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Key Features

Essentials of Diagnosis

  • Steady, severe pain and tenderness in the right hypochondrium or epigastrium

  • Nausea and vomiting

  • Fever and leukocytosis

General Considerations

  • Associated with gallstones in over 90% of cases

  • Occurs when a stone becomes impacted in the cystic duct and inflammation develops behind the obstruction

  • Acalculous cholecystitis should be considered when

    • Unexplained fever or right upper quadrant (RUQ) pain occurs within 2–4 weeks of major surgery

    • A critically ill patient has had no oral intake for a prolonged period

  • Acute cholecystitis may be caused by infectious agents (eg, cytomegalovirus, cryptosporidiosis, or microsporidiosis) in patients with AIDS or by vasculitis (eg, polyarteritis nodosa, Henoch-Schönlein purpura)

Clinical Findings

Symptoms and Signs

  • The acute attack is often precipitated by a large or fatty meal

  • Relatively sudden, severe, steady pain that is localized to the epigastrium or right hypochondrium and may gradually subside over a period of 12–18 h

  • Vomiting occurs in about 75% of patients and affords variable relief in 50%

  • RUQ abdominal tenderness

    • Almost always present

    • Usually associated with muscle guarding and rebound pain

  • A palpable gallbladder is present in about 15% of cases

  • Jaundice

    • Present in about 25% of cases

    • When persistent or severe, suggests the possibility of choledocholithiasis

  • Fever is usually present

Differential Diagnosis

  • Perforated peptic ulcer

  • Acute pancreatitis

  • Appendicitis

  • Perforated colonic carcinoma or diverticulum of hepatic flexure

  • Acute hepatitis or liver abscess

  • Pneumonia with pleurisy on right side

  • Myocardial infarction

  • Radicular pain in T6–T10 dermatome, eg, preeruptive zoster

Diagnosis

Laboratory Tests

  • The white blood cell count is usually high (12,000–15,000/mcL [12–15 × 109/L])

  • Total serum bilirubin values of 1–4 mg/dL (17.1–68.4 mcmol/L) may be seen even in the absence of bile duct obstruction

  • Serum aminotransferase and alkaline phosphatase levels are often elevated—the former as high as 300 units/mL, or even higher when associated with acute (ascending) cholangitis

  • Serum amylase may also be moderately elevated

Imaging Studies

  • Plain films of the abdomen may show radiopaque gallstones in 15% of cases

  • 99mTc hepatobiliary imaging (using iminodiacetic acid compounds) (HIDA scan)

    • Useful in demonstrating an obstructed cystic duct, which is the cause of acute cholecystitis in most patients

    • This test is reliable if the bilirubin is under 5 mg/dL (85.5 mcmol/L) (98% sensitivity and 81% specificity for acute cholecystitis)

  • RUQ abdominal ultrasound

    • May show gallstones

    • However, it is not sensitive for acute cholecystitis (67% sensitivity, 82% specificity)

  • CT may show complications of acute cholecystitis, such as gallbladder perforation or gangrene

Treatment

Medications

  • Will usually subside on a conservative regimen (withholding of oral feedings, intravenous alimentation, analgesics, and antibiotics, eg, ceftriaxone 1 g every 24 hours intravenously plus metronidazole, 500 mg every ...

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