Cholecystitis

Fred F. Ferri, M.D.

Basic Information

Definition

Cholecystitis is acute or chronic inflammation of the gallbladder generally caused by gallstones (>95% of cases).

Synonyms

Gallbladder attack

ICD-10CM CODES
K81.9	Acute cholecystitis
K80.00	Calculus of gallbladder with acute cholecystitis without obstruction
K81.9	Cholecystitis, unspecified

Epidemiology & Demographics

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Acute cholecystitis occurs most commonly in women during the fifth and sixth decades. Approximately 120,000 cholecystectomies are performed for acute cholecystitis annually in the U.S.
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The incidence of gallstones is 0.6% in the general population and much higher in certain ethnic groups (>75% of Native Americans by age 60 yr). Most patients with gallstones are asymptomatic. Of such patients, biliary colic develops in 1% to 4% annually.

Physical Findings & Clinical Presentation

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Pain and tenderness in the right hypochondrium or epigastrium; pain possibly radiating to the infrascapular region
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Palpation of the right upper quadrant (RUQ) eliciting marked tenderness and stoppage of inspired breath (Murphy’s sign)
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Guarding
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Fever (33%)
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Jaundice (25% to 50% of patients)
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Palpable gallbladder (20% of cases)
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Nausea and vomiting (>70% of patients)
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Fever and chills (>25% of patients)
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Medical history often revealing ingestion of large, fatty meals before onset of pain in the epigastrium and RUQ

Etiology

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Gallstones (>95% of cases)
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Ischemic damage to the gallbladder, critically ill patient (acalculous cholecystitis)
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Infectious agents, especially in patients with AIDS (cytomegalovirus, Cryptosporidium)
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Strictures of the bile duct
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Neoplasms, primary or metastatic
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Risk factors for cholelithiasis include age, obesity, female sex, rapid weight loss, ethnicity/race (Native American), use of contraceptives, pregnancy, diabetes mellitus, hemolysis, total parenteral nutrition, biliary parasites

Diagnosis

Differential Diagnosis

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Hepatic: hepatitis, abscess, hepatic congestion, neoplasm, trauma
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Biliary: neoplasm, stricture, sphincter of Oddi dysfunction
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Gastric: pelvic ulcer disease, neoplasm, alcoholic gastritis, hiatal hernia, non-ulcer dyspepsia
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Pancreatic: pancreatitis, neoplasm, stone in the pancreatic duct or ampulla
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Renal: calculi, infection, inflammation, neoplasm, ruptured kidney
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Pulmonary: pneumonia, pulmonary infarction, right-sided pleurisy
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Intestinal: retrocecal appendicitis, intestinal obstruction, high fecal impaction, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD)
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Cardiac: myocardial ischemia (particularly involving the inferior wall), pericarditis
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Cutaneous: herpes zoster
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Trauma
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Fitz-Hugh–Curtis syndrome (perihepatitis), ruptured ectopic pregnancy
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Subphrenic abscess
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Dissecting aneurysm
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Nerve root irritation caused by osteoarthritis of the spine

Workup

Workup consists of detailed history and physical examination coupled with laboratory evaluation and imaging studies. No single clinical finding or laboratory test is sufficient to establish or exclude cholecystitis without further testing.

Laboratory Tests

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Leukocytosis (12,000 to 20,000) is present in >70% of patients.
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Elevated alkaline phosphatase, ALT, AST, bilirubin; bilirubin elevation >4 mg/dl is unusual and suggests presence of choledocholithiasis.
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Elevated amylase may be present (consider pancreatitis if serum amylase elevation exceeds 500 U).

Imaging Studies

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Ultrasound of the gallbladder (Fig. E1) is the preferred initial test; it will demonstrate the presence of stones and also dilated gallbladder with thickened wall and surrounding edema in patients with acute cholecystitis.

FIG.E1

Thickened gallbladder wall in acute cholecystitis.

The gallbladder contains echogenic calculi.

From Grainger RG et al. [eds]: Grainger and Allison’s diagnostic radiology, ed 4, Philadelphia, 2001, Churchill Livingstone.
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Nuclear imaging (HIDA scan) (Fig. E2) is useful for diagnosis of cholecystitis when sonogram is inconclusive: sensitivity and specificity exceed 90% for acute cholecystitis. This test is only reliable when bilirubin is <5 mg/dl. A positive test result (absence of gallbladder filling within 60 min after the administration of tracer) will demonstrate obstruction of the cystic or common hepatic duct; the test will not demonstrate the presence of stones.

FIG.E2

Acute cholecystitis.

Following the intravenous administration of 200 MBq (5 mCi) of 99mTc-HIDA and a stimulus of CCK, the region of the liver and gallbladder is imaged. Intrahepatic bile ducts are visualized, as is excretion through the common duct into the small bowel. The gallbladder is not seen. This patient had gallstones demonstrated by ultrasound and confirmed at surgery. The pathologic diagnosis was acute cholecystitis.

From Grainger RG et al. [eds]: Grainger and Allison’s diagnostic radiology, ed 4, Philadelphia, 2001, Churchill Livingstone.
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CT scan of abdomen is useful in cases of suspected abscess, neoplasm, or pancreatitis.
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Plain radiograph of the abdomen generally is not useful because <25% of stones are radiopaque.

Treatment

Nonpharmacologic Therapy

Provide IV hydration; withhold oral feedings.

Acute General Rx

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Laparoscopic (percutaneous) cholecystectomy (PC) is considered the treatment of choice for most patients. The rate of conversion to open cholecystectomy is higher when laparoscopic cholecystectomy (CCY) is performed for acute cholecystitis rather than for uncomplicated cholelithiasis; conservative management with IV fluids and antibiotics (ampicillin-sulbactam 3 g IV q6h or piperacillin-tazobactam 4.5 g IV q8h) may be justified in some high-risk patients to convert an emergency procedure into an elective one with a lower mortality rate.
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Endoscopic retrograde cholangiopancreatography with sphincterectomy and stone extraction can be performed in conjunction with laparoscopic cholecystectomy for patients with choledochal lithiasis; approximately 7% to 15% of patients with cholelithiasis also have stones in the common bile duct.

Disposition

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Prognosis is good; elective laparoscopic cholecystectomy can be performed as outpatient procedure.
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Hospital stay (when necessary) varies from overnight with laparoscopic cholecystectomy to 4 to 7 days with open cholecystectomy.
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Complication rate is approximately 1% (hemorrhage and bile leak) for laparoscopic cholecystectomy and <0.5% (infection) with open cholecystectomy.

Referral

Surgical referral in all patients with acute cholecystitis

Pearls & Considerations

Comments

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Patients should be instructed that stones may recur in bile ducts.
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Gallbladder aspiration, in which all fluid visualized by ultrasound is aspirated, represents a nonsurgical treatment when patients who are at high operative risk develop acute cholecystitis. Salvage cholecystectomy is reserved for nonresponders.

Ferri – Cholecystitis