Definition: Acute inflammation of the gallbladder

Variant Forms

  • Acalculous cholecystitis (10% of cases): Inflammation of the gallbladder in the absence of gallstones or cystic duct obstruction that is more common in older patients and after non-biliary tract surgery
  • Emphysematous cholecystitis (1% of cases): Inflammation of the gallbladder along with the presence of gas in the gallbladder wall. It is more commonly seen in diabetic patients.

Pathophysiology

  • Cystic duct obstruction is the proximate cause of cholecystitis
  • Obstruction leads to gallbladder distension
  • An inflammatory reaction occurs due to either mucosal ischemia from increased hydrostatic pressure or cytotoxic effects of bile degradation
  • Causes
    • Gallstones (95% of patients with cholecystitis)
    • Fibrosis
    • Parasitic infection
    • Tumor
    • Lymphadenopathy

Differential Diagnosis

  • Biliary colic
  • Choledocholithiasis
  • Mirizzi syndrome (gallstone impaction in the cystic duct or gallbladder neck causing common bile duct (CBD) or common hepatic duct compression)
  • Acute Hepatitis
  • Hepatic abscess
  • Right lower lobe pneumonia
  • Cholangitis
  • Pancreatitis
  • Pyelonephritis

Presentation

  • History
    • Right upper quadrant (RUQ) pain
    • History of similar, self-limited pain (biliary colic)
    • Nausea/Vomiting
    • Radiation of pain to the tip of the right scapula (referred pain)
  • Physical Examination
    • RUQ/epigastric tenderness to palpation
    • Variable presence of rebound/guarding
    • Tenderness with an inspiratory pause during palpation of the RUQ during a deep breath (Murphy’s sign)
      • Best test for diagnosis of acute cholecystitis (Jain 2017)
      • (+) LR = 15.64
      • (-) LR = 0.40
    • Fever is poorly sensitive (35%) and nonspecific (80%) (Towbridge 2003)

Diagnostic Test Performance in Acute Cholecystitis (The Resus Room)

Diagnostics

  • Laboratory Tests
    • Overall, laboratory tests are insensitive and non-specific. They can neither rule in nor out the disease
    • WBC count: Elevation with a left shift is common but may be absent in up to 40% of patients (Gruber 1996)
    • AST/ALT: May be mildly elevated but are poorly sensitive (38%) and specific (62%)
    • Total/Direct Bilirubin: If elevated, it raises suspicion for choledocholithiasis, cholangitis, or Mirizzi syndrome

      Acute Cholecystitis (Long Axis US) Case courtesy of Dr Hani Al Salam, Radiopaedia.org. From the case rID: 16067

      Acute Cholecystitis (Long Axis US) Case courtesy of Dr Hani Al Salam, Radiopaedia.org. From the case rID: 16067

  • Ultrasound (US)
    • Common findings
      • Presence of gallstones (absence of stones has a high negative predictive value for cholecystitis)
      • Thickened gallbladder wall (> 3 mm)
      • Pericholecystic fluid
      • Maximal tenderness elicited over the visualized gallbladder by the US probe (Sonographic Murphy’s sign)
    • Test characteristics
      • Impacted gallstones (in the neck or cystic duct) + sonographic Murphy’s sign have a positive predictive value of 70% (Rosen 2001) to 92% (Ralls 1985)
      • Overall sensitivity 88%, specificity 80% (Shea 1994)
  • Acute Cholecystitis (CT Scan Sagittal Images) Case courtesy of Dr Hani Al Salam, Radiopaedia.org. From the case rID: 16067

    Acute Cholecystitis (CT Scan Sagittal Images) Case courtesy of Dr Hani Al Salam, Radiopaedia.org. From the case rID: 16067

    CT

    • Higher accuracy than US for defining complications related to cholecystitis (gangrene, emphysematous cholecystitis)
    • Common findings (Fidler 1996)
      • Thickened gallbladder wall (> 3 mm)
      • Increased attenuation of the gallbladder bile
      • Subserosal edema
  • Nuclear Scintigraphy with Technetium-99m-labeled hepatobiliary iminodiacetic acid (HIDA)
    • Gold standard for diagnosis with high sensitivity and specificity
    • Positive study: Failure of HIDA to outline the gallbladder within 1 hour of administration

Management:

  • Basic Supportive Care
    • IV crystalloids: optimize volume status
    • Check + replete electrolytes as needed (may be significant losses from vomiting)
    • Antiemetics
    • Pain control
  • Antibiotics
    • The role of bacterial infection in the pathogenesis of cholecystitis is not completely understood
    • If the patient exhibits signs of sepsis, administer broad-spectrum antibiotics covering gram negative/positive pathogens as well as anaerobes
      • Vancomycin AND an advanced generation penicillin (i.e. piperacillin/tazobactam)
      • Vancomycin AND a 3rd/4th generation cephalosporin (i.e. cefepime) AND metronidazole

        Gangrenous Cholecystitis Case courtesy of Dr David Cuete, Radiopaedia.org. From the case rID: 38882

        Gangrenous Cholecystitis Case courtesy of Dr David Cuete, Radiopaedia.org. From the case rID: 38882

    • In the absence of sepsis, consider administration of a 2nd/3rd generation cephalosporin
    • Emphysematous cholecystitis
      • Likely caused by invasion of gas-producing pathogens (E. coli, Klebsiella, Clostridium perfringens)
      • Advanced generation penicillin (i.e. piperacillin/tazobactam) +/- metronidazole
  • Surgical Consultation for cholecystectomy
  • Complications
    • Gangrene leading to necrosis and perforation
    • Emphysematous cholecystitis
    • Pericholecystic abscess
    • Sepsis

Disposition:

  • Admission for IV antibiotics and pain control
  • Cholecystectomy is typically performed during the initial hospitalization as early cholecystectomy appears to have improved outcomes
  • Patients with gangrene or perforation may undergo immediate cholecystectomy or cholecystostomy and drainage

Take Home Points

  • Acute cholecystitis is an inflammation of the gallbladder that is most readily diagnosed by US
  • Treatment focuses on fluid resuscitation when indicated, supportive care, antibiotics and surgical consultation for cholecystectomy
  • Although uncommon, be aware that patients can develop gangrene, necrosis and perforation as well as frank sepsis and require aggressive resuscitation

The Resus Room: Acute Cholecystitis

Oyama LC: Disorders of the liver and biliary tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 90: p 1186-1205.

Leschka S et al. Chapter 5.1: Acute abdominal pain: diagnostic strategies In: Schwartz DT: Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2008.

Menu Y, Vuillerme MP. Chapter 5.5: Non-traumatic Abdominal Emergencies: Imaging and Intervention in Acute Biliary Conditions In: Schwartz DT: Emergency Radiology: Case Studies. New York, NY: McGraw-Hill, 2008.

Fidler J et al. CT evaluation of acute cholecystitis: findings and usefulness in diagnosis. Am J Roentgenol. 1996; 166:1085–1088. PMID: 8615248

Gruber PJ et al. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med 1996; 28: 273. PMID: 8780469

Jain A et al. History, physical examination, laboratory testing and emergency department ultrasonography for the diagnosis of acute cholecystitis. Acad Emerg Med 2017; 24(3):281-297. PMID: 27862628

Ralls PW et al. Real-time sonography in suspected acute cholecystitis.Prospective evaluation of primary and secondary signs. Radiology 1985; 155:767–771. PMID: 3890007

Rosen CL et al. Ultrasonography by emergency physicians in patients with suspected cholecystitis. Am J Emerg Med. 2001; 19(1):32-36. PMID: 11146014

Shea JA, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994; 154(22):2273. PMID: 7979854

Towbridge RL et al. Does this patient have acute cholecystitis? JAMA 2003; 289(1);80-6. PMID: 12503981