Acute Cholecystitis


Article Author:
Mark Jones
Rafaella Genova


Article Editor:
Maria O'Rourke


Editors In Chief:
Anne Kennedy


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/26/2019 2:31:19 PM

Introduction

Cholecystitis is a condition best treated with surgery. This condition can be associated with or without the presence of gallstones. It is also classified as acute or chronic. It is found both in men and women but may have a propensity for certain populations. It may also present with certain classic signs and symptoms. It may also be confused with other illnesses such as peptic ulcer disease, irritable bowel disease, and cardiac disease. Chronic and acute pancreatitis can also mimic gallbladder disease.[1][2][3]

Etiology

A malfunctioning gallbladder causes cholecystitis. Bile is made in the liver and travels down the bile duct and is stored in the gallbladder. After eating certain foods, especially spicy or greasy foods, the gallbladder is stimulated to empty the bile out of the gallbladder, through the cystic duct, down the bile duct into the duodenum. This process aids in food digestion. If the gallbladder is not functioning properly, for various reasons, the bile may not empty completely. This may lead to stone formation. Gallstones can cause mechanical blockage of the cystic duct. A poorly functioning gallbladder without formation of stones causes acalculous cholecystitis.[4][5]

Epidemiology

Gallbladder disease occurs in men and women. Certain populations are more prone to gallbladder disease. The risk of gallbladder disease increases in women, obese patients, pregnant women, and patients in their 40s. Drastic weight loss or acute illnesses may also increase the risk. There is also a family propensity for this condition and the formation of gallstones. Other conditions that cause breakdown of blood cells, for example, sickle cell disease, also increase the incidence of gallstones.

Pathophysiology

Occlusion of the cystic duct or malfunction of the mechanics of the gallbladder emptying is the pathophysiology of this disease. Cases of acute untreated cholecystitis could lead to perforation of the gallbladder, sepsis, and death. Gallstones form from various materials such as bilirubinate or cholesterol. These materials increase the likelihood of cholecystitis and cholelithiasis in conditions such as sickle cell disease where red blood cells are broken down forming excess bilirubin and forming pigmented stones. Patients with excessive calcium such as in hyperparathyroidism can form calcium stones. Patients with excessive cholesterol can form cholesterol stones. Occlusion of the common bile duct such as in neoplasms or strictures can also lead to stasis of the bile flow causing gallstone formation.[6][7]

Histopathology

During the early phase, the gallbladder will usually reveal extensive venous congestion and edema. With time, fibrosis and presence of chronic inflammatory cells may appear. More advanced cases may reveal the presence of perforation or gangrene.

History and Physical

Cases of chronic cholecystitis present with progressing right upper abdominal pain with bloating, food intolerances (especially greasy and spicy foods), increased gas, nausea, and vomiting. Pain in the midback or shoulder may also occur. This pain could be present for years until diagnosis. Cases of acute cholecystitis have similar symptoms only more severe. Often symptoms are mistaken for cardiac issues. The finding of right upper abdominal pain with deep palpation, Murphy's sign, is usually classic for this disease. Often, there is a specific dietary event leading to the acute attack, "I ate pork chops and gravy last night."

Evaluation

A physical exam with a comprehensive history is paramount in making the diagnosis of cholecystitis. A complete blood count (CBC) and a comprehensive metabolic panel are also important. In cases of chronic cholecystitis, these results may be normal. In acute cholecystitis or severe disease, white blood cell count (WBC) may be elevated. Liver enzymes may also be elevated. If there is a high bilirubin level above 2, then consider a possible common bile duct stone. Note that even in the presence of severe gallbladder disease, lab values may be normal. Amylase and lipase must also be checked to rule out pancreatitis. Often a CT scan is ordered in the emergency department as the first test in the work up. Findings of cholecystitis and gallstones can often be seen on this imaging. A gallbladder ultrasound is the best test to evaluate gallbladder disease initially. A thickened gallbladder wall and gallstones are common findings with this condition. In cases of acute cholecystitis, a hepatobiliary (HIDA) scan is recommended. This scan will diagnose gallbladder function or cystic duct obstruction. The addition of cholecystokinin (CCK) in cases of no gallstones may also diagnose acalculous cholecystitis. This is indicated by an ejection fracture less than 35%.[8][9]

Treatment / Management

The best treatment for cholecystitis is laparoscopic cholecystectomy. There are low morbidity and mortality rates with quick recovery. This can also be done with an open technique in cases where the patient is not a good laparoscopic candidate. In situations in which the patient is acutely ill and considered a poor surgical candidate, he or she may be treated with temporizing percutaneous drainage of the gallbladder. Milder cases of chronic cholecystitis in patients considered poor surgical candidates, they may be treated with dietary adjustments of low-fat and low-spice diets. Results of this treatment vary. Medical treatment of gallstones with ursodiol also has been reported to have occasional success.[10][11][3]

Differential Diagnosis

  • Appendicitis
  • Biliary colic
  • Cholangitis
  • Mesenteric ischemia
  • Gastritis
  • Peptic ulcer disease

Complications

  • Bile Duct injury
  • Small bowel injury
  • Infection
  • Retained stones in the bile duct
  • Bleeding
  • Conversion to an open procedure

Postoperative and Rehabilitation Care

Once the gallbladder has been removed, most patients can be discharged on the same day.

The pain is minimal and can be managed by over the counter analgesics.

Pearls and Other Issues

Cholecystitis can occur in the very young and very old, but the highest incidence is in the fourth decade. The classic mantra of "fat, forty, fertile, and flatulent" often applies. Food intolerances are usually the initiating factor of nausea, vomiting, and bloating, but as this condition progresses, there may be persistent symptoms even when the patient has not eaten. The preferred recommended treatment is the removal of the gallbladder. In the past, this was done through an open laparotomy incision. Now laparoscopic cholecystectomy is the procedure of choice. This procedure has low mortality and morbidity, a quick recovery time (usually one week), and good results. At times, patients present to the primary care practitioner with mild symptoms of cholecystitis and gallstones. This can present a challenge to the physician to know what is the appropriate treatment. Often conservative medical management is recommended. This would include low-fat diet modification and possible weight loss. Unfortunately, for surgeons, these patients often present to the emergency department with symptoms of acute cholecystitis and undergo urgent surgery. This situation also increases operative morbidity rates. Therefore, general surgeons usually recommend patients undergo elective laparoscopic cholecystectomy earlier than later in the course of the disease. Other considerations would be the passing of gallstones into the bile duct causing biliary obstruction and possible pancreatitis.

Enhancing Healthcare Team Outcomes

Managing acute cholecystitis is now routine, and most patients have an excellent prognosis. However, problems arise in patients with acalculous cholecystitis and when there are bile duct stones. Patients with acalculous cholecystitis are often managed in the ICU and may undergo an initial aspiration procedure until they are fit to undergo formal surgery. Since many of these patients have high comorbidity, monitoring them is critical. Educating the patient and family is vital since the condition does carry a high mortality. The other group of patients who may have a prolonged stay are those with a bile duct stone. These patients require an ERCP prior to the cholecystectomy. Again ERCP is not a benign procedure, and patients need to be educated about the procedure and potential complications. 

Patients with numerous comorbid factors need to be evaluated by the cardiologist prior to general anesthesia. The preoperative nurse should ensure that the patient has the requisite clearance, ECG, Chest x-ray, and blood work prior to the surgery.[12][13][14] (level V)

Outcomes

For patients with uncomplicated acute cholecystitis, the prognosis is excellent. The mortality rates are very low. Perforation or gangrene of the gallbladder may occur in delayed cases. 

Patients with acalculous cholecystitis have a high mortality varying from 20-50%.

In severe cases of acute cholecystitis, the intense inflammation can make surgery difficult, resulting in injury to the bile duct, which has a substantial morbidity.[15][16] (Level V)


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Acute Cholecystitis - Questions

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Which of the following is false about acute cholecystitis?



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Which of the following is false of acute cholecystitis?



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Which of the following is not a treatment for acute cholecystitis?



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A 42-year-old female presents to the emergency department with persistent epigastric abdominal pain for the past 10 hours while she was at a barbecue party. She also complains of nausea and bloating. The patient states experiencing similar symptoms in the past; however, they were self resolved. All laboratory results were normal. Abdominal ultrasound revealed a thickened gallbladder wall with pericholecystic fluid, gallstones, and positive murphy's sign. Which of the following is the best treatment for this condition?



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Which treatment is preferred for a 24-year-old who is 24-weeks pregnant and diagnosed with acute cholecystitis?



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A 65-year-old male with a past medical history of uncontrolled diabetes presents to the emergency department with mild abdominal tenderness and altered mental status. Patient's temperature is 103.4 F, heart rate 105 bpm, blood pressure 90/55 mmHg, respiratory rate 22/min, white blood count 18,000 mm3, and lactic acid 1.5 mmol/L. The physical examination is notable for mild tenderness to palpation on the right upper quadrant (RUQ). The patient is transferred to the intensive care unit (ICU). Blood cultures are sent, and the patient is started on a broad-spectrum antibiotic. A computed tomography (CT) abdomen/pelvis demonstrated a distended gallbladder without duct dilatation. Surgery is consulted, and due to the patient's instability, a percutaneous cholecystostomy tube (PCT) is recommended. What is the most common organism isolated in a high-risk patient with acute cholecystitis who requires PCT?



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A 56-year-old female is referred to the surgical clinic after she was found to have gallstones on abdominal imaging. Patient denies abdominal pain, discomfort with food intake, dark urine, or pale stool. Patient's complete blood count (CBC), basic metabolic panel (BMP), and liver function test (LFT) are unremarkable. What is her risk of developing acute cholecystitis as a primary presentation, in the next 20 years?



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A 51-year-old woman presents to the emergency department complaining of right upper quadrant, colicky abdominal pain onset two days ago. The patient states the pain has become constant for the past 8 hours, urging her to seek medical attention. The patient also complains of nausea and vomiting. During the physical exam, palpation to the right upper quadrant elicits pain. The patient's white blood count is 18,000 mm3, alkaline phosphatase (ALP) 55 IU/L, alanine aminotransferase (ALT) 30 IU/L, aspartate aminotransferase (AST) 40 IU/L, total bilirubin 1mg/dL, and lipase is 105 IU/L. What is the most likely diagnosis?



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What is the MOST SENSITIVE test for diagnosing acute cholecystitis?



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A 50-year-old female presented to the emergency department complaining of right upper quadrant abdominal pain onset one day ago. Labs reveal a mild elevation on liver function test (LFT) and normal total bilirubin. An abdominal ultrasound is ordered, demonstrating cholelithiasis with 6mm gallbladder wall, pericholecystic fluid, and 9mm common bile duct (CBD). The patient was taken to the operating room for cholecystectomy and intraoperative cholangiogram. Initial cholangiogram demonstrated a filling defect. After administration of an IV medication, CBD is clearly visualized, without filling the defect, and contrast reaches the duodenum. Which of the following medication was administered?



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A 74-year-old presents with acute cholecystitis. She is diabetic and has been on steroids for rheumatoid arthritis. Which of the following is most appropriate for the management of this patient?



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In a patient with acute cholecystitis, what is the most common organism isolated from the gall bladder?



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A 43-year-old female presents to the emergency department with right upper quadrant pain and is found to have gallstones. Which of the following drugs can make her biliary discomfort worse?



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A 44-year-old patient with a known history of alcohol use averaging 9 drinks a day is admitted for midepigastric pain. Surgery is subsequently planned for cholecystectomy. Which of the following should NOT be included in preoperative treatment?



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Why is a T-tube placed during common bile duct exploration?



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What is the function of a T tube after cholecystectomy with bile duct exploration?



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Which of the following is seen in acute cholecystitis?



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Which of the following pain medications should be avoided in patients with acute cholecystitis?



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Which condition is most likely to cause upper abdominal pain radiating to the scapula?



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A patient with right sided abdominal pain ceases respiratory effort with deep palpation to the right upper quadrant. Select the most likely diagnosis.



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Select the most appropriate evaluation for gallbladder disease.



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A 52-year-old female complains of an 8-hour history of nausea and right upper quadrant pain. She has no significant past medical history. The patient has a low-grade fever and rebound tenderness in the right upper quadrant. White blood cell count is 11,000/mm3, liver functions are normal, and urinalysis is normal. What is the most likely diagnosis?



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All of the following are risk factors for calculous cholecystitis EXCEPT:



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Murphy's sign is specific for:



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A physician requests a 99mTc-albumin colloid scan to rule out acute cholecystitis. What should be the practitioner's response?



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Gallstones are typically found in what percentage of patients with acute cholecystitis?



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A 16-year-old female is eight weeks postpartum. She complains of right upper quadrant abdominal pain, nausea, and vomiting. The patient is jaundiced and tender at the right upper quadrant. Lungs are clear and the chest X-ray is normal. Select the appropriate diagnostic test.



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A patient presents with right upper quadrant pain, nausea, and vomiting. She is febrile, but the rest of the vital signs are normal. Exam and radiologic studies confirm acute cholecystitis. Pain medication is administered. What is the best next step in management?



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A 74-year-old female with type 2 diabetes mellitus presents with generalized abdominal pain for 12 hours. She denies vomiting, diarrhea, hematemesis, hematochezia, or melena. Vital signs are normal. Abdominal exam shows decreased bowel sounds but no rebound, guarding, masses, or hepatosplenomegaly. Rectal exam shows no masses and is guaiac negative. WBC is 13,500 cells/microL. KUB is unremarkable and ultrasound of the gallbladder is inconclusive as it is obscured by bowel gas. Select the next step in management.



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Which disease process presents with positive Murphy sign?



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Murphy sign is elicited by?



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Which is not a risk factor for cholecystitis?



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In which situation is an open cholecystectomy most likely to be preferred over a laparoscopic cholecystectomy?



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A 9 year old female with sickle cell anemia presents with nausea, abdominal pain, and vomiting for 10 hours. She has had several similar episodes that had resolved within a few hours. The patient is slightly jaundiced and tender at the right upper quadrant. Select the most sensitive and specific test for diagnosis.



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In which situation is the conversion from laparoscopic to open cholecystectomy least likely?



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A 45-year-old woman with acute upper abdominal pain is asked to take a deep breath as an examiner's fingers are inserted deeply under the right costal margin. The patient suddenly stops inspiring because of sharp pain. Which of the following is most likely?



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The most common malignant tumor of the gallbladder is:



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A female presents with right upper quadrant pain and fever. She has been nauseated for the past 2 days and has no appetite. It is suspected that she may have acute cholecystitis. Which of the following is not a criterion for acute cholecystitis on ultrasound?



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A 33-year-old female presents with right upper quadrant pain and fever. She has been nauseated for the past 2 days and has no appetite. It is suspected that she may have acute cholecystitis. The patient is then sent for scintigraphy. What is this particular test highly sensitive for in patients with suspected acute cholecystitis?



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A patient presents with cholecystitis and referred pain. Where would the referred pain most often be located?



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A patient arrives in the emergency department with right upper quadrant abdominal pain, nausea, and vomiting after eating fried chicken the night before. The provider orders an abdominal ultrasound and lab work. Which findings would the nurse expect with these presenting symptoms? Select all that apply.



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Acute Cholecystitis - References

References

Burmeister G,Hinz S,Schafmayer C, [Acute Cholecystitis]. Zentralblatt fur Chirurgie. 2018 Aug     [PubMed]
Walsh K,Goutos I,Dheansa B, Acute Acalculous Cholecystitis in Burns: A Review. Journal of burn care     [PubMed]
Kohga A,Suzuki K,Okumura T,Yamashita K,Isogaki J,Kawabe A,Kimura T, Is postponed laparoscopic cholecystectomy justified for acute cholecystitis appearing early after onset? Asian journal of endoscopic surgery. 2018 Mar 25     [PubMed]
Yun SP,Seo HI, Clinical aspects of bile culture in patients undergoing laparoscopic cholecystectomy. Medicine. 2018 Jun     [PubMed]
Wilkins T,Agabin E,Varghese J,Talukder A, Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. Primary care. 2017 Dec     [PubMed]
Apolo Romero EX,Gálvez Salazar PF,Estrada Chandi JA,González Andrade F,Molina Proaño GA,Mesías Andrade FC,Cadena Baquero JC, Gallbladder duplication and cholecystitis. Journal of surgical case reports. 2018 Jul     [PubMed]
Sureka B,Rastogi A,Mukund A,Thapar S,Bhadoria AS,Chattopadhyay TK, Gangrenous cholecystitis: Analysis of imaging findings in histopathologically confirmed cases. The Indian journal of radiology     [PubMed]
Tootian Tourghabe J,Arabikhan HR,Alamdaran A,Zamani Moghadam H, Emergency Medicine Resident versus Radiologist in Detecting the Ultrasonographic Signs of Acute Cholecystitis; a Diagnostic Accuracy Study. Emergency (Tehran, Iran). 2018     [PubMed]
Joshi G,Crawford KA,Hanna TN,Herr KD,Dahiya N,Menias CO, US of Right Upper Quadrant Pain in the Emergency Department: Diagnosing beyond Gallbladder and Biliary Disease. Radiographics : a review publication of the Radiological Society of North America, Inc. 2018 May-Jun     [PubMed]
Thangavelu A,Rosenbaum S,Thangavelu D, Timing of Cholecystectomy in Acute Cholecystitis. The Journal of emergency medicine. 2018 Jun     [PubMed]
Ke CW,Wu SD, Comparison of Emergency Cholecystectomy with Delayed Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage in Patients with Moderate Acute Cholecystitis. Journal of laparoendoscopic     [PubMed]
Yeh DD,Chang Y,Tabrizi MB,Yu L,Cropano C,Fagenholz P,King DR,Kaafarani HMA,de Moya M,Velmahos G, Derivation and validation of a practical Bedside Score for the diagnosis of cholecystitis. The American journal of emergency medicine. 2018 Apr 25     [PubMed]
Gulaya K,Desai SS,Sato K, Percutaneous Cholecystostomy: Evidence-Based Current Clinical Practice. Seminars in interventional radiology. 2016 Dec     [PubMed]
Bagla P,Sarria JC,Riall TS, Management of acute cholecystitis. Current opinion in infectious diseases. 2016 Oct     [PubMed]
Kohga A,Suzuki K,Okumura T,Yamashita K,Isogaki J,Kawabe A,Kimura T, Outcomes of early versus delayed laparoscopic cholecystectomy for acute cholecystitis performed at a single institution. Asian journal of endoscopic surgery. 2018 Apr 3     [PubMed]
Ahmed O,Rogers AC,Bolger JC,Mastrosimone A,Lee MJ,Keeling AN,Cheriyan D,Robb WB, Meta-analysis of outcomes of endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for the management of acute cholecystitis. Surgical endoscopy. 2018 Apr     [PubMed]

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