Acute Cholecystitis

Aka: Acute Cholecystitis, Hydrops Gallbladder, Cholecystitis

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II. Definitions

  1. Cholecystitis
    1. Gallbladder inflammation resulting from cystic duct blockage by Gallstones

III. Pathophysiology

  1. Gallstone obstructs cystic duct
  2. Gallbladder retains bile, distends and becomes inflamed
  3. May progress to infection and rupture

IV. Precautions

  1. Acute Cholecystitis may present cryptically yet requires emergent management
  2. Fever and chills are frequently absent
    1. Fever or chills are only present in a third of patients with Acute Cholecystitis
  3. Right upper quadrant pain or tenderness may be absent
    1. As many as a quarter of Acute Cholecystitis cases do not have right upper quadrant findings
  4. Clinical gestalt has the highest Likelihood Ratio for Acute Cholecystitis
    1. Trowbridge (2003) JAMA 289(1): 80-86 [PubMed]

V. Risk Factors

  1. See Gallstone (Cholelithiasis)

VI. Symptoms

  1. Biliary Colic with additional characteristics below
    1. Acute Cholecystitis is typically preceded by at least one Biliary Colic episode
  2. Characteristics
    1. Starts as dull visceral poorly localized pain
    2. Develops into sharp parietal focal RUQ Pain
  3. Timing
    1. Pain persists beyond typical 5-6 hours
    2. Contrast with Biliary Colic which typically subsides within 5-6 hours, once Gallstone dislodges
  4. Associated Symptoms
    1. Fever is present in only 35% of Acute Cholecystitis
    2. Chills are present in only 13% of Acute Cholecystitis

VII. Signs

  1. Appearance
    1. Toxic appearance in moderate to severe discomfort
    2. Tachycardia
  2. Non-specific gastrointestinal findings
    1. RUQ Abdominal tenderness
      1. Test Sensitivity: 77%
      2. Test Specificity: 54%
    2. Hypoactive bowel sounds
  3. Peritoneal Signs
    1. Localized irritation is comon
    2. Generalized signs (rare) suggests perforation
  4. Murphy Sign positive (LR+ 11 to 21)
    1. Examiner palpates the abdominal RUQ while the patient takes a deep breath
    2. Positive test if the patient suddenly halts their inspiration due to pain

VIII. Labs

  1. Complete Blood Count
    1. Leukocytosis with Left Shift
    2. Normal WBC Count does not rule out Acute Cholecystitis
    3. Very high WBC Count may suggest gallbladder gangrene or perforated gallbladder
  2. Liver Function Tests (LFTs)
    1. Serum Bilirubin elevated (typically mild)
    2. Serum Alkaline Phosphatase elevated
    3. Serum Aminotransferases normal
  3. Pancreatic Studies (for Gallstone Pancreatitis)
    1. Serum Lipase (some also obtain Serum Amylase)
  4. Urine Studies
    1. Urinalysis
    2. Urine HCG

IX. Imaging: First-Line

  1. RUQ Ultrasound (preferred)
    1. See Gallbladder Ultrasound for diagnostic criteria
    2. Consider serial Ultrasound in 12-16 hours if non-diagnostic Ultrasound
      1. Repeat Ultrasound may demonstrate increased gallbladder wall thickness, ultrasonic murphy's sign
  2. CT Abdomen and Pelvis
    1. Indications
      1. Often performed in the Emergency Department as initial imaging for non-focal Acute Abdominal Pain
      2. Indicated for non-diagnostic Ultrasound
      3. Evaluation of Cholecystitis complications (Ascending Cholangitis, Gallstone Pancreatitis, post-operative findings)
    2. CT Abdomen has Test Sensitivity 90% for Cholecystitis (localized inflammation) and also identifies choledocolithiasis
      1. Non-contrast CT does not decrease Test Sensitivity (contrast does not penetrate Gall Bladder)
    3. However, CT misses at least 20% of Gallstones (esp. Cholesterol stones which are isodense with bile)
      1. Consider RUQ Ultrasound when CT Negative despite high pretest probability for Gall Bladder disease
    4. References
      1. Pensa, Weinstock, Mason, Raja and Swaminathan in Swadron (2022) EM:Rap 22(10): 19-20
  3. Hepatobiliary Iminodiacetic Acid Scan (HIDA Scan)
    1. Acute Cholecystitis evaluation for cystic duct obstruction
    2. Normal gallbladder visualization on HIDA Scan has high Negative Predictive Value (99%)
  4. Magnetic Resonance Cholangiopancreatography (MRCP)
    1. Indicated for suspected Common Duct Stone (Choledocholithiasis)

X. Imaging: Other

  1. XRay Abdomen
    1. Test Sensitivity for Gallstones: 10-20%
    2. Most stones are Cholesterol (radiolucent)
  2. Chest XRay
    1. Assess for Right Lower Lobe Pneumonia
    2. Assess for Pleural Effusion (seen in Pancreatitis)
    3. Assess for free air under the diaphragm

XI. Differential Diagnosis

  1. See Right Upper Quadrant Abdominal Pain
  2. Biliary Colic
  3. Ascending Cholangitis
  4. Acute Pancreatitis (or Gallstone Pancreatitis)

XII. Management

  1. Intravenous Fluid hydration
  2. Nasogastric suction
  3. Antibiotics (start within 1 hour of skin incision)
    1. Initial Antibiotic regimen (see Cholecystectomy)
      1. Piperacillin-Tazobactam 4.5 g IV q8 hours OR
      2. Ertapenem 1 g IV every 24 hours
    2. Alternative Antibiotic regimens
      1. Metronidazole 1 g IV load, then 500 mg IV every 6 hours AND
      2. Ceftriaxone 2 g IV OR (Moxifloxacin 400 IV q24h or Ciprofloxacin 400 mg IV q12 h)
        1. Risk of Fluoroquinolone resistance
    3. Consider broadening Antibiotics for severe cases
      1. See Ascending Cholangitis
    4. References
      1. (2017) Sanford Guide
  4. Laparoscopic Cholecystectomy
    1. Recommended within first 48 hours
      1. In poor surgical candidates, strongly consider decompression (e.g. percutaneous)
    2. Immediate Cholecystectomy is safe and preferred
      1. Stevens (2006) Am J Surg 192:756-61 [PubMed]
      2. Zafer (2015) JAMA Surg 150(2):129-36 +PMID:25517723 [PubMed]
  5. Percutaneous cholecystostomy drainage (with delayed Cholecystectomy)
    1. Indicated for older or critically ill patients with gallbladder empyema (and associated Sepsis)
  6. Alternatives to surgery
    1. Extracorporeal Shock Wave Lithotripsy (ESWL)
    2. Oral Dissolution Therapy

XIII. Course

  1. Spontaneous resolution in 60% of cases

XIV. Complications

  1. Acute Pancreatitis
  2. Ascending Cholangitis
  3. Gallbladder Empyema
  4. Gallbladder Gangrene (Emphysematous Cholecystitis)

XV. References

  1. Abraham (2014) Am Fam Physician 89(10): 795-802 [PubMed]
  2. Jain (2017) Acad Emerg Med 24(3):281-97 +PMID: 27862628 [PubMed]
  3. Patel (2024) Am Fam Physician 109(6): 518-24 [PubMed]
  4. Portincasa (2006) Lancet 368(9531):230-9 [PubMed]

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