cause intestinal obstruction (gallstone ileus). The typical symptom
is of sudden-onset right upper quadrant abdominal pain which radiates into the back. In
uncomplicated cases the pain improves within 24 h. Fever suggests a bacterial infection.
Jaundice usually occurs if there is a stone in the common bile duct. There is usually
guarding and rebound tenderness in the right upper quadrant (Murphy’s sign).
In this patient the leucocytosis and raised CRP are consistent with acute cholecystitis. If
the serum bilirubin and liver enzymes are very deranged, acute cholangitis due to a stone
in the common bile duct should be suspected. The abdominal X-ray is normal; the majority
of gallstones are radiolucent and do not show on plain films.This patient should be admitted under the surgical team. Serum amylase should be measured
to rule out pancreatitis. Blood cultures should be taken. Chest X-ray should be performed
to exclude pneumonia, and erect abdominal X-ray to rule out air under the
diaphragm which occurs with a perforated peptic ulcer. An abdominal ultrasound will
show inflammation of the gallbladder wall. The patient should be kept nil by mouth, given
intravenous fluids and commenced on intravenous cephalosporins and metronidazole.
The patient should be examined regularly for signs of generalized peritonitis or cholangitis.
If the symptoms settle down the patient is normally discharged to be readmitted in a
few weeks once the inflammation has settled down to have a cholecystectomy