PLAB 2 Surgery: Mastering Acute Cholecystitis Management Guidelines

PLAB 2 Surgery: Mastering Acute Cholecystitis Management Guidelines

Acute cholecystitis, the acute inflammation of the gallbladder, is a ubiquitous presentation in emergency medicine and general surgery. For the PLAB 2 OSCE, mastering this scenario goes beyond textbook knowledge; it requires clear diagnostic steps, guideline-driven management, and effective patient communication.

This guide breaks down the essential clinical and management guidelines for acute cholecystitis, ensuring you impress the examiner with a systematic, safe approach.

1. Recognition and Initial Assessment in the OSCE

When faced with a patient presenting with right upper quadrant (RUQ) pain, your primary goal is to establish the diagnosis and rule out differentials (such as perforated peptic ulcer, acute hepatitis, or pyelonephritis).

Key History Points:

1. Pain Characteristics: Severe, persistent RUQ pain, often radiating to the right shoulder tip or back (Boas' sign), typically lasting more than 4-6 hours. Unlike biliary colic, the pain does not subside.

2. Associated Symptoms: Nausea, vomiting, fever (usually low grade), and anorexia.

3. Risk Factors (The 5 Fs): Female, Forty (or older), Fertile (multiparity), Fat (obese), Fair (though this demographic link is less strong now, the underlying risk factors remain).

Essential Examination Findings:

1. Tenderness: Localised RUQ tenderness.

2. Murphy's Sign: Highly specific. Ask the patient to exhale, then palpate deeply under the right costal margin. Ask the patient to inhale; a sharp halt in inspiration due to pain is a positive Murphy's sign.

3. Vitals: Tachycardia and pyrexia are common.

2. Guideline-Driven Investigations (The PLAB 2 Standard)

In a real-life A&E setting, investigations are sequential. In the OSCE, you must demonstrate knowledge of which investigations are needed.

Initial Blood Tests:

• FBC: Leukocytosis (elevated WCC) suggests infection/inflammation.

• U&Es, LFTs: To assess for systemic compromise. Mild elevation of bilirubin/ALP is common, but significant elevation should raise suspicion of Cholangitis (obstructive pathology, e.g., CBD stone).

• Amylase/Lipase: To rule out concurrent or differential diagnosis of acute pancreatitis.

• CRP: Elevated inflammatory marker.

Gold Standard Imaging:

• Abdominal Ultrasound (USS): The primary diagnostic tool. Look for the classic triad:

  1. Thickened gallbladder wall (>3mm).

  2. Pericholecystic fluid.

  3. Gallstones (cholelithiasis).

  4. Sonographic Murphy's Sign (pain elicited by the ultrasound probe).

Note: If the diagnosis remains unclear, or if complications like perforation or abscess are suspected, a CT scan or HIDA scan (rarely needed acutely) might be considered, but USS is key for PLAB 2 initial management.

3. Management Guidelines: The Acute Phase

The management of acute cholecystitis follows the principles of supportive care, control of infection, and definitive surgical treatment.

A. Supportive Care (The Immediate Steps):

1. NPO Status (Nil by Mouth): Preparation for potential surgery.

2. IV Fluids: Resuscitation and maintenance (especially if vomiting).

3. Analgesia: IV Paracetamol and often an opioid (e.g., IV Morphine). NSAIDs (like Diclofenac) can be effective in reducing inflammation, but check renal function and suitability first.

4. Anti-emetics: For nausea and vomiting.

B. Antimicrobial Therapy:

Acute cholecystitis is primarily inflammatory, but bacterial infection (often E. coli, Klebsiella) is a major concern, particularly in severe cases.

• Guidelines mandate antibiotics if the patient has a high temperature, features of systemic sepsis, or signs of severe disease (as per Tokyo Guidelines).

• Common Regimens: A broad-spectrum antibiotic covering Gram-negative rods (e.g., Cefuroxime, Ceftriaxone, or Piperacillin/Tazobactam) is typically started empirically until culture results are available.

C. Definitive Treatment: Surgery Timing

For fit patients, laparoscopic cholecystectomy is the definitive treatment. The key debate in guidelines is the timing:

• Early Cholecystectomy (Preferred Guidance): Surgery performed within 72 hours (ideally 24-48 hours) of presentation/diagnosis. This is associated with shorter hospital stays and fewer readmissions, provided the surgery is performed by an experienced team. This is the standard recommendation for PLAB 2 unless contraindications exist.

• Delayed Cholecystectomy: If the patient presents late (>7 days from onset) and the inflammation has subsided, or if the patient is too unstable for immediate surgery, medical management (antibiotics, supportive care) is initiated, and surgery is scheduled electively 6-8 weeks later.

4. Recognizing and Communicating Severity (Tokyo Guidelines Simplified)

While you don't need to quote the Tokyo Guidelines (TG) explicitly, understanding the severity informs your surgical urgency and communication.

PLAB 2 Communication Tip: When talking to the patient, explain that the condition is treatable, but surgery is usually necessary to prevent recurrence and complications. Clearly explain the risks of the operation (bleeding, infection, bile duct injury) and the risks of not having the operation (gangrene, perforation, sepsis).

5. Management of Complications

Be prepared for complication questions, especially in a high-scoring station:

• Gallbladder Perforation/Gangrene: Indicated by worsening pain, local rigidity, or signs of peritonitis/sepsis. This is a surgical emergency, often requiring open rather than laparoscopic surgery.

• Associated Cholangitis: High fever, jaundice, and RUQ pain (Charcot's triad). This indicates obstruction. Management requires emergency intervention (ERCP) to relieve the obstruction, followed by cholecystectomy later. If you suspect cholangitis, escalate care immediately.