Cholecystitis (and biliary tract pathologies)

Objectives

To guide the investigation and management of suspected cholecystitis and biliary tract pathologies in the deployed environment.

Scope

This guideline describes the management of patients with suspected cholecystitis and biliary tract pathologies in a forward medical context or deployed Emergency Department.

Definitive diagnosis of severity or complications is unlikely to be available in the deployed setting below Role 2e facilities.

There are separate guidelines for Acute Pancreatitis and Peptic Ulcer Disease (links to follow).

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in a forward medical location or in an Emergency Department on deployed operations.

Background

Most biliary tract emergency presentations relate to gallstones.  Solitary and multiple gallstones of various compositions are common (more than 1 in every 10 adults in the UK has gallstones), with increased risk in those who are overweight, female or aged 40 or over.

Patients may present along a spectrum of illness.   Biliary colic pain following food and without features of inflammation may be self-limiting or intermittent.  Acute cholecystitis with evidence of inflammation (fever, persistent pain) can become complicated by mucocele, empyema, septic shock and perforation.  Stones and bile stasis in the common bile duct can lead to obstructive jaundice, ascending cholangitis, or acute pancreatitis (see separate CGO - link to follow).

Initial Assessment & Management

History: Right hypochondrial or epigastric pain, radiating to the right side and back +/- vomiting.  Referred pain may be felt in shoulder tip or interscapular area. May be difficult to differentiate from other causes such as acute pancreatitis and peptic ulcer disease - see separate CGOs. Also consider atypical presentation of acute coronary syndrome (see CGO).

Examination: look for features of acute inflammation – fever, right hypochondrial tenderness (felt particularly on inspiration – Murphy’s sign).  A palpable mass may indicate empyema (often high fever, extreme tenderness, septic shock). Charcot’s triad (abdominal pain, jaundice, and fever) implies ascending cholangitis – the patient may be very ill and require fluid resuscitation.

Analgesia: analgesic requirements are likely to be significant in patients with acute cholecystitis, often requiring opioids. Pain should be managed in accordance with individual capabilities. NSAIDS should be avoided.

Anti-emetics: nausea and vomiting are likely to be present. Anti-emetics should be used routinely to reduce these symptoms.

Antibiotics: In the presence of acute inflammation or fever, IV antibiotics should be administered in accordance with deployed antimicrobial guidance for non-traumatic intra-abdominal infection (link to follow).

Oxygen: Pulmonary complications are rare. Utilise supplemental oxygen to aim for SaO2 >92%.

Fluid resuscitation: Hartmanns or other balanced crystalloid are preferred to be used, otherwise saline, with a bolus of 10-20ml/kg if evidence of shock.

Monitoring: monitor urine output and adjust fluid resucitation accordingly, with a target of >0.5ml/kg/hr. In mild cases 4 hourly observations, in moderate or severe hourly observations. 12 lead ECG is advisable as the differential diagnosis for cholecystitis includes inferior myocardial infarction.

Nutrition: eating may exacerbate biliary pain, but there is no need for a patient to be kept formally "nil by mouth" - diet should be allowed as tolerated. Following adequate initial resuscitation, oral fluid intake should be encouraged and intravenous maintenance fluids utilised only if oral intake is inadequate.

Evacuation: Although patients may be able to be temporised in a forward location, evacuation should be considered early as there is significant potential to deteriorate. The management of patients with a prolonged hold is outlined in ‘Prolonged Casualty Care’.

Advanced Assessment & Management

Monitoring goals: urine output of 0.5ml/kg/hr. MAP ≥ 65.

Bloods: VBG, FBC, U&E, LFTs, and Amylase.

Imaging: Trans-abdominal ultrasound is the preferred initial study to detect gallstone disease. If available, CT (contrast-enhanced) scan may be utilised in patients that become systemically unwell, septic or fail to improve.

Nutrition: diet should be encouraged as tolerated, but patients may wish to avoid foods that exacerbate their symptoms (such as fatty foods).

Prolonged Casualty Care

Fluid balance: if evacuation is delayed, continue to encourage oral fluids, supplementing with intravenous fluids only if needed to maintain adequate organ perfusion - target a urine output of >0.5ml/kg/hour either by catheterisation if the patient is unwell or by simply measuring output otherwise.

Analgesia: a regular analgesia plan should be devised. IV preparations should be used unless confident of enteral absorption – gallstone ileus may be present. NSAIDs should be avoided. Regular opioids are likely to be required.

Antibiotics: continue further doses of antibiotics in accordance with deployed antimicrobial guidelines if evacuation is delayed.

Nutrition: patients may trial oral nutrition as pain and nausea allows; those with severe symptoms who are unable to take diet should be encouraged to at least take oral fluids if able.