Basics
Description
Cholecystitis is defined as inflammation of the gallbladder.
Etiology
- Acute calculous cholecystitis:
- Owing to bile stasis secondary to prolonged obstruction by a gallstone (see "Cholelithiasis"ť) in the gallbladder neck, cystic duct, or common bile duct
- Leads to increased intraluminal pressure and mucosal damage
- Release of inflammatory mediators results in distention, edema, and increased vascularity.
- Coliforms and anaerobes lead to infection-primary causal role is controversial.
- Acalculous cholecystitis:
- 10% of cases
- Underlying critical illness leads to biliary stasis and mucosal ischemia.
- Subsequent mucosal inflammation and infection
- Acute calculous cholecystitis extremely rare in childhood (see "Cholelithiasis"ť)
- Acalculous cholecystitis more common than calculous form in children:
- Associated with systemic bacterial infections, scarlet fever, Kawasaki disease, and parasitic infections
Diagnosis
Signs and Symptoms
History
- Acute calculous cholecystitis:
- Dull, aching, epigastric, or right upper quadrant (RUQ) pain
- Radiation to tip of right scapula, acromion, or thoracic spine
- Duration >6 hr more suggestive of cholecystitis than uncomplicated biliary colic
- As inflammation progresses, parietal peritoneal irritation leads to sharp, localized pain.
- Nausea, vomiting, fever, and chills often reported, but absent in most cases
- Jaundice in 20%
- History of prior attacks of biliary colic or known gallstones favors diagnosis.
- Acalculous cholecystitis:
- Occurs in critically ill patients (burns, sepsis, trauma, or postoperative)
- Localized pain and tenderness frequently absent
- Often presents with symptoms of generalized sepsis of unknown source
Physical Exam
- Localized parietal peritoneal signs:
- Percussion tenderness
- Rebound
- Found as the disease progresses
- Murphy sign:
- Inspiratory arrest with gentle palpation of RUQ owing to increased pain
- Found in most cases
Essential Workup
- ECG in patients at risk for coronary artery disease
- CBC
- LFT
- Amylase, lipase
- Urinalysis
- Human chorionic gonadotropin (hCG)
- Gallbladder US or HIDA scan
Diagnosis Tests & Interpretation
Lab
- CBC:
- WBC >12,000 cells/mm3 supports diagnosis, but may be normal in more than half of cases
- LFTs:
- Transaminases, bilirubin, amylase, and lipase may be minimally elevated, but are generally normal.
- Disproportionate elevation of direct bilirubin and alkaline phosphatase compared with transaminases suspicious for common duct obstruction or cholangitis
Imaging
- US:
- Generally the 1st-line imaging procedure
- Positive findings include gallbladder wall thickening (>5 mm) or pericolic fluid-sensitivity, 90%; specificity, 80%.
- Optimal if patient NPO >8 hr
- Radionuclide scanning (HIDA):
- Most useful when clinical suspicion remains high despite equivocal findings on US or when acalculous cholecystitis suspected
- Positive when tracer seen in small bowel but inflamed gallbladder fails to visualize
- Sensitivity, >95%; specificity, 90%
- False-positive results increase in nonfasting state.
- Addition of IV morphine induces Sphincter of Oddi contraction which improves gallbladder filling and reduces false-positive scan results.
- CT scanning:
- Exclude intestinal perforation or obstruction
- Air in the gallbladder wall consistent with emphysematous cholecystitis
- Gallstones radiopaque in up to 20%
Differential Diagnosis
- Biliary colic
- Hepatitis or hepatic abscess
- Cholangitis
- AIDS sclerosing cholangitis
- Pancreatitis
- Intestinal perforation
- Peptic ulcer disease
- Gastritis
- Duodenal perforation
- Right lower lobe pneumonia, pleurisy, or pulmonary infarction
- MI
- Abdominal aortic aneurysm
- Appendicitis
- Fitz-Hugh and Curtis syndrome
- Pyelonephritis
Treatment
Pre-Hospital
Establish IV access for patients with vomiting or severe pain.
Initial Stabilization/Therapy
- IV, oxygen, cardiac monitoring until myocardial ischemic cause excluded
- Initiate IV fluid therapy for dehydration, hemodynamic compromise, or sepsis.
Ed Treatment/Procedures
- Broad-spectrum antibiotics for coliforms, anaerobes, and enterococcus:
- Ampicillin/sulbactam
- Piperacillin/tazobactam
- Add aminoglycoside if sepsis or cholangitis suspected (see "Cholangitis"ť).
- Alternative antibiotics for penicillin allergic:
- Adults: Levofloxacin (Levaquin) and metronidazole
- Peds: Clindamycin with aminoglycoside
- NPO
- IV fluid replacement and maintenance
- Antiemetics (ondansetron) if vomiting
- Nasogastric (NG) suctioning if refractory vomiting or ileus
- Narcotic analgesics (hydromorphone) with antiemetic (ondansetron):
- Administer for refractory pain once diagnosis is reasonably established.
- Morphine sulfate may lead to spasm at sphincter of Oddi (clinical significance not well established).
- Anticholinergics (glycopyrrolate) of no proven benefit for acute biliary pain.
- Surgical consultation
Medication
- Ampicillin/sulbactam: 3 g (peds: 200 mg/kg/24h) IV piggyback (IVPB) q6h
- Clindamycin: 600-900 mg (peds: 25-40 mg/kg/24h) IVPB q6-q8h
- Gentamicin: 1.5-2 mg/kg (peds: 6-7 mg/kg/24h) IVPB q8h; follow levels
- Levaquin: 500 mg IVPB q24h; contraindicated in peds
- Hydromorphone: 0.5-2 mg IV (0.01-0.02 mg/kg), titrated to pain relief.
- Metronidazole: 500 mg (peds: 30 mg/kg/24h) IVPB q6h
- Piperacillin/tazobactam: 3.375 mg (peds: 300 mg/kg/24h) IVPB q6h
- Ondansetron: 4-8 mg IV (peds: 0.15-0.3 mg/kg) IV (not to exceed 8 mg/dose IV), q4h PRN vomiting
Follow-Up
Disposition
Admission Criteria
- All cases of cholecystitis should be admitted for parenteral antibiotics, analgesia, fluid replacement, and cholecystectomy in 24-72 hr.
- Unstable patients (gallbladder perforation or sepsis) require immediate surgery.
Discharge Criteria
None
Issues for Referral
General surgery consult for patients with cholecystitis. GI consult if choledocholisthiasis or cholangitis suspected.
Followup Recommendations
Inpatient admission for antibiotics and surgical evaluation.
Pearls and Pitfalls
- US is the 1st-line imaging procedure.
- Perform a radionuclide scanning (HIDA) when clinical suspicion is high with equivocal US or when acalculous cholecystitis suspected.
Additional Reading
- Barie PS, Eachempati SR. Acute acalculous cholecystitis. Gastroenterol Clin North Am. 2010;39:243-357.
- Silen W, ed. Cholecystitis and other causes of acute pain in the right upper quadrant of the abdomen. Copes Early Diagnosis of the Acute Abdomen. 22nd ed. Oxford, UK: Oxford University Press; 2010:131-141.
- Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis. 2010;50:997; 133-164.
- Strasberg SM. Acute calculous cholecystitis. N Eng J Med. 2008;358:2804-2811.
- Yusuf TE, Baron TH, AIDS cholangiopathy. Curr Treat Options Gastroenterol. 2004;7:111-117.
See Also (Topic, Algorithm, Electronic Media Element)
- Cholangitis
- Cholelithiasis
Codes
ICD9
- 574.00 Calculus of gallbladder with acute cholecystitis, without mention of obstruction
- 575.0 Acute cholecystitis
- 575.10 Cholecystitis, unspecified
- 574.01 Calculus of gallbladder with acute cholecystitis, with obstruction
ICD10
- K80.00 Calculus of gallbladder w acute cholecyst w/o obstruction
- K81.0 Acute cholecystitis
- K81.9 Cholecystitis, unspecified
- K80.01 Calculus of gallbladder w acute cholecystitis w obstruction
SNOMED
- 76581006 Cholecystitis (disorder)
- 59771005 Calculus of gallbladder with acute cholecystitis (disorder)
- 34346002 Acute cholecystitis without calculus
- 197378004 gallbladder calculus with acute cholecystitis and obstruction (disorder)