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  • • Cholesterol stones form in 20% of women and 10% of men by age 60

    • Cholesterol stone risk factors include:

    • -Female gender

      -Age

      -Obesity

      -Estrogen exposure

      -Fatty diet

      -Rapid weight loss

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Epidemiology

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  • • Symptoms develop in about 3% of asymptomatic patients each year (20-30% over 20 years)

    • Acalculous cholecystitis affecting patients with acute, severe systemic illness

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Symptoms and Signs

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  • • Biliary colic but becoming unremitting and steady in epigastrium or right upper quadrant

    • Fever

    • Nausea

    • Vomiting

    • Right upper quadrant pain to palpation with peritoneal signs

    • Murphy sign

    • Anorexia

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Laboratory Findings

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  • • Leukocytosis

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Imaging Findings

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  • • Right upper quadrant US showing gallstones, gallbladder wall thickening (> 4 mm), or pericholecystic fluid (no stones if acalculous cholecystitis)

    • HIDA scan showing failure of filling of gallbladder (> 95% sensitive)

    • CT showing gallbladder wall thickening (> 4 mm), pericholecystic fluid (for patients with suspected acalculous cholecystitis) as sensitive as US

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  • • Other causes of acute abdominal pain

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Rule Out

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  • • Choledocholithiasis

    • Pancreatitis

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  • • History and physical exam

    • CBC

    • Amylase and lipase

    • Liver function tests

    • Right upper quadrant US

    • HIDA scan for difficult cases

    • CT if abdominal US not technically possible (patients with suspected acalculous cholecystitis, large wounds etc)

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Medical

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  • • All patients require IV fluids and antibiotics

    • Management then can include either early cholecystectomy (generally preferred) or cholecystectomy after about 6 weeks

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Surgery

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  • • Laparoscopic cholecystectomy

    • Open cholecystectomy

    • Cholecystostomy tube (if cholecystectomy too hazardous)

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Indications

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  • • Suspected acute cholecystitis

    • Suspected acalculous cholecystitis

    • Failure to resolve cholecystitis on antibiotics

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Complications

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  • • Bile duct injury or leak

    • Empyema

    • -Suppurative cholecystitis occurs with frank pus in the gallbladder, high fever, chills and systemic toxicity

      -Percutaneous drainage or cholecystectomy is necessary

    • Pericholecystic abscess

    • -Localized perforation at the gallbladder can result in a pericholecystic abscess

      -Treatment requires drainage with or without initial cholecystectomy

    • Free perforation

    • -Rare but causes generalized peritonitis

      -This occurs when a gangrenous portion of the wall necroses prior to local adhesion formation

      -The diagnosis is rarely made before urgent laparotomy

      -Treatment is cholecystectomy

    • Cholecystoenteric fistula

    • -Perforation at the gallbladder into an adjacent viscous generally resolves the acute episode

      -Symptomatic fistula and/or patients with continued gallstone symptoms should have cholecystectomy and closure at the fistula

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References

Berber E et al. Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis. Arch Surg. 2000;135:341.  [PubMed: 10722039]
Svanvik J. Laparoscopic cholecystectomy for acute cholecystitis. Eur J Surg. 2000;(Suppl 585):16.
Kolla SB. et al. Early versus delayed laparoscopic cholecystectomy for ...

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