Cholecystitis (Acute and Chronic)

• • 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

Epidemiology

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

  • Acalculous cholecystitis affecting patients with acute, severe systemic illness

Symptoms and Signs

• • 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

Laboratory Findings

• • Leukocytosis

Imaging Findings

• • 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

• • Other causes of acute abdominal pain

Rule Out

• • Choledocholithiasis

  • Pancreatitis

• • 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)

Medical

• • All patients require IV fluids and antibiotics

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

Surgery

• • Laparoscopic cholecystectomy

  • Open cholecystectomy

  • Cholecystostomy tube (if cholecystectomy too hazardous)

Indications

• • Suspected acute cholecystitis

  • Suspected acalculous cholecystitis

  • Failure to resolve cholecystitis on antibiotics

Complications

• • 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

References