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 usu-
ally 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 spontan-
eously 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 major-
ity of gallstones are radiolucent and do not show on plain films.
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The major differential diagnoses of acute cholecystitis include perforated peptic
ulcer, acute pancreatitis, acute hepatitis, subphrenic abscess, retrocaecal appendicitis
and perforated carcinoma or diverticulum of the hepatic flexure of the colon.
Myocardial infarction or right lower lobe pneumonia may also mimic cholecystitis.Differential diagnosisThis patient should be admitted under the surgical team. Serum amylase should be meas-
ured to rule out pancreatitis. Blood cultures should be taken. Chest X-ray should be per-
formed 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 cholangi-
tis. 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.
- Acute cholecystitis typically causes right upper quadrant pain and a positive Murphy’s sign.
- Potential complications include septicaemia and peritonitis.