Cholecystitis, Acute

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 ...