Cholecystitis, Acute

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)

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

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

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 6 hours intravenously)

• In severe cases, a fluoroquinolone such as ciprofloxacin, 400 mg intravenously every 12 hours, plus metronidazole, 500 mg every 6 hours intravenously, may be given

• Whether antibiotics are necessary for patients undergoing immediate cholecystectomy is debatable

• Morphine or meperidine may be given for pain

Surgery

• Cholecystectomy (generally laparoscopic)

  • Should be performed within 24 hours after admission to the hospital for acute cholecystitis because of the high risk of recurrent attacks (up to 10% by 1 month and over 30% by 1 year)

  • Compared with delayed surgery, surgery within 24 hours is associated with shorter length of stay, lower costs, and greater patient satisfaction

• Surgical treatment of chronic cholecystitis is the same as for acute cholecystitis

  • If indicated, cholangiography can be performed during laparoscopic cholecystectomy

  • Choledocholithiasis can also be excluded by either preoperative or postoperative endoscopic retrograde or magnetic resonance cholangiopancreatography

Therapeutic Procedures

• In high-risk patients, the following may postpone or even avoid the need for surgery:

  • Ultrasound-guided aspiration of the gallbladder

  • Percutaneous or endoscopic ultrasound-guided cholecystostomy

  • Endoscopic insertion of a stent or nasobiliary drain into the gallbladder

• Cholecystectomy is mandatory when there is evidence of gangrene or perforation

Follow-Up

• If treating nonsurgically, watch the patient (especially if diabetic or elderly) for

  • Recurrent symptoms

  • Evidence of gangrene of the gallbladder

  • Cholangitis

Complications

Gangrene of the gallbladder

• After 24–48 h, the following suggests severe inflammation and possible gangrene of the gallbladder:

  • Continuation or progression of RUQ abdominal pain

  • Tenderness

  • Muscle guarding

  • Fever

  • Leukocytosis

• Necrosis may develop without specific signs in the obese, diabetic, elderly, or immunosuppressed patient

• May lead to gallbladder perforation, usually with formation of a pericholecystic abscess and rarely to generalized peritonitis

• Other serious acute complications include emphysematous cholecystitis (secondary infection with a gas-forming organism) and empyema

Chronic cholecystitis and other complications

• Result from repeated episodes of acute cholecystitis or chronic irritation of the gallbladder wall by stones

• Calculi are usually present

• Gallbladder villi undergo polypoid enlargement due to cholesterol deposition ("strawberry gallbladder," cholesterolosis) (4–5%)

• Marked adenomatous hyperplasia of the gallbladder resembles a myoma (adenomyomatosis)

• Hydrops of the gallbladder results when acute cholecystitis subsides but cystic duct obstruction persists, producing distention of the gallbladder with a clear mucoid fluid

• A stone in the neck of the gallbladder may compress the common hepatic duct and cause jaundice (Mirizzi syndrome)

• Cholelithiasis with chronic cholecystitis may be associated with

  • Acute exacerbations of gallbladder inflammation

  • Bile duct stone

  • Fistulization to the bowel

  • Pancreatitis

  • Carcinoma of the gallbladder (rarely)

• Calcified (porcelain) gallbladder may have a high association with gallbladder carcinoma (particularly when the calcification is mucosal rather than intramural) and appears to be an indication for cholecystectomy

Prognosis

• The mortality rate of cholecystectomy is < 0.2%

• Hepatobiliary tract surgery in the elderly has a higher mortality rate

• Mortality rate is also higher in patients who have diabetes mellitus and cirrhosis

• A successful surgical procedure is generally followed by complete resolution of symptoms

When to Admit

• All patients should be hospitalized