Acute Cholecystitis is inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct. Symptoms include right upper quadrant pain and tenderness, sometimes accompanied by fever, chills, nausea, and vomiting. Abdominal ultrasonography detects the gallstone and sometimes the associated inflammation. Treatment usually involves antibiotics and cholecystectomy.
Acute cholecystitis is the most common complication of cholelithiasis. Conversely, ≥ 95% of patients with acute cholecystitis have cholelithiasis. When a stone becomes impacted in the cystic duct and persistently obstructs it, acute inflammation results. Bile stasis triggers release of inflammatory enzymes (eg, phospholipase A, which converts lecithin to lysolecithin, which then may mediate inflammation). The damaged mucosa secretes more fluid into the gallbladder lumen than it absorbs. The resulting distention further releases inflammatory mediators (eg, prostaglandins), worsening mucosal damage and causing ischemia, all of which perpetuate inflammation. Bacterial infection can supervene. The vicious circle of fluid secretion and inflammation, when unchecked, leads to necrosis and perforation. If acute inflammation resolves then continues to recur, the gallbladder becomes fibrotic and contracted and does not concentrate bile or empty normally—features of chronic cholecystitis.
Acute acalculous cholecystitis: Acalculous cholecystitis is cholecystitis without stones. It accounts for 5 to 10% of cholecystectomies done for acute cholecystitis. Risk factors include the following:
Critical illness (eg, major surgery, burns, sepsis, or trauma)
Prolonged fasting or TPN (both predispose to bile stasis)
Vasculitis (eg, SLE, polyarteritis nodosa)
The mechanism probably involves inflammatory mediators released because of ischemia, infection, or bile stasis. Sometimes an infecting organism can be identified (eg, Salmonella sp or cytomegalovirus in immunodeficient patients). In young children, acute acalculous cholecystitis tends to follow a febrile illness without an identifiable infecting organism.
Symptoms and Signs
Most patients have had prior attacks of biliary colic or acute cholecystitis. The pain of cholecystitis is similar in quality and location to biliary colic but lasts longer (ie, > 6 h) and is more severe. Vomiting is common, as is right subcostal tenderness. Within a few hours, the Murphy sign (deep inspiration exacerbates the pain during palpation of the right upper quadrant and halts inspiration) develops along with involuntary guarding of upper abdominal muscles on the right side. Fever, usually low grade, is common.
In the elderly, the first or only symptoms may be systemic and nonspecific (eg, anorexia, vomiting, malaise, weakness, fever). Sometimes fever does not develop.
Acute cholecystitis begins to subside in 2 to 3 days and resolves within 1 wk in 85% of patients even without treatment.
Complications: Without treatment, 10% of patients develop localized perforation, and 1% develop free perforation and peritonitis. Increasing abdominal pain, high fever, and rigors with rebound tenderness or ileus suggest empyema (pus) in the gallbladder, gangrene, or perforation. When acute cholecystitis is accompanied by jaundice or cholestasis, partial common duct obstruction is likely, usually due to stones or inflammation.
• Cholescintigraphy if ultrasonography results are equivocal or if acalculous cholecystitis is suspected
• Acute cholecystitis is suspected based on symptoms and signs.
Transabdominal ultrasonography is the best test to detect gallstones. The test may also elicit local abdominal tenderness over the gallbladder (ultrasonographic Murphy sign). Pericholecystic fluid or thickening of the gallbladder wall indicates acute inflammation.
Cholescintigraphy is useful when results are equivocal; failure of the radionuclide to fill the gallbladder suggests an obstructed cystic duct (ie, an impacted stone). False-positive results may be due to the following:
A critical illness
Receiving TPN and no oral foods (because gallbladder stasis prevents filling)
Severe liver disease (because the liver does not secrete the radionuclide)
Previous sphincterotomy (which facilitates exit into the duodenum rather than the gallbladder)
Morphine provocation, which increases tone in the sphincter of Oddi and enhances filling, helps eliminate false-positive results.
Abdominal CT identifies complications such as gallbladder perforation or pancreatitis.
Laboratory tests are done but are not diagnostic. Leukocytosis with a left shift is common. In uncomplicated acute cholecystitis, liver function tests are normal or only slightly elevated. Mild cholestatic abnormalities (bilirubin up to 4 mg/dL and mildly elevated alkaline phosphatase) are common, probably indicating inflammatory mediators affecting the liver rather than mechanical obstruction. More marked increases, especially if lipase (amylase is less specific) is elevated > 2-fold, suggest bile duct obstruction. Passage of a stone through the biliary tract increases aminotransferases (ALT, AST).
Acute acalculous cholecystitis: Acute acalculous cholecystitis is suggested if a patient has no gallstones but has ultrasonographic Murphy sign or a thickened gallbladder wall and pericholecystic fluid. A distended gallbladder, biliary sludge, and a thickened gallbladder wall without pericholecystic fluid (due to low albumin or ascites) may result simply from a critical illness.
CT identifies extrabiliary abnormalities. Cholescintigraphy is more helpful; failure of a radionuclide to fill may indicate edematous cystic duct obstruction. Giving morphine helps eliminate a false-positive result due to gallbladder stasis.
• Supportive care (hydration, analgesics, antibiotics)
Management includes hospital admission, IV fluids, and analgesics, such as an NSAID (ketorolac) or opioid. Nothing is given orally, and nasogastric suction is instituted if vomiting or an ileus is present. Parenteral antibiotics are usually initiated to treat possible infection, but evidence of benefit is lacking. Empiric coverage, directed at gram-negative enteric organisms, involves IV regimens such as ceftriaxone 2 g q 24 h plus metronidazole 500 mg q 8 h, piperacillin/tazobactam 4 g q 6 h, or ticarcillin/clavulanate 4 g q 6 h.
Cholecystectomy cures acute cholecystitis and relieves biliary pain. Early cholecystectomy is generally preferred, best done during the first 24 to 48 h in the following situations:
The diagnosis is clear and patients are at low surgical risk.
Patients are elderly or have diabetes and are thus at higher risk of infectious complications.
Patients have empyema, gangrene, perforation, or acalculous cholecystitis.
Surgery may be delayed when patients have an underlying severe chronic disorder (eg, cardiopulmonary) that increases the surgical risks. In such patients, cholecystectomy is deferred until medical therapy stabilizes the comorbid disorders or until cholecystitis resolves. If cholecystitis resolves, cholecystectomy may be done ≥ 6 wk later. Delayed surgery carries the risk of recurrent biliary complications.
Percutaneous cholecystostomy is an alternative to cholecystectomy for patients at very high surgical risk, such as the elderly, those with acalculous cholecystitis, and those in an ICU because of burns, trauma, or respiratory failure.
• Most (≥ 95%) patients with acute cholecystitis have cholelithiasis.
• In the elderly, symptoms of cholecystitis may be nonspecific (eg, anorexia, vomiting, malaise, weakness), and fever may be absent.
• Although acute cholecystitis resolves spontaneously in 85% of patients, localized perforation or another complication develops in 10%.
• Do ultrasonography and, if results are equivocal, cholescintigraphy.
• Treat patients with IV fluids, antibiotics, and analgesics; do cholecystectomy when patients are stable.
A 44-year-old obese woman presents to the emergency department complaining of 3 hours of severe abdominal pain. She has also had multiple episodes of vomiting during this time. She describes the pain as "worse than labor," and it radiates to the interscapular region. Her temperature is 38.9 C (102 F), and she has severe tenderness in her right upper quadrant. She reports that she has had multiple similar episodes in the past that have lasted approximately 30 minutes and then resolved spontaneously. Which of the following is most likely being obstructed by a gallstone?
A. Common bile duct
B. Common hepatic duct
C. Cystic duct
D. Pancreatic duct
E. Right hepatic duct
C. This patient with acute cholecystitis has multiple risk factors, including female gender, obesity, and a classic history of prolonged biliary colic in association with fevers. The presentation illustrated is typical and results from obstruction of the cystic duct, which drains the gallbladder.
Obstruction of the common bile duct (choice A) or the pancreatic duct (choice D) will produce acute bacterial cholangitis, which would be demonstrated by Charcot's triad, i.e., right upper quadrant pain, fever, and jaundice.
Obstruction of either the common hepatic duct (choice B) or the right hepatic duct (choice E) may give a limited episode of cholangitis but will not cause cholecystitis, since the obstruction occurs in the biliary tree above the level of the entry of the cystic duct.
A 43-year-old white woman presents to the emergency department with 1 day of increasingly severe pain localized to the right upper quadrant and radiating to the right lower scapula. She has also been experiencing nausea and vomiting. The woman has had similar, but milder, episodes of pain in the past, which had resolved spontaneously in a few days. Physical examination demonstrates involuntary guarding of abdominal muscles on the right. The gallbladder is palpable. Which of the following is the most appropriate next step in diagnosis?
A. CT scan
B. Endoscopic retrograde cholangiography
D. MRI scan
E. The presentation is typical for acute cholecystitis, which occurs most frequently in the setting of cholelithiasis (gallstones). Other common features include an initially low-grade fever with neutrophilia and painful splinting during deep breathing. Serum amylase is typically elevated in gallstone pancreatitis. Seriously ill patients with high fever, rigors, or significant rebound tenderness may require urgent surgical intervention; in less seriously ill patients, it is feasible to establish the diagnosis and defer surgical intervention until after the acute episode has resolved. In most hospitals, ultrasound is ordered first, since this relatively inexpensive, fast, and noninvasive study can usually establish the presence of gallstones. In atypical cases, when acute cholecystitis without stones is present, cholescintigraphy using radioactive technetium 99m may be used to sequentially visualize the liver, extrahepatic bile ducts, gallbladder, and duodenum.
CT (choice A) and MRI (choice D) scans are expensive and are usually not required for typical acute cholecystitis.
Endoscopic retrograde cholangiography (choice B) can be helpful in defining a small stone in the extrahepatic bile duct system, but it is not usually used as an initial test.
Esophagogastroduodenoscopy (choice C) would not be helpful in classic gallstone disease, but might demonstrate a duodenal cancer compressing the ampulla of Vater if a patient with what appeared clinically to be gallstone disease had a negative ultrasound.