Acute Cholecystitis

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

• 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

• 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

  • 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.

References

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