What is acute cholecystitis?
Acute cholecystitis is inflammation of the gallbladder wall owing to obstruction of the cystic duct or gallbladder neck.
This is most often caused by gallstones (calculous cholecystitis), although in 5% to 10% of cases, gallstones are not present (acalculous cholecystitis).
Acalculous cholecystitis tends to occur in the setting of prolonged illness, such as with prior traumatic or burn injury or with a prolonged intensive care unit stay.
Most patients present with right upper quadrant pain and tenderness (Murphy sign), although in the setting of severe advanced inflammation, diabetes mellitus, or elderly age, these clinical findings may be less severe or absent.
Treatment generally involves cholecystectomy (or percutaneous cholecystostomy for patients at high surgical risk) along with antimicrobial therapy.
7 Interesting Facts of Acute Cholecystitis
- Stone positioned in right upper ureter can mimic biliary colic, as both can cause flank pain
- Differentiate with:
- Urinalysis: hematuria found in approximately 80% of patients with nephrolithiasis; not typically found in cholecystitis
- Liver function tests: obstructive pattern (ie, elevated bilirubin and alkaline phosphatase levels) is found in acute cholecystitis, not in nephrolithiasis
- Gallbladder ultrasonography: reveals dilated gallbladder with stones, thickened wall, and surrounding edema in acute cholecystitis
- Noncontrast CT of abdomen and pelvis
- Hydroureteronephrosis is visible to the level of an obstructing stone in nephrolithiasis; detects approximately 90% of renal stones and approximately 95% of ureteral stones
- Gallstone can be visualized on a noncontrast study in some cases; however, contrast material is usually necessary to demonstrate typical finding of gallbladder wall thickening, gallbladder distention, and pericholecystitic fluid
Clinical hallmarks of acute cholecystitis
• Patients often give a history of prior episodes of milder abdominal pain.
• Abdominal pain usually arises after a meal, especially in the evening after a large or fat-containing meal.
• Pain typically crescendos over 20 to 30 minutes and then plateaus.
• Pain lasting longer than 1 to 2 hours is usually accompanied by gallbladder wall inflammation.
• Associated nausea occurs in 90% of patients; vomiting may follow onset of pain in 50% to 80%.
• Radiation of pain to the back is common; pain radiates to the right scapula in 10% of cases.
• Low-grade fever is common.
• Right hypochondrium tenderness is generally present. Inspiratory arrest during gentle palpation of the right upper quadrant (Murphy’s sign) suggests acute cholecystitis.
• Diagnostic tests include HIDA scan or US.