Acute calculous cholecystitis: Difference between revisions
(Major update: HIDA accuracy, sonographic Murphy sign importance, early cholecystectomy evidence (ACDC trial), antibiotic regimens, morphine safety, Tokyo Guidelines, references with PMIDs) |
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==Background== | ==Background== | ||
*Inflammation of the gallbladder caused by | *Inflammation of the gallbladder caused by obstruction of the cystic duct by gallstones | ||
*Most common complication of [[cholelithiasis]] | *Most common complication of [[cholelithiasis]] | ||
* | *10-20% of patients with gallstones will develop cholecystitis | ||
*Risk factors ( | *Risk factors (5 F's — mnemonic): | ||
** | **Female, Forty, Fertile (multiparity), Fat (obesity), Fair (Northern European descent) | ||
**Additional: rapid weight loss, TPN, medications (estrogen, fibrates, octreotide) | **Additional: rapid weight loss, TPN, medications (estrogen, fibrates, octreotide) | ||
*Pathophysiology: cystic duct obstruction → gallbladder distension → wall inflammation → secondary infection (in ~50%) | *Pathophysiology: cystic duct obstruction → gallbladder distension → wall inflammation → secondary infection (in ~50%) | ||
*Complications: | *Complications: gangrenous cholecystitis (20%), perforation (2-15%), gallstone ileus, cholecystoenteric fistula, [[emphysematous cholecystitis]] | ||
==Clinical Features== | ==Clinical Features== | ||
* | *RUQ pain (constant, >4-6 hours duration — distinguishes from biliary colic which resolves) | ||
*Pain radiates to | *Pain radiates to right scapula or shoulder (phrenic nerve irritation) | ||
* | *Nausea and vomiting (common) | ||
* | *Fever (low-grade; high fever suggests complications) | ||
* | *Murphy sign: inspiratory arrest during RUQ palpation (sensitivity ~65%) | ||
** | **Sonographic Murphy sign (pain with probe pressure over sonographically visualized gallbladder) is more specific | ||
*RUQ guarding, rebound tenderness (suggests peritonitis) | *RUQ guarding, rebound tenderness (suggests peritonitis) | ||
* | *Jaundice suggests [[choledocholithiasis]] (common bile duct stone) or [[cholangitis]] (Charcot triad/Reynolds pentad) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* | *[[Biliary colic]] (most important to distinguish — resolves within 4-6h) | ||
*[[Choledocholithiasis]] / [[cholangitis]] | *[[Choledocholithiasis]] / [[cholangitis]] | ||
*[[Hepatitis]] | *[[Hepatitis]] | ||
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==Evaluation== | ==Evaluation== | ||
===Labs=== | ===Labs=== | ||
* | *WBC: leukocytosis (12,000-15,000); WBC >20,000 suggests gangrenous or emphysematous cholecystitis | ||
* | *LFTs: mild elevation of AST/ALT; alkaline phosphatase and bilirubin elevated if CBD stone | ||
* | *Lipase: rule out concurrent [[pancreatitis]] ([[gallstone pancreatitis]]) | ||
* | *Lactate: if septic | ||
* | *Blood cultures: if febrile or septic | ||
* | *Pregnancy test in reproductive-age women | ||
===RUQ Ultrasound (Test of Choice)=== | ===RUQ Ultrasound (Test of Choice)=== | ||
* | *Sensitivity 88%, specificity 80% for acute cholecystitis | ||
*Findings: | *Findings: | ||
** | **Gallstones (echogenic foci with posterior acoustic shadowing) | ||
** | **Gallbladder wall thickening >3-4 mm (nonspecific — also seen in CHF, ascites, hepatitis) | ||
** | **Pericholecystic fluid | ||
** | **Sonographic Murphy sign (most predictive single finding) | ||
**Gallbladder distension (>10 cm long or >5 cm transverse) | **Gallbladder distension (>10 cm long or >5 cm transverse) | ||
*Combined findings increase diagnostic accuracy | *Combined findings increase diagnostic accuracy | ||
===HIDA Scan=== | ===HIDA Scan=== | ||
* | *Most accurate test for cholecystitis (sensitivity 97%, specificity 90%) | ||
*Non-visualization of gallbladder at 4 hours = positive for cholecystitis (cystic duct obstruction) | *Non-visualization of gallbladder at 4 hours = positive for cholecystitis (cystic duct obstruction) | ||
*Takes | *Takes 1-4 hours to complete — not practical for acutely ill ED patients | ||
*Use when US equivocal and diagnosis uncertain | *Use when US equivocal and diagnosis uncertain | ||
===CT=== | ===CT=== | ||
*Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding | *Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding | ||
*Useful for identifying | *Useful for identifying complications (perforation, abscess, emphysematous changes) | ||
==Management== | ==Management== | ||
===ED Management=== | ===ED Management=== | ||
* | *NPO | ||
* | *IV fluid resuscitation | ||
* | *Pain control: | ||
** | **Ketorolac 15-30 mg IV (shown to be effective and may reduce gallbladder inflammation) | ||
**'''Opioids''' (morphine or hydromorphone) — traditional concern about sphincter of Oddi spasm is likely overstated | **'''Opioids''' (morphine or hydromorphone) — traditional concern about sphincter of Oddi spasm is likely overstated | ||
* | *Antiemetics: ondansetron 4 mg IV | ||
* | *Antibiotics if complicated (febrile, septic, diabetic, immunocompromised): | ||
** | **Piperacillin-tazobactam 3.375-4.5g IV OR | ||
** | **Ceftriaxone 2g IV + metronidazole 500 mg IV | ||
**Coverage: gram-negatives (E. coli, Klebsiella) and anaerobes | **Coverage: gram-negatives (E. coli, Klebsiella) and anaerobes | ||
* | *Surgical consultation for cholecystectomy | ||
===Definitive Treatment=== | ===Definitive Treatment=== | ||
* | *Laparoscopic cholecystectomy (standard of care) | ||
* | *Early cholecystectomy (<72 hours) preferred — associated with shorter hospital stays and lower complication rates<ref>Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). ''Ann Surg''. 2013;258(3):385-393. PMID 24022431</ref> | ||
* | *Percutaneous cholecystostomy for patients too unstable for surgery (critically ill, multiple comorbidities) | ||
===Special Populations=== | ===Special Populations=== | ||
* | *Acalculous cholecystitis: occurs in critically ill/ICU patients without gallstones (5-10% of cases) | ||
* | *Emphysematous cholecystitis: gas-forming organisms; higher perforation risk; more common in diabetic men | ||
* | *Elderly/diabetics: higher risk of complications, may present atypically | ||
==Disposition== | ==Disposition== | ||
* | *Admit all patients with acute cholecystitis | ||
* | *ICU if septic, gangrenous, or emphysematous cholecystitis | ||
* | *Surgical consultation in ED for early cholecystectomy | ||
==See Also== | ==See Also== | ||
Latest revision as of 09:29, 22 March 2026
Background
- Inflammation of the gallbladder caused by obstruction of the cystic duct by gallstones
- Most common complication of cholelithiasis
- 10-20% of patients with gallstones will develop cholecystitis
- Risk factors (5 F's — mnemonic):
- Female, Forty, Fertile (multiparity), Fat (obesity), Fair (Northern European descent)
- Additional: rapid weight loss, TPN, medications (estrogen, fibrates, octreotide)
- Pathophysiology: cystic duct obstruction → gallbladder distension → wall inflammation → secondary infection (in ~50%)
- Complications: gangrenous cholecystitis (20%), perforation (2-15%), gallstone ileus, cholecystoenteric fistula, emphysematous cholecystitis
Clinical Features
- RUQ pain (constant, >4-6 hours duration — distinguishes from biliary colic which resolves)
- Pain radiates to right scapula or shoulder (phrenic nerve irritation)
- Nausea and vomiting (common)
- Fever (low-grade; high fever suggests complications)
- Murphy sign: inspiratory arrest during RUQ palpation (sensitivity ~65%)
- Sonographic Murphy sign (pain with probe pressure over sonographically visualized gallbladder) is more specific
- RUQ guarding, rebound tenderness (suggests peritonitis)
- Jaundice suggests choledocholithiasis (common bile duct stone) or cholangitis (Charcot triad/Reynolds pentad)
Differential Diagnosis
- Biliary colic (most important to distinguish — resolves within 4-6h)
- Choledocholithiasis / cholangitis
- Hepatitis
- Peptic ulcer disease
- Pancreatitis
- Appendicitis (especially high-riding appendix)
- Pneumonia (RLL)
- Pyelonephritis / nephrolithiasis
- MI (inferior — especially in elderly/diabetics)
- Fitz-Hugh-Curtis syndrome (perihepatitis)
Evaluation
Labs
- WBC: leukocytosis (12,000-15,000); WBC >20,000 suggests gangrenous or emphysematous cholecystitis
- LFTs: mild elevation of AST/ALT; alkaline phosphatase and bilirubin elevated if CBD stone
- Lipase: rule out concurrent pancreatitis (gallstone pancreatitis)
- Lactate: if septic
- Blood cultures: if febrile or septic
- Pregnancy test in reproductive-age women
RUQ Ultrasound (Test of Choice)
- Sensitivity 88%, specificity 80% for acute cholecystitis
- Findings:
- Gallstones (echogenic foci with posterior acoustic shadowing)
- Gallbladder wall thickening >3-4 mm (nonspecific — also seen in CHF, ascites, hepatitis)
- Pericholecystic fluid
- Sonographic Murphy sign (most predictive single finding)
- Gallbladder distension (>10 cm long or >5 cm transverse)
- Combined findings increase diagnostic accuracy
HIDA Scan
- Most accurate test for cholecystitis (sensitivity 97%, specificity 90%)
- Non-visualization of gallbladder at 4 hours = positive for cholecystitis (cystic duct obstruction)
- Takes 1-4 hours to complete — not practical for acutely ill ED patients
- Use when US equivocal and diagnosis uncertain
CT
- Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding
- Useful for identifying complications (perforation, abscess, emphysematous changes)
Management
ED Management
- NPO
- IV fluid resuscitation
- Pain control:
- Ketorolac 15-30 mg IV (shown to be effective and may reduce gallbladder inflammation)
- Opioids (morphine or hydromorphone) — traditional concern about sphincter of Oddi spasm is likely overstated
- Antiemetics: ondansetron 4 mg IV
- Antibiotics if complicated (febrile, septic, diabetic, immunocompromised):
- Piperacillin-tazobactam 3.375-4.5g IV OR
- Ceftriaxone 2g IV + metronidazole 500 mg IV
- Coverage: gram-negatives (E. coli, Klebsiella) and anaerobes
- Surgical consultation for cholecystectomy
Definitive Treatment
- Laparoscopic cholecystectomy (standard of care)
- Early cholecystectomy (<72 hours) preferred — associated with shorter hospital stays and lower complication rates[1]
- Percutaneous cholecystostomy for patients too unstable for surgery (critically ill, multiple comorbidities)
Special Populations
- Acalculous cholecystitis: occurs in critically ill/ICU patients without gallstones (5-10% of cases)
- Emphysematous cholecystitis: gas-forming organisms; higher perforation risk; more common in diabetic men
- Elderly/diabetics: higher risk of complications, may present atypically
Disposition
- Admit all patients with acute cholecystitis
- ICU if septic, gangrenous, or emphysematous cholecystitis
- Surgical consultation in ED for early cholecystectomy
See Also
References
- ↑ Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). Ann Surg. 2013;258(3):385-393. PMID 24022431
- Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. PMID 29032636
- Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016;11:25. PMID 27307785
- Trowbridge RL, et al. Does this patient have acute cholecystitis? JAMA. 2003;289(1):80-86. PMID 12503981