Acute calculous cholecystitis

Clinical Features

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

Diagnosis

Local Signs

1. RUQ tenderness
2. Murphy Sign
   1. Highest positive LR of any clinical finding or lab value

Sysemtic signs

1. Fever
2. Leukocytosis

Imaging

1. Ultrasound: Gallbladder
   1. Gallstones
      1. Distinguish by characteristic "shadowing"
      2. Better seen with patient in left lateral decub
   2. GB wall thickening (>3mm)
      1. May also be seen w/ Pancreatitis, ascites, Congestive heart failure, alcoholic hepatitis
   3. Pericholecystic fluid
   4. Sonographic Murphy's Sign (PPV 92%)
      1. May be absent in pts w/ DM, gangrenous cholecystitis
2. CT
   1. 1. Useful when US results are equivocal

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Symptomatic cholelithiasis (biliary colic)
  • Choledocholithiasis
  • Acute cholecystitis
  • Ascending cholangitis
  • Acalculous cholecystitis
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • Pulmonary embolism
  • Abdominal aortic aneurysm

Treatment

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

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
5. Mirizzi Syndrome
   1. Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
   2. Symptoms of acute cholecystitis + dilated intrahepatic ducts + jaundice
   3. Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
      1. US and CT can usually delineate the fistula
   4. Treatment = open cholecystectomy
6. Gallstone Ileus
   1. Bowel obstruction due to impaction of gallstone at terminal ileum
      1. Gallstone enters small bowel through biliary-duodenal fistula
   2. Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone

See Also

• Gallbladder Disease (Main)

Source

• UpToDate
• Tintinalli