Special Operations Forces Medical Handbook

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Do not race through the operation. Take your time and operate safely. It is much better to be safe than
to move too fast.
Do not operate without a dedicated anesthesia technician. The ‘surgeon’ will have enough on his mind.
Do not operate without 2 assistants for retraction. They will also be accessory eyes and brains during this
procedure.

GI: Acute Cholecystitis

COL (Ret) Peter McNally, MC, USA

Introduction: Gallbladder stones are common in the United States, seen in 10-15% of adults. They are 2-3
times more common in women (4 Fs: fat, forty, female, and fertile). Cholecystitis (gall bladder inammation)
occurs more commonly in certain diseases such as malaria, sickle cell, and ascaris infestations. When
gallstones become symptomatic, cholecystectomy is indicated.

Subjective: Symptoms
Biliary colic pain: usually located in the upper abdomen, frequently in the right upper quadrant (RUQ), may
radiate to the right scapula; may be precipitated by a meal, but more commonly there is no inciting event;
gradually increases over 15-60 min., plateaus for 1 or 2 hrs before slowly going away; if persists longer than
4 hrs it is unlikely to spontaneously resolve. 75% of patients have a history of previous attacks of biliary colic
before acute cholecystitis. May include nausia and vomiting.

Objective: Signs
Using Basic Tools: Inspection: Patients with acute cholecystitis appear uncomfortable and ill. Febrile but
< 102°F. Mild jaundice/icterus seen in 20%.
Auscultation: Bowel sounds should be present, unless gangrenous gallbladder or gallstone pancreatitis.
Palpation: Murphy’s Sign - During palpation of the right subcostal region, pain and inspiratory arrest may
occur when the patient takes a deep breath, bringing the examiner’s hand in contact with the inflamed
gallbladder. The obstructed and swollen gallbladder is palpable in 1/3 of acute cholecystitis.
Using Advanced Tools: Lab: WBC with differential will demonstrate infection.

Assessment:
Differential Diagnosis
Ascending cholangitis - fever, RUQ pain and jaundice (Charcot’s Triad) - a surgical emergency!
Obstruction of the common bile duct (gall stone or tumor) - marked jaundice, dark urine, clay-colored stools
Pancreatitis - diffuse abdominal pain with ileus and vomiting
Peptic Ulcer Disease - vomiting, hematemesis or melena if bleeding
Cardiac Pain - angina, heart attack
Esophageal reux, hiatal hernia - acid taste, pain relieved with antacid
Pleurisy/pneumonia - respiratory complaints, pain with deep inspiration
Liver Mass (abscess, tumor, cirrhosis) - jaundice, RUQ pain, no fever, no relationship to meals

Plan:
Treatment

1. IV uids (see Shock Fluid Resuscitation)


2. Antibiotics (ticarcillin 4 gm IV q 6 hr plus metronidazole 500 mg IV q 6 hr, or aztreonam 2 gm IV q 8
   hr plus clindamycin 450 mg IV q 8 hr).

Pain Assessment and Control 8-

4. Antipyretics (Tylenol, etc.)


5. Antiemetic medications should be given as needed (e.g., Compazine 5-10 mg IM q 3-4 hours, max 40
   mg/day)


6. Evacuate: High fever > 102°F, the presence of jaundice, persistent pain or vomiting—evacuate
   immediately; otherwise, worsening symptoms or failure to improve over 24 hours should prompt medical
   evacuation.
   Remember — cholangitis (pus in the biliary tree) is a surgical emergency.