Give a case scenario for Gall stones and cholecystitis
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Clinical Case: Gallstones and Acute Cholecystitis
Case Presentation
Patient: Mrs. Anita Sharma, 42-year-old woman
BMI: 31 kg/m² | Parity: G3P3 | Past medical history: Type 2 diabetes mellitus (diet-controlled), no prior surgeries
Chief Complaint
"Severe pain in my upper right abdomen for the past 8 hours - it won't go away."
History of Present Illness
Mrs. Sharma presents to the Emergency Department at 11 PM with an 8-hour history of constant, severe right upper quadrant (RUQ) pain radiating to the right shoulder and back. She describes having experienced 3-4 similar but shorter episodes over the past 6 months - each lasting 1-2 hours and resolving on its own, typically after eating fatty food (fried rice, mutton curry). Tonight's episode started after dinner and has progressively worsened rather than resolving.
She also reports:
- Nausea and two episodes of vomiting (non-bilious)
- Low-grade fever (she feels warm)
- No jaundice, dark urine, or pale stools
- No diarrhoea or dysuria
She denies any previous diagnosis of gallstones, though she recalls being told her liver "looked a little fatty" on a scan 2 years ago.
Risk factors present (the "5 F's"):
- Fat - BMI 31 (overweight)
- Female - 42-year-old woman
- Fertile - 3 pregnancies (elevated estrogen promotes cholesterol supersaturation in bile)
- Forty - age in the fourth decade
- Family - her mother had a cholecystectomy at age 50
Physical Examination
| Parameter | Finding |
|---|---|
| Temperature | 38.2°C |
| HR | 98 bpm |
| BP | 124/78 mmHg |
| RR | 18/min |
| SpO₂ | 98% on room air |
Abdomen:
- Soft, with voluntary guarding in the RUQ
- No rigidity or rebound tenderness
- Murphy's sign: POSITIVE - deep palpation of the RUQ causes sharp pain and sudden cessation of inspiration. Murphy's sign is 65% sensitive and 87% specific for acute cholecystitis.
- No palpable gallbladder mass (Courvoisier's sign negative)
- Bowel sounds present and normal
- No jaundice, no scleral icterus
Differential Diagnosis
| Diagnosis | For | Against |
|---|---|---|
| Acute cholecystitis | Positive Murphy's, fever, persistent RUQ pain, prior biliary colic episodes | - |
| Biliary colic | Prior similar episodes | This episode >6 hours, fever, Murphy's sign |
| Choledocholithiasis | RUQ pain, history of stones | No jaundice, no dark urine |
| Acute pancreatitis | RUQ/epigastric pain, vomiting | No radiation to back in a band-like pattern |
| Peptic ulcer disease | Epigastric pain | Pain is RUQ, not epigastric; no NSAID/alcohol history |
Investigations
Bloods:
| Test | Result | Interpretation |
|---|---|---|
| WBC | 14,200/µL | Leukocytosis - suggests active inflammation |
| CRP | 68 mg/L | Elevated - inflammatory marker |
| Total Bilirubin | 1.1 mg/dL | Normal - no duct obstruction |
| ALT / AST | 42 / 38 U/L | Mildly elevated |
| ALP | 95 U/L | Normal |
| Serum Lipase | 38 U/L | Normal - pancreatitis excluded |
| Serum Amylase | 55 U/L | Normal |
| Blood glucose | 7.2 mmol/L | Mildly elevated (background T2DM) |
| Urea / Creatinine | Normal | No organ dysfunction |
| Urine dipstick | Negative | UTI excluded |
Note: Bilirubin >2 mg/dL with a significant direct component would raise concern for choledocholithiasis, Mirizzi syndrome, or cholangitis.
Imaging:
Abdominal Ultrasound (US) - the first-line imaging of choice:
- Multiple echogenic foci with posterior acoustic shadowing in the gallbladder lumen - gallstones confirmed, largest measuring 1.4 cm
- Gallbladder wall thickening: 6 mm (normal <4 mm)
- Pericholecystic fluid present
- Sonographic Murphy's sign positive (pain reproduced when probe pressed over gallbladder)
- Common bile duct: 4 mm (normal) - no choledocholithiasis
US sensitivity for acute cholecystitis is 88-90%, specificity 80%. It identifies gallstones as small as 2 mm and can demonstrate the "double wall sign" (sonolucent halo around the gallbladder wall) in acute inflammation.
Diagnosis
Acute Calculous Cholecystitis (Grade I - Mild, Tokyo Guidelines)
- Grade I (Mild): No organ dysfunction, no severe local inflammation (no gangrenous or emphysematous change, no pericholecystic abscess, no perforation)
Understanding the Pathophysiology
The prior short-lived RUQ pain episodes were biliary colic - a gallstone intermittently obstructing the cystic duct, causing gallbladder distension and pain, then passing back into the lumen. Tonight, a stone became persistently impacted in the cystic duct. The sustained obstruction caused:
- Increased intraluminal pressure and gallbladder distension
- Ischemia of the gallbladder wall
- Release of prostaglandins and inflammatory mediators
- Secondary bacterial colonisation (E. coli, Klebsiella are the predominant organisms in ~50% of cases)
- Transmural inflammation = acute cholecystitis
Management
Immediate (ED):
- IV access + IV fluids - volume replacement, keep NBM (nil by mouth)
- Analgesia - IV ketorolac (NSAID first-line; analgesic efficacy comparable to opioids for biliary pain and may reduce short-term complications). Opioids (e.g., morphine) can be added if insufficient.
- Antiemetics - IV ondansetron or metoclopramide
- Antibiotics - IV cefuroxime + metronidazole (or piperacillin-tazobactam). Appropriate regimens include 2nd/3rd generation cephalosporins, carbapenems, beta-lactam/beta-lactamase inhibitor combinations, or fluoroquinolone + metronidazole.
- Surgical consultation - urgent
Definitive Treatment:
Early Laparoscopic Cholecystectomy - within 72 hours of admission (within the first week of symptom onset) is the treatment of choice. This approach results in a shorter hospital stay without increased serious complications compared to delayed surgery. This is a Grade 1A recommendation (Yamada's Gastroenterology).
If early surgery is not possible due to late presentation or high surgical risk, elective cholecystectomy after 6 weeks is preferred, as morbidity is higher between days 7-45.
Severity Grading and Management Algorithm (Tokyo Guidelines 2013)
Management of acute cholecystitis based on Tokyo 2013 severity grading. LC = laparoscopic cholecystectomy; GB = gallbladder.
| Grade | Criteria | Management |
|---|---|---|
| Grade I (Mild) | No organ dysfunction; mild local inflammation | Antibiotics + supportive care → Early Laparoscopic Cholecystectomy |
| Grade II (Moderate) | Marked local inflammation (e.g., elevated WBC >18k, onset >72h, GB mass) | Antibiotics → Emergency surgery if advanced laparoscopic technique available; otherwise delayed/elective LC after successful therapy |
| Grade III (Severe) | Organ dysfunction (cardiovascular, neurological, respiratory, renal, hepatic, haematologic) | Antibiotics + organ support → Urgent gallbladder drainage → Delayed elective LC + bile culture |
Complications to Watch For
If left untreated or undertreated, Mrs. Sharma could develop:
| Complication | Description |
|---|---|
| Gangrenous cholecystitis | Necrosis of the GB wall; occurs in up to 20% of cases |
| Empyema of gallbladder | Pus-filled gallbladder from bacterial superinfection (E. coli, Klebsiella, Pseudomonas, Streptococci) |
| Gallbladder perforation | Usually at the fundus; can lead to pericholecystic abscess or peritonitis; rare but carries high mortality |
| Emphysematous cholecystitis | Gas-forming organisms (Clostridium, E. coli) infect the wall; more common in diabetic men; high mortality - requires urgent cholecystectomy |
| Choledocholithiasis | Stone migrating to the CBD causing jaundice and obstruction |
| Cholangitis | Infection of the biliary tree; life-threatening, demands urgent biliary decompression (ERCP preferred) |
| Gallstone pancreatitis | Stone impacting at the ampulla of Vater |
| Gallstone ileus (rare) | Cholecystoenteric fistula + stone impacting at ileocecal valve; causes bowel obstruction |
| Mirizzi syndrome | Impacted stone in cystic duct causing extrinsic compression of the CBD |
Patient Course
Mrs. Sharma is admitted, started on IV fluids, IV cefuroxime + metronidazole, and IV ketorolac. Her pain improves significantly within 4 hours. She undergoes laparoscopic cholecystectomy on day 2 of admission. Intraoperatively, the gallbladder is found to be oedematous with a 1.4 cm stone impacted in Hartmann's pouch. The surgery proceeds without conversion to open. She is discharged home on day 3 with analgesia and dietary advice to avoid high-fat meals in the short term.
Key Teaching Points
- Gallstones are common - 8% prevalence in men, 17% in women in the USA; prevalence rises with age and BMI.
- Most gallstones are asymptomatic - risk of developing symptoms/complications is 1-4% per year.
- Biliary colic vs. acute cholecystitis: Biliary colic is self-limiting (hours); cholecystitis is persistent (>6 hours) with fever and positive Murphy's sign.
- Murphy's sign is 65% sensitive, 87% specific for acute cholecystitis.
- Ultrasound is first-line imaging - cheap, no radiation, sensitivity 88-90%.
- Early laparoscopic cholecystectomy (within 1 week) is the standard of care - Grade 1A evidence.
- NSAIDs are first-line analgesia and may also reduce the risk of progression to cholecystitis in biliary colic.
- Diabetic patients are at special risk for emphysematous and gangrenous cholecystitis and should be monitored closely.
Sources: Tintinalli's Emergency Medicine, 9th ed. | Yamada's Textbook of Gastroenterology, 7th ed. | Fischer's Mastery of Surgery, 8th ed. | Sleisenger and Fordtran's Gastrointestinal and Liver Disease | Mulholland and Greenfield's Surgery, 7th ed.
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