Cholecystitis/Cholelithiasis

CHOLECYSTITIS/CHOLELITHIASIS

Acute cholecystitis involves gallbladder inflammation, often developing over several hours. It is almost always caused by an obstructing gallstone in the cystic duct. Common symptoms include right upper quadrant abdominal pain, nausea, vomiting, chills, and fever. More fluid builds up in the gallbladder lumen and there will be mucosal injury and ischemia or necrosis. Perforation can result from this.

Acute acalculous cholecystitis involves gallbladder inflammation without stone formation. Only about five to ten percent of attacks are caused by this phenomenon. Predisposing factors include bile stasis from prolonged fasting or total parenteral nutrition, severe or critical illness, vasculitis, immunodeficiency, and shock.

It is uncommon to have acute cholecystitis without prior attacks of cholelithiasis. The pain is more severe and long-lasting with cholecystitis versus cholelithiasis. A positive Murphy sign involves pain on deep inspiration when palpating the right upper quadrant. Guarding and low-grade fever are common. Older patients will have fever, malaise, anorexia, and weakness. It will resolve within a week in 85 percent of patients in the absence of treatment.

About 10 percent of patients will perforate locally and one percent can have free perforation. Those with perforation have a high risk of peritonitis. Expect the possibility of perforation or empyema with pus in the gallbladder if you see evidence of rebound tenderness, high fever, rigors, ileus, and increasing abdominal pain. Jaundice is seen if there is cholestasis.

Other complications include impaction of the cystic duct with compression of the common bile duct, called Mirizzi syndrome, gallstone pancreatitis, and erosion of the gallstone through the gallbladder wall, called a cholecystoenteric fistula.

The diagnosis of acute cholecystitis can be made clinically with or without a diagnostic ultrasound, which is the best way to detect gallstones. Cholescintigraphy can be helpful, which looks at radionuclide filling of the gallbladder, which will be minimal in cases of acalculous cholecystitis. Morphine can be given as a provocative agent to minimize the risk of false-positive cholescintigraphy testing.