Acute inflammation of the gallbladder is usually caused by cystic duct obstruction by an impacted stone. Inflammatory response is evoked by (1) mechanical inflammation from increased intraluminal pressure; (2) chemical inflammation from release of lysolecithin; (3) bacterial inflammation, which plays a role in 50–85% of pts with acute cholecystitis.
Approximately 90% calculous; 10% acalculous. Acalculous cholecystitis is associated with higher complication rate and acute illness (i.e., burns, trauma, major surgery), fasting, hyperalimentation leading to gallbladder stasis, vasculitis, carcinoma of gallbladder or CBD, some gallbladder infections (Leptospira, Streptococcus, Salmonella, or Vibrio cholerae), but in >50% of cases an underlying explanation is not found.
(1) Biliary colic (RUQ or epigastric pain) that progressively worsens; (2) nausea, vomiting, anorexia; and (3) fever. Examination typically reveals RUQ tenderness; palpable RUQ mass found in 20% of pts. Murphy’s sign is present when deep inspiration or cough during palpation of the RUQ produces increased pain or inspiratory arrest.
Mild leukocytosis; serum bilirubin, alkaline phosphatase, and aspartate aminotransferase (AST) may be mildly elevated.
Ultrasonography is useful for demonstrating gallstones and occasionally a phlegmonous mass surrounding the gallbladder. Radionuclide scans (HIDA, DIDA, DISIDA, etc.) may identify cystic duct obstruction.
Includes acute pancreatitis, appendicitis, pyelonephritis, PUD, hepatitis, and hepatic abscess.
Empyema, hydrops, gangrene, perforation, fistulization, gallstone ileus, porcelain gallbladder.
TREATMENT: ACUTE CHOLECYSTITIS
No oral intake, nasogastric suction, IV fluids and electrolytes, analgesia (meperidine or NSAIDs), and antibiotics (ureidopenicillins, ampicillin sulbactam, ciprofloxacin, third-generation cephalosporins; anaerobic coverage should be added if gangrenous or emphysematous cholecystitis is suspected; imipenem/meropenem covers the spectrum of bacteria causing ascending cholangitis but should be reserved for the most life-threatening infections when other antibiotics have failed). Acute symptoms will resolve in 70% of pts. Optimal timing of surgery depends on pt stabilization and should be performed as soon as feasible. Urgent cholecystectomy is appropriate in most pts with a suspected or confirmed complication. Delayed surgery is reserved for pts with high risk of emergent surgery and where the diagnosis is in doubt.