Definition, Etiology, PathogenesisTop
Acute cholecystitis is an acute inflammation of the gallbladder and one of the major complications of cholelithiasis (see Figure 7.1-2). It may be caused by impaired bile outflow from the gallbladder (as a result of occlusion of the cystic duct or edema of the cystic duct mucosa). Approximately 10% of cases of cholecystitis occur in persons without gallstones and usually with serious systemic diseases (acalculous cholecystitis).
Signs and symptoms include persistent biliary colic, fever, rigors, vomiting, poor general condition, severe right upper abdominal quadrant tenderness, positive Murphy sign (see Diagnostic Tests, below), sometimes a palpable tender gallbladder, signs of peritonitis (in some patients), tachycardia, and tachypnea.
1. Laboratory tests: Elevated white blood cell (WBC) counts with a shift to the left in the differential blood count; elevated C-reactive protein (CRP) levels; elevated serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and bilirubin (if the case of obstruction of the common bile duct or a concomitant liver disease). Amylase could be elevated in patients with concomitant biliary pancreatitis and cholecystitis.
2. Imaging studies: Ultrasonography may reveal major features of cholecystitis, including gallstones, edema of the gallbladder wall with an increased gallbladder wall thickness, gas within the gallbladder wall (gangrenous cholecystitis), and a positive ultrasonographic Murphy sign (tenderness in the right upper abdominal quadrant evoked by pressure from the ultrasound transducer over the visualized gallbladder). Minor features include an enlarged gallbladder, a thickened gallbladder wall, abnormal gallbladder content (eg, sludge), and fluid collections near the gallbladder.Evidence 1Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to methodologic limitations. Jain A, Mehta N, Secko M, et al. History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis. Acad Emerg Med. 2017 Mar;24(3):281-297. doi: 10.1111/acem.13132. PMID: 27862628. Hwang H, Marsh I, Doyle J. Does ultrasonography accurately diagnose acute cholecystitis? Improving diagnostic accuracy based on a review at a regional hospital. Can J Surg. 2014 Jun;57(3):162-8. PubMed PMID: 24869607; PubMed Central PMCID: PMC4035397. Pinto A, Reginelli A, Cagini L, et al. Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the literature. Crit Ultrasound J. 2013 Jul 15;5 Suppl 1:S11. doi: 10.1186/2036-7902-5-S1-S11. Epub 2013 Jul 15. PubMed PMID: 23902680; PubMed Central PMCID: PMC3711721. Ralls PW, Colletti PM, Lapin SA, et al. Real-time sonography in suspected acute cholecystitis. Prospective evaluation of primary and secondary signs. Radiology. 1985 Jun;155(3):767-71. PubMed PMID: 3890007. Computed tomography (CT) is useful in the diagnosis of patients with acute cholecystitis and in the diagnosis of complications.
Signs, symptoms, and ultrasonographic features.
1. Stop oral intake of food and fluids.
2. Administer IV fluids, for example, an isotonic crystalloid.
3. Use analgesics and spasmolytics as in biliary colic (see Cholelithiasis).
4. Empiric broad-spectrum antibiotic treatment is rarely, if ever, used in Canada in patients who can undergo cholecystectomy in a timely fashion (<8 hours from presentation to the hospital) and without signs of sepsis.Evidence 2Weak recommendation (downsides likely outweigh benefits, but the balance is close or uncertain; an alternative course of action may be better for some patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to methodologic limitations. Loozen CS, Kortram K, Kornmann VN, et al. Randomized clinical trial of extended versus single-dose perioperative antibiotic prophylaxis for acute calculous cholecystitis. Br J Surg. 2017 Jan;104(2):e151-e157. doi: 10.1002/bjs.10406. PMID: 28121041. van Dijk AH, de Reuver PR, Tasma TN, van Dieren S, Hugh TJ, Boermeester MA. Systematic review of antibiotic treatment for acute calculous cholecystitis. Br J Surg. 2016 Jun;103(7):797-811. doi: 10.1002/bjs.10146. Epub 2016 Mar 30. PMID: 27027851. Mazeh H, Mizrahi I, Dior U, et al. Role of antibiotic therapy in mild acute calculus cholecystitis: a prospective randomized controlled trial. World J Surg. 2012 Aug;36(8):1750-9. doi: 10.1007/s00268-012-1572-6. PMID: 22456803.
5. Cholecystectomy is indicated in every patient with acute cholecystitis caused by gallstones within 72 hours of admission to the hospital; in most patients a laparoscopic procedure can be performed.Evidence 3Strong recommendation (benefits clearly outweigh downsides; right action for all or almost all patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to indirectness and the observational nature of some studies. Overby DW, Apelgren KN, Richardson W, Fanelli R; Society of American Gastrointestinal and Endoscopic Surgeons. SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. Surg Endosc. 2010 Oct;24(10):2368-86. doi: 10.1007/s00464-010-1268-7. Epub 2010 Aug 13. PubMed PMID: 20706739. NIH Consensus conference. Gallstones and laparoscopic cholecystectomy. JAMA. 1993 Feb 24;269(8):1018-24. Review. PubMed PMID: 8429583. Song GM, Bian W, Zeng XT, Zhou JG, Luo YQ, Tian X. Laparoscopic cholecystectomy for acute cholecystitis: early or delayed?: Evidence from a systematic review of discordant meta-analyses. Medicine (Baltimore). 2016 Jun;95(23):e3835. doi: 10.1097/MD.0000000000003835. Review. PubMed PMID: 27281088; PubMed Central PMCID: PMC4907666. If the procedure cannot be performed within 7 days from the onset of symptoms, it should be delayed until ≥6 weeks of the onset. However, it may also need to be delayed from the start in elderly patients with severe cardiovascular and respiratory comorbidities.
Complications that require urgent surgical treatment include empyema, necrosis, or perforation (limited or with diffuse biliary peritonitis) of the gallbladder. Other complications include hygroma of the gallbladder, liver abscess, biliary intestinal fistula (passage of large gallstones to the intestinal lumen may result in gallstone ileus), and Mirizzi syndrome (obstruction of the neck of the gallbladder or the cystic duct by a large gallstone resulting in symptoms of common bile duct compression).