Acute Cholecystitis

Acute cholecystitis predominantly occurs as a complication of gallstone disease and typically develops in patients with a history of symptomatic gallstones. The term cholecystitis refers to inflammation of the gallbladder. It may develop acutely in association with gallstones (acute cholecystitis) or, less often, without gallstones (acalculous cholecystitis).
Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation that is usually related to gallstone disease.

CLINICAL MANIFESTATIONS:

The clinical manifestations of acute cholecystitis include prolonged (more than 4-6 hours), steady, severe right upper quadrant or epigastric pain, fever, abdominal guarding, a positive Murphy’s sign, and leukocytosis.

Patients typically complain of abdominal pain, most commonly in the right upper quadrant or epigastrium. The pain may radiate to the right shoulder (referred phrenic nerve pain) or back. Pain is typically steady and severe. Associated complaints may include fever, nausea, vomiting, and anorexia. There is often a history of fatty food ingestion one hour or more before the initial onset of pain.

RISK FACTORS ASSOCIATED WITH INCREASED OCCURRENCE OF GALLSTONES:

— Body habitus: obesity, rapid weight loss, cyclic weight loss
— Childbearing
— Drugs: ceftriaxone (Rocephin), postmenopausal estrogens, total parenteral nutrition
— Ethnicity: Native American (Pima Indian), Scandinavian
— Female gender
— Heredity: first-degree relatives
— Ileal disease, resection, or bypass
— Increasing age

LABORATORY EVALUATION:

— Leukocytosis with an increased number of band forms (ie, a left shift)
— Mild elevations in serum aminotransferases and amylase, along with hyperbilirubinemia and jaundice, even in the absence of these complications.
— Elevation in the serum total bilirubin and alkaline phosphatase concentrations are not common in uncomplicated acute cholecystitis since biliary obstruction is limited to the gallbladder; if present, they should raise concerns about complicating conditions such as acute cholangitis, choledocholithiasis.

DIAGNOSIS:

— Murphy’s sign — Patients with acute cholecystitis frequently have a positive Murphy’s sign. The sensitivity and specificity of a positive Murphy’s sign is 97% and 48%, respectively. However, the sensitivity may be diminished in the elderly.
— Imaging studies — Patients presenting with clinical features suggestive of acute cholecystitis should undergo abdominal imaging to confirm the diagnosis. Ultrasonography is usually the first test obtained and can often establish the diagnosis. Nuclear cholescintigraphy may be useful in cases in which the diagnosis remains uncertain after ultrasonography.

— Ultrasonography — The presence of stones in the gallbladder in the clinical setting of right upper quadrant abdominal pain and fever supports the diagnosis of acute cholecystitis but is not diagnostic. Additional sonographic features include: Gallbladder wall thickening (greater than 4 to 5 mm) or edema (double wall sign). A “sonographic Murphy’s sign” is similar to the Murphy’s sign elicited during abdominal palpation, except that the positive response is observed during palpation with the ultrasound transducer. This is more accurate than hand palpation.

— Cholescintigraphy (HIDA scan) — Cholescintigraphy using 99mTc-hepatic iminodiacetic acid is done if the diagnosis remains uncertain following ultrasonography. The HIDA scan is also useful for demonstrating patency of the common bile duct and ampulla. It has a sensitivity of 90-97% and specificity 71-90%.

— Magnetic resonance cholangiography (MRCP) — is a noninvasive technique for evaluating the intrahepatic and extrahepatic bile ducts. MRCP is superior to ultrasound for detecting stones in the cystic duct but was less sensitive than ultrasound for detecting gallbladder wall thickening. MRCP may be appropriate if there is concern that the patient may have a stone in the common bile duct.

DIFFERENTIAL DIAGNOSIS:

A variety of other conditions can give rise to symptoms in the upper abdomen, which may be confused with biliary colic or acute cholecystitis. These include:

— Acute pancreatitis
— Acute hepatitis
— Peptic ulcer disease
— Functional gallbladder disorder
— Sphincter of Oddi dysfunction
— Diseases of the right kidney
— Right-sided pneumonia
— Fitz-Hugh-Curtis syndrome (perihepatitis caused by gonococcal infection)
— Subhepatic or intraabdominal abscess
— Perforated viscus
— Myocardial infarction

TREATMENT:

Once a patient develops symptoms or complications related to gallstones (biliary colic, acute cholecystitis, cholangitis, and/or pancreatitis), definitive therapy (cholecystectomy, cholecystostomy, endoscopic sphincterotomy, medical gallstone dissolution) is recommended. Without treatment to eliminate the gallstones, the likelihood of subsequent symptoms or complications is high. Complications include the development of gangrene and gallbladder perforation, which can be life-threatening.
— Supportive Care:

– Pain control: Pain control in patients with acute cholecystitis can usually be achieved with nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids.
– Antibiotics: Acute cholecystitis is primarily an inflammatory process, but secondary infection of the gallbladder can occur as a result of cystic duct obstruction and bile stasis. The rate of empyema and pericholecystic abscess is overall low, but patients can easily develop life-threatening gram negative sepsis from uncomplicated, acute cholecystitis. Thus, antibiotics are commonly administered at the outset to protect against sepsis and wound infection

— Surgery: The choice and timing of intervention for acute cholecystitis (cholecystectomy, gallbladder drainage) depends upon the severity of symptoms and the patient’s overall risk of surgery. Drainage options include percutaneous or open cholecystostomy and endoscopic transpapillary or transmural drainage.

— Emergent intervention is indicated for patients with:
– Progressive symptoms and signs such as high fever, hemodynamic instability, or intractable pain in spite of adequate pain medication.
– Suspicion of gallbladder gangrene or gallbladder perforation

— For patients without emergent indications for definitive therapy who are low risk for surgery, we recommend cholecystectomy during the initial hospitalization. Cholecystectomy performed early rather than later in the hospitalization may be associated with reduced perioperative morbidity and mortality. Low-risk patients generally undergo laparoscopic cholecystectomy.

— For patients without emergent indications for definitive therapy, and in whom the risk of cholecystectomy outweighs the potential benefits, gallbladder drainage with percutaneous cholecystostomy or one of the endoscopic drainage procedures is indicated if symptoms do not improve with supportive care. Once cholecystitis resolves, the patient’s risk for surgery should be reassessed. Patients who have become reasonable candidates for surgery should undergo elective cholecystectomy. Patients who stabilize with gallbladder drainage but continue to be at high-risk for surgery can be considered for percutaneous gallstone extraction with or without mechanical lithotripsy.

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