Acute calculous cholecystitis

Clinical Features

• Upper abdominal pain (esp RUQ)
  • Not necessarily related to meals or fatty food intolerance
• N/V, fever

Diagnosis

1. Local Signs
   1. RUQ tenderness
   2. Murphy Sign
      1. Highest positive LR of any clinical finding or lab value
2. Sysemtic signs
   1. Fever
   2. Leukocytosis
3. Imaging
   1. Ultrasound: Gallbladder
      1. GB wall thickening (>3mm)
         1. May also be seen w/ pancreatitis, ascites, heart failure, alcoholic hepatitis
      2. Pericholecystic fluid
      3. Sonographic Murphy's Sign (PPV 92%)
         1. May be absent in pts w/ DM, gangrenous cholecystitis
   2. CT
      1. Useful when US results are equivocal

Treatment

1. Antibiotics
   1. Although clear evidence is lacking, assoc/ w/ decreased wnd infection and bacteremia
   2. CTX + metronidazole OR piperacillin/tazobactam OR ampicillin-sulbactam
      1. Bacteria: Gm negative (75%), gm positive (15%), anaerobes (8%)

Disposition

• Admit

Complications

1. Gangrene
   1. Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
   2. Consider if pt presents with sepsis in addition to cholecystitis
2. Perforation
   1. Occurs in 2% after development of gangrene
   2. Usually localized, leading to pericholecystic abscess
3. Gallstone Ileus
   1. Due to cholecystoenteric fistula
4. Emphysematous cholecystitis
   1. Due to secondary infection of GB by gas-forming organisms (C. perfringens)
   2. Presents like cholecystitis but often progresses to sepsis and gangrene
   3. IV abx and cholecystectomy are essential
   4. Ultrasound report may mistake GB wall gas for bowel gas
   5. Mortality as high as 15% due to gangrene or perforation

See Also

• Gallbladder Disease (Main)
• Cholangitis
• Symptomatic Cholelithiasis

Source

• UpToDate
• Tintinalli