Acute Cholecystitis

Urgent case, unprepared patient - Most arrive on short notice after a day or more of pain and vomiting. Assume volume depletion and treat the stomach as full.

Preop labs that change the plan - CBC for leukocytosis, a comprehensive metabolic panel with liver enzymes and bilirubin (a bilirubin above 2 points to a common bile duct stone and an ERCP before the cholecystectomy), and amylase and lipase to rule out pancreatitis. Labs can be normal even with severe gallbladder disease, so a clean panel does not lower the guard.

Imaging tells you the severity - Right upper quadrant ultrasound is the first-line study, looking for a thickened wall and stones. A HIDA scan is recommended when the picture is unclear, and an ejection fraction under 35% with CCK supports acalculous disease. Gas in the gallbladder wall means emphysematous cholecystitis and a patient headed toward shock.

GETT with maintained paralysis - Laparoscopic cholecystectomy needs general anesthesia, an ETT, and muscle relaxation. Place an OG tube shortly after induction to clear stomach contents before the surgeon starts.

Pneumoperitoneum physiology - CO2 insufflation runs to about 15 mmHg. Anything above 10 mmHg starts to change hemodynamics: cardiac output falls, SVR rises, peak inspiratory and plateau pressures climb, renal vessels are compressed so urine output drops and the renin-angiotensin-aldosterone system fires, and absorbed CO2 drives hypercarbia and acidosis you will see in the end-tidal trace.

Positioning - Supine, reverse Trendelenburg, airplaned left, one arm extended and one tucked. Run a second IV before the arm goes down; an IV problem mid-case with tucked arms is very hard to fix.

Opioids and biliary tone - Morphine contracts the biliary tree. That effect is the basis of the Nardi test, in which morphine is given deliberately to reproduce sphincter of Oddi pain, so keep it in mind if the surgeon reports a tight duct on cholangiogram.

PONV - Give a full range of antiemetics for prophylaxis. This is a high-risk population for postoperative nausea and vomiting.

Fast close, fast wake-up - The port sites close quickly at the end of the case, so the operation can end sooner than you expect. Have the wake-up plan ready before the surgeon starts closing.

The sick end of the spectrum - Perforation, gangrene, and emphysematous disease can present in sepsis. Preoperative antibiotics go in within 30 minutes of incision. A patient too unstable for the OR may get a temporizing percutaneous cholecystostomy drain instead and return later for the definitive operation.

Postop shoulder pain - Retained CO2 from insufflation causes referred shoulder pain that can take up to three days to resolve. Tell the patient in advance so it isn't read as a complication.

Acute cholecystitis is inflammation of the gallbladder caused by obstruction of the cystic duct, and about 95% of cases involve gallstones. Bile stays trapped, the wall becomes venously congested and edematous, and with time it goes ischemic and gangrenous. A gangrenous gallbladder can be infected by gas-forming organisms to produce emphysematous cholecystitis, and perforation carries a high mortality. Biliary colic that does not resolve within six hours is reclassified as acute calculous cholecystitis. Acalculous disease is a functional obstruction in critically ill patients and carries 20% to 50% mortality.

What reaches the OR is usually an urgent laparoscopic cholecystectomy in a patient who has been vomiting, is volume depleted, and may be septic, with pneumoperitoneum and reverse Trendelenburg layered on top.