Introduction

In the textbooks the pain one gets with these conditions is different, the former colicky and the latter sharp.  In practise the patients description of the pain can be somewhere between the 2 fro both conditions.  Management is different between the 2 conditions. Gallstones are common  -1:8 men and 1:4 women will get them. Prevalence increases with age. 80% of stones remain asymptomatic

 

Distinguishing Between The 2 Conditions

  • Symptoms and signs go some way (in a typical presentation)
  • Fever, raised WCC more suggestive of cholecystitis
  • Don’t bother with ESR or CRP – it is raised in both and of no help

 

 Biliary Colic  Cholecystitis
  • Spasmodic Central epigastric pain, sometimes felt on the right
  • No fever, may have tachycardia if pain is bad
  • tender over gallbladder if it is distended

 

  • Constant sharp/stabbing pain in right upper quadrant
  • may radiate to Rt shoulder/back
  • Fever, tachycardia
  • Tenderness in right upper quadrant
  • Murphy's sign - guarding in right upper quadrant on deep inspiration

 

Investigations

  • USS - keep on clear fluids only when admitted until this is done
    • gallstones
    • Wall thickening / pericholecystic fluid suggest cholecystitis
  • CT - not as helpful as USS
  • HIDA scans - hardly ever used now

Initial Management

  1. Pain relief is the very important.
  2. Patients can have clear fluids only until the USS is done.  No milky drinks at all, inc milk in tea or coffee
  3. Check FBC, U&E, LFT
  4. Patients with suspected cholecystitis need IV Cefuroxime. Patients with biliary colic DO NOT.
  5. If jaundice is present then add Metronidazole.
  6. Make sure you get accurate fluid balance charts
  7. Arrange an USS ASAP
  8. DVT Prophylaxis for all patients

Continuing Management

  1. Fat free diet can be introduced after the USS.  Go back to fluids if the pain is worse.
  2. Jaundiced patients with a high Bn & ALP need urgent referral to Gastroenterologist for consideration of ERCP.  For this you will need available recent FBC, U&E, LFT, and Clotting Studies.
  3. In fit patients consider early lap chole (preferably within same admission)

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