Acute calculous cholecystitis: Difference between revisions

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(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==
<translate>
*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):
**'''F'''emale, '''F'''orty, '''F'''ertile (multiparity), '''F'''at (obesity), '''F'''air (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]]


==Background== <!--T:1-->
==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)


<!--T:2-->
==Differential Diagnosis==
[[File:Gallstones 2.jpg |thumb|Acute cholecystitis on gross pathology of removed gallbladder containing multiple stones.]]
*'''[[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)


{{Gallbladder disease types}}
{{RUQ pain DDX}}


{{Gallbladder background}}
==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


==Clinical Features== <!--T:3-->
===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


===Local Signs=== <!--T:4-->
===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)


<!--T:5-->
===Special Populations===
*[[Special:MyLanguage/RUQ pain|RUQ pain]]
*'''Acalculous cholecystitis''': occurs in critically ill/ICU patients without gallstones (5-10% of cases)
*Murphy Sign
*'''Emphysematous cholecystitis''': gas-forming organisms; higher perforation risk; more common in diabetic men
**Highest positive LR (2.8) of any clinical finding or lab value<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
*'''Elderly/diabetics''': higher risk of complications, may present atypically
*Boas sign: hyperaesthesia below the right scapula from referred pain<ref>Iyer HV. Boas' sign revisited. Ir J Med Sci. 2011;180(1):301. doi:10.1007/s11845-010-0640-x</ref>


==Disposition==
*'''Admit all patients with acute cholecystitis'''
*'''ICU''' if septic, gangrenous, or emphysematous cholecystitis
*'''Surgical consultation''' in ED for early cholecystectomy


===Systemic signs=== <!--T:6-->
==See Also==
 
*[[Biliary colic]]
<!--T:7-->
*[[Choledocholithiasis]]
*[[Special:MyLanguage/Fever|Fever]]
*[[Cholangitis]]
*[[Special:MyLanguage/Nausea and vomiting|Nausea and vomiting]]
*[[Gallstone pancreatitis]]
 
*[[Acalculous cholecystitis]]
 
==Differential Diagnosis== <!--T:8-->
 
 
{{DDX RUQ}}
 
 
 
==Evaluation== <!--T:9-->
 
<!--T:10-->
[[File:Ultrasonography of sludge and gallstones, annotated.jpg|thumb|Abdominal ultrasound showing biliary sludge and gallstones]]
[[File:Cholecystitis_Neck_Stone_Bowra.gif|thumbnail|Gallstone impacted in neck of gallbladder<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
[[File:Gallstones.png|thumb|Gallstone impacted in the neck of the gallbladder and 4 mm gall bladder wall thickening consistent with acute cholecystitis.]]
[[File:GB_Thickening_Fluid_Bowra.gif|thumbnail|Gallbladder wall thickening with pericholecystic fluid<ref>http://www.thepocusatlas.com/hepatobiliary/</ref>]]
 
 
===Workup=== <!--T:11-->
 
 
====Laboratory Findings==== <!--T:12-->
 
<!--T:13-->
*Common findings:
**[[Special:MyLanguage/Leukocytosis|Leukocytosis]]
**[[Special:MyLanguage/LFTs|LFT]] abnormalities (obstructive picture)
*Meta-analysis shows there is no history, physical exam, or lab test or combination thereof that allows rule-out or rule-in without imaging.<ref>Trowbridge RL et al. Does this patient have acute cholecystitis? JAMA. 2003, 289(1): 80-6.</ref>
 
 
====Imaging==== <!--T:14-->
 
<!--T:15-->
*[[Special:MyLanguage/Biliary ultrasound|Biliary ultrasound]] (preferred test<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>; sensitivity 84%; specificity 99%)<ref>Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994;154:2573–81.</ref>
**Gallstones
***Distinguish by characteristic "shadowing"
***Better seen with patient in left lateral decub
**GB wall thickening (>3mm)
***May also be seen with [[Special:MyLanguage/pancreatitis|pancreatitis]], [[Special:MyLanguage/ascites|ascites]], [[Special:MyLanguage/congestive heart failure|congestive heart failure]], alcoholic hepatitis
**Pericholecystic fluid
**Sonographic Murphy's Sign (PPV 92%)
***May be absent in patients with DM, gangrenous cholecystitis
*HIDA scan
**Gold standard when other imaging modalities are equivocal<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
*Other imaging
**CT: there is a lack of evidence to support diagnostic accuracy<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
**MRI: Accuracy similar to ultrasound<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
 
 
===Diagnosis=== <!--T:16-->
 
<!--T:17-->
*"Combining clinical, laboratory and imaging investigations is recommended, although the best combination is not yet known"<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
 
 
==Management== <!--T:18-->
 
 
===[[Special:MyLanguage/Antibiotics|Antibiotics]]=== <!--T:19-->
 
</translate>
{{Cholecystitis Antibiotics}}
<translate>
 
 
===Surgical consultation=== <!--T:20-->
 
<!--T:21-->
*Definitive treatment: surgical cholecystectomy<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
**More effective than antibiotics alone<ref name=“WSES 2016”>Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5</ref>
 
 
==Disposition== <!--T:22-->
 
<!--T:23-->
*Admit
 
 
==Complications== <!--T:24-->
 
 
===[[Special:MyLanguage/Gangrene|Gangrene]]=== <!--T:25-->
 
<!--T:26-->
*Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
*Consider if patient presents with sepsis in addition to cholecystitis


==References==
<references/>
*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


===Perforation=== <!--T:27-->
<!--T:28-->
*Occurs in 2% after development of gangrene 
*Usually localized, leading to pericholecystic abscess
===Gallstone [[Special:MyLanguage/Ileus|Ileus]]=== <!--T:29-->
<!--T:30-->
*Due to cholecystoenteric fistula
*[[Special:MyLanguage/Bowel obstruction|Bowel obstruction]] due to impaction of gallstone at terminal ileum
**Gallstone enters small bowel through biliary-duodenal fistula
*Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone
===Emphysematous cholecystitis=== <!--T:31-->
<!--T:32-->
*Due to secondary infection of GB by gas-forming organisms (C. perfringens)
*Presents like cholecystitis but often progresses to sepsis and gangrene
*IV antibiotic and cholecystectomy are essential
*Ultrasound report may mistake GB wall gas for bowel gas
*Mortality as high as 15% due to gangrene or perforation
===Mirizzi Syndrome=== <!--T:33-->
<!--T:34-->
*Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
*Symptoms of acute cholecystitis + dilated intrahepatic ducts + [[Special:MyLanguage/jaundice|jaundice]]
*Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
**US and CT can usually delineate the fistula
*Treatment = open cholecystectomy
==See Also== <!--T:35-->
<!--T:36-->
*[[Special:MyLanguage/Gallbladder Disease (Main)|Gallbladder Disease (Main)]]
*[[Special:MyLanguage/Biliary ultrasound|Biliary ultrasound]]
==References== <!--T:37-->
<!--T:38-->
<references/>
[[Category:GI]]
[[Category:GI]]
[[Category:ID]]
[[Category:Surgery]]
</translate>

Revision as of 19:48, 21 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

Template:RUQ pain DDX

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

  1. ↑ 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
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