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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Related Studies

Ontology: Cholecystitis (C0008325)

Definition (MSHCZE) Zánět žlučníku. Obv. vzniká při současné cholecystolitiáze (kalkulózní ch.). Ch. bez přítomnosti kaménků (akalkulózní ch.) je vzácnější, vzniká spíše v souvislosti s celkovými chorobami (poruchy výživy, šok, operační výkony aj.) a mívá těžší průběh. Postihuje např. pacienty na jednotkách intenzivní péče. Větš. se prezentuje jako sepse neznámého původu, postižení nemívají bolest v pravém podžebří. Na ultrazvuku lze často pozorovat ztluštění a projasnění stěny žlučníku. Ch. může být akutní s výraznými bolestmi v pravém podžebří, teplotou a třesavkou, nebo chronická, jejíž příznaky se pohybují od poměrně malých obtíží až k opakovaným záchvatům podobným zánětu akutnímu exacerbace. V akutním stavu je nutné vyloučit příjem potravy, podávají se antibiotika a led na břicho; po odeznění může být provedena cholecystektomie. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) An acute or chronic inflammation involving the gallbladder wall. It may be associated with the presence of gallstones.
Definition (NCI_CTCAE) A disorder characterized by inflammation involving the gallbladder. It may be associated with the presence of gallstones.
Definition (MSH) Inflammation of the GALLBLADDER; generally caused by impairment of BILE flow, GALLSTONES in the BILIARY TRACT, infections, or other diseases.
Definition (CSP) inflammation of the gallbladder; generally caused by impairment of bile flow, gallstones in the biliary tract, infections, or other diseases.
Concepts Disease or Syndrome (T047)
MSH D002764
ICD9 575.10
ICD10 K81 , K81.9
SnomedCT 197414008, 76581006
French CHOLECYSTITE, Cholécystite SAI, Cholécystite, Inflammation de la vésicule biliaire
English CHOLECYSTITIS, Cholecystitis, unspecified, Cholecystitis NOS, GALLBLADDER INFLAMM, Cholecystitis, cholecystitis (diagnosis), cholecystitis, Cholecystitis [Disease/Finding], gall bladder inflammation, gallbladder inflammation, Gallbladder inflammation, Inflammation gallbladder, Cholecystitis NOS (disorder), Gallbladder Inflammation, Inflammation, Gallbladder, Cholecystitis (disorder), gallbladder; inflammation, inflammation; gallbladder, Cholecystitis, NOS
Portuguese COLECISTITE, Inflamação da vesícula biliar, Colecistite NE, Colecestite, Colecistite, Inflamação da Vesícula Biliar
Spanish COLECISTITIS, Colecistitis NEOM, Inflamación de la vesícula biliar, colecistitis, SAI (trastorno), colecistitis, SAI, colecistitis (trastorno), colecistitis, Colecistitis, Inflamación de la Vesícula Biliar
German CHOLEZYSTITIS, Gallenblasenentzuendung, Cholezystitis NNB, Entzuendung, Gallenblase, Cholezystitis, nicht naeher bezeichnet, Cholezystitis
Dutch cholecystitis NAO, galblaasontsteking, onsteking galblaas, galblaas; ontsteking, ontsteking; galblaas, Cholecystitis, niet gespecificeerd, cholecystitis, Cholecystitis, Galblaasontsteking
Italian Colecistite NAS, Infiammazione della colecisti, Infiammazione della vescica biliare, Colecistite
Japanese 胆嚢の炎症, 胆嚢炎ＮＯＳ, ﾀﾝﾉｳｴﾝNOS, ﾀﾝﾉｳｴﾝ, ﾀﾝﾉｳﾉｴﾝｼｮｳ, 胆嚢炎, 胆嚢膿腫, 胆嚢蓄膿, 胆のう炎, 蓄膿-胆嚢
Swedish Gallblåseinflammation
Czech zánět žlučníku, cholecystitida, žlučník - zánět, Zánět žlučníku, Cholecystitida NOS, Cholecystitida
Finnish Sappirakkotulehdus
Russian KHOLETSISTIT, EMPIEMA ZHELCHNOGO PUZYRIA, ХОЛЕЦИСТИТ, ЭМПИЕМА ЖЕЛЧНОГО ПУЗЫРЯ
Korean 상세불명의 담낭염, 담낭염
Croatian KOLECISTITIS
Polish Zapalenie pęcherzyka żółciowego
Hungarian Cholecystitis, Cholecystitis k.m.n., Epehólyag-gyulladás, Epehólyag gyulladás
Norwegian Galleblærebetennelse, Kolecystitt
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Cholecystitis, Acute (C0149520)

Definition (MSH) Acute inflammation of the GALLBLADDER wall. It is characterized by the presence of ABDOMINAL PAIN; FEVER; and LEUKOCYTOSIS. Gallstone obstruction of the CYSTIC DUCT is present in approximately 90% of the cases.
Concepts Disease or Syndrome (T047)
MSH D041881
ICD9 575.0
ICD10 K81.0
SnomedCT 197411000, 155827009, 197409009, 197408001, 65275009
English Acute cholecystitis NOS, Acute cholecystitis unspecif., Acute cholecystitis unspecified, CHOLECYSTITIS ACUTE, acute cholecystitis (diagnosis), acute cholecystitis, Cholecystitis acute NOS, Cholecystitis, Acute [Disease/Finding], Acute calculous cholecystitis, Acute cholecystitis unspecified (disorder), Acute cholecystitis NOS (disorder), Acute Cholecystitis, Cholecystitis, Acute, Cholecystitis acute, Acute cholecystitis, Acute cholecystitis (disorder), cholecystitis; acute, acute; cholecystitis
Dutch acute cholecystitis, cholecystitis acuut NAO, acute calculeuze cholecystitis, acuut; cholecystitis, cholecystitis; acuut, Acute cholecystitis, cholecystitis acuut, Cholecystitis, acute, Galblaasontsteking, acute
French Cholécystite aiguë SAI, Cholécystite aiguë, Cholécystite aigüe, Cholécystite calculeuse aiguë
German Cholezystitis akut NNB, Akute kalkuloese Cholezystitis, akute Cholezystitis, Akute Cholezystitis, Cholezystitis, akute
Italian Colecistite acuta NAS, Colecisti acuta calcolosa, Colecistite acuta
Portuguese Colecistite aguda NE, Colecistite aguda, Colecistite aguda com cálculos, Colecestite aguda, Colecistite Aguda
Spanish Colecistitis aguda NEOM, Colecistitis aguda calculosa, colecistitis aguda, SAI, colecistitis aguda no especificada (trastorno), colecistitis aguda no especificada, colecistitis aguda, SAI (trastorno), colecistitis aguda (trastorno), colecistitis aguda, Colecistitis aguda, Colecistitis Aguda
Japanese 急性胆嚢炎ＮＯＳ, ｷｭｳｾｲﾀﾝﾉｳｴﾝNOS, ｷｭｳｾｲﾀﾝﾉｳｴﾝ, 急性胆嚢炎, 胆嚢炎-急性, ｷｭｳｾｲｹｯｾｷｾｲﾀﾝﾉｳｴﾝ, 急性結石性胆嚢炎
Swedish Gallblåseinflammation, akut
Czech cholecystitida akutní, Akutní cholecystitida, Akutní cholecystitida NOS, Akutní kalkulózní cholecystitida
Finnish Äkillinen sappirakkotulehdus
Russian KHOLETSISTIT OSTRYI, ХОЛЕЦИСТИТ ОСТРЫЙ
Korean 급성 담낭염
Polish Zapalenie pęcherzyka żółciowego ostre
Hungarian Acut cholecystitis, Heveny epehólyag-gyulladás, Acut cholecystitis k.m.n., Akut cholecystitis calculousa
Norwegian Akutt galleblærebetennelse, Cholecyctitis acuta, Akutt kolecystitt
Derived from the NIH UMLS (Unified Medical Language System)

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