Acute Cholecystitis

Acute cholecystitis is defined as an inflammation of the gallbladder wall, which occurs in response to obstruction of the cystic duct. It develops in up to 20% of patients with untreated gallstones.

This disease stems from the following process: infectious.

Presentation

Acute cholecystitis is a pathologic complication of prolonged biliary obstruction. It presents classically with epigastric or right upper quadrant pain which is similar to the pain in gallbladder colic, but it is continuous and more prolonged, lasting for several hours. Low-grade fever, vomiting, anorexia, malaise, and nausea are common symptoms of acute cholecystitis.

Patients with acute cholecystitis are usually more acutely ill-looking than those with biliary colic. Typically, patients with acute cholecystitis tend not to move at all as any movement may exacerbate the peritoneal signs. In elderly patients and diabetics who present with fever, altered mental status, or septic features, acute cholecystitis should be excluded, because in these patients, nonspecific symptoms may be the only presentation of acute cholecystitis.

On abdominal examination, acute cholecystitis and gallstones present with a classic finding of pain in the epigastric or right upper quadrant, with guarding. Murphy's sign is a characteristic finding on abdominal examination in acute cholecystitis and is described as a sudden pause in inspiration on palpation of the right upper quadrant. A study by Singer et al. indicated that Murphy's sign is highly sensitive and diagnostic of acute cholecystitis, with a sensitivity rate of 97% [10]. However, Murphy's sign may not be so sensitive in elderly patients.

In up to 85% of patients with acute cholecystitis, symptoms resolve spontaneously within a week.

Workup

Laboratory blood studies, including white blood cell count, and liver function tests, including serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphate (ALP), as well as bilirubin levels are necessary for the diagnosis of acute cholecystitis. These indices may be normal or mildly elevated in uncomplicated cholecystitis, hence, not sensitive for ruling out a diagnosis of acute cholecystitis.

Leukocytosis with a left shift is often present. Total bilirubin and ALP elevation may be absent in uncomplicated cholecystitis. A finding of highly elevated serum bilirubin is highly suggestive of a biliary obstruction or pancreatic duct obstruction. Typically in acute cholecystitis, marked elevation of AST and ALT is suggestive of common bile duct obstruction. However, in all cases where these values are increased, complications of cholecystitis should be excluded.

The preferred imaging studies for the diagnosis of acute cholecystitis and gallstones are ultrasonography and nuclear medicine studies. The initial modality often recommended is ultrasonography while nuclear studies are reserved for cases in which ultrasound scans fail to give conclusive results. Plain radiography, endoscopic retrograde cholangiopancreatography (ERCP), and computed tomography (CT) scans are useful alternatives [11].

Transabdominal ultrasonography may also be used to elicit Murphy's sign. Typically, the ultrasound images reveal fluid around the gallbladder and thickening of the gallbladder wall, which is indicative of an inflammation of the gallbladder. Abdominal CT scans demonstrate complications of acute cholecystitis such as pancreatitis and perforation.

Treatment

The diagnostic criteria and treatment guidelines for acute cholecystitis has been established in detail in the "Tokyo guidelines" which was published in 2007 [12]. According to this publication, which was updated in 2013, diagnosis of acute cholecystitis is made when a patient shows at least one sign of local gallbladder inflammation and at least one sign of systemic inflammation. Local signs of inflammation include a positive Murphy's sign and demonstration of mass/tenderness/pain in the right upper quadrant on physical examination, while the systemic features of inflammation include fever, elevated C-reactive protein and leukocytosis [13]. The diagnosis is confirmed by findings on imaging studies [12].

Upon diagnosis of acute cholecystitis, treatment is commenced and it is usually on an inpatient basis. A few patients may be managed as outpatients. Management of acute cholecystitis consists of IV hydration, antibiotics and analgesia with a strict Nil-per-ora (NPO) protocol. Analgesia may be achieved by NSAIDs or opioids. Nasogastric sanction is recommended if there's concomitant vomiting or ileus. Empiric antimicrobial therapy includes intravenous ceftriaxone 2g daily plus metronidazole 500mg every 8 hours, piperacillin/tazobactam 4g 6 hourly or ticarcillin/clavulanate 4g 6 hourly.

Cholecystectomy is the definitive treatment for acute cholecystitis providing significant pain relief. Cholecystectomy is best done early: within the first 48 hours of presentation especially in diabetic or elderly patients, in cases where investigations reveal inconclusive results, and in complicated cholecystitis. However, delayed cholecystectomy may be recommended in patients with severe coexisting chronic disease such as cardiac or pulmonary disease, in which case stabilization of the comorbid disease must be achieved preoperatively. If symptoms resolve, interval cholecystectomy (done after 6 weeks of onset of symptoms) may be performed. Recurrence of biliary complications is common when surgery is delayed. High-risk patients such as elderly patients, patients with acalculous cholecystitis, and those managed in the ICU for acute severe illnesses such as trauma, may need percutaneous cholecystectomy.

Prognosis

Acute cholecystitis develops more frequently as a complication of gallstones in diabetic patients than in non-diabetics. Complications of acute cholecystitis are also more common in diabetics than non-diabetics [9].

Generally, uncomplicated cholecystitis is not associated with significant mortality, however, in the immunocompromised patient, mortality may be up to 15%. Complicated cholecystitis, on the other hand, is associated with a mortality rate of 25%. Such complications include perforation and gangrenous transformation of the gallbladder, and emphysematous infection by gas-forming organisms such as the clostridium species. Gallbladder perforation occurs in 3-15% of cases and may cause death in 60% of cases. While localized perforation of the gallbladder is seen in 10% of the cases, peritonitis is seen in 1% of patients. Findings of abdominal pain increasing in intensity, very high fever, and rebound tenderness are suggestive of gangrene, perforation, and empyema of the gallbladder.

If acute cholecystitis presents with jaundice, it suggests a common bile duct obstruction.

Mirizzi syndrome is a rare complication of acute cholecystitis which is characterized by the impaction of stones in the cystic duct, obstructing the common bile duct and causing cholestasis. Stones may also move from the gallbladder through the biliary tract into the pancreatic duct causing acute pancreatitis.

Cholecystoenteric fistula is another rare complication of acute cholecystitis in which a large stone damages and erodes the gallbladder wall, leading to the formation of a fistula into the adjacent viscera particularly the small intestine. In some cases, the stone may pass through the bowel without causing complications, however, if large enough, it may obstruct the bowel, causing gallstone ileus.

Generally, prompt treatment is recommended if any of these complications sets in.

Etiology

The risk factors for acute cholecystitis as well as gallstones include obesity, advanced age, pregnancy, Northern European and Hispanic ethnicity and history of liver transplant [2]. The risk factors for acute cholecystitis and gallstones are highlighted as persons who are "fair, female, fat, and fertile". Although acute cholecystitis is more common in women than in men, men present with severer symptoms and are more likely to develop cholecystitis from gallstones [3].

Certain medications are associated with an increased risk of gallstones and acute cholecystitis, and these include estrogen replacements, oral contraceptives, ceftriaxone and octreotide [4] [5].

Cholecystitis occurring in the absence of gallstones (acalculous cholecystitis) develops in the setting of many risk factors including diabetes, HIV infection, prolonged fasting, vascular diseases, total parenteral nutrition and ICU care. Acalculous cholecystitis is most commonly seen in children. Additionally, gallstones in children most likely result from hemolytic diseases, burns, trauma, and total parenteral nutrition.

Epidemiology

Up to 10% of all cases of abdominal pain are caused by acute cholecystitis [6] [7] [8]. Studies have shown that the incidence of acute cholecystitis is higher in those above the age of 50 [8].

Sex distribution
Age distribution

Pathophysiology

Acute cholecystitis is the most common complication of cholelithiasis. Acute cholecystitis occurs as a complication of gallstones in 95% of cases.

Inflammatory changes to the gallbladder wall are triggered when continuous obstruction of the gallbladder by the stone occurs, causing bile stasis. The release of inflammatory enzymes such as phospholipase A is triggered by bile stasis. Phospholipase A converts lecithin to lysolecithin , which is a pro-inflammatory agent. With the inflammation, mucosal fluid secretion occurs which eventually overwhelms the absorptive capacity of the gallbladder, thus resulting in its distension. The distension of the gallbladder, in turn, triggers the release of other pro-inflammatory agents which aggravate the inflammatory processes in the gallbladder mucosa. There may be a superimposed bacterial infection which further worsens the inflammation. These inflammatory changes, if uncontrolled, lead to necrotic changes and perforation of the gallbladder walls. Over time, chronic inflammation sets in with the gallbladder becoming fibrotic and shrunken.

Acalculous cholecystitis is usually triggered by infection, typically Salmonella spp or CMV in the immunocompromised population. It may also be a result of other causes of bile stasis.

Prevention

Preventive measures for gallstones and cholecystitis include maintaining a healthy weight and gradual weight loss for overweight individuals. Sudden weight loss may increase one's risk of cholelithiasis. A diet rich in fat, as well as a diet low in fiber may increase the risk of cholelithiasis and cholecystitis, while vegetables, fruits, and whole grains tend to reduce the risk.

Summary

Acute cholecystitis is the inflammation of the gallbladder. It often develops secondary to obstruction of the gallbladder and cystic duct by gallstones [1]. Risk factors for cholelithiasis and acute cholecystitis are similar and include obesity, pregnancy, diabetes mellitus, and old age. It is, however, more common among women than men.

Acute cholecystitis presents with sudden severe epigastric or right upper quadrant pain which is continuous and prolonged. Nonspecific symptoms, including nausea, vomiting, malaise, and anorexia, are also common in acute cholecystitis.

Diagnosis of acute cholecystitis may be made on physical examination of the patient with a characteristic finding of a momentary halt in inspiration on palpation of the epigastrium or right upper quadrant of the abdomen; this finding is referred to as "Murphy's sign". However, diagnosis is confirmed by findings of imaging studies, preferably ultrasonography. Liver function tests and other blood tests are necessary but not sensitive enough to confirm or exclude acute cholecystitis.

Treatment of acute cholecystitis is mainly conservative with IV fluids, empirical antibiotics and analgesia. Surgery may be immediate or delayed depending on the presence of complications.

Patient Information

Acute cholecystitis is defined as a sudden onset of symptoms caused by inflammation of the gallbladder. The gallbladder is an organ located in the upper abdomen, which stores bile. The gallbladder delivers bile through the cystic duct which becomes the common bile duct after joining a duct from the liver. Finally, the common bile duct joins the duct from the pancreas before entering the small bowel, where bile serves to emulsify fats. These ducts are small passageways. Acute cholecystitis presents with a sudden sharp abdominal pain which is severe and lasts for several hours.

Acute cholecystitis is most commonly caused by gallstones, a condition in which tiny to large-sized particles accumulate in the gallbladder and block the ducts. There are a number of risk factors for both gallstones and acute cholecystitis and these can be highlighted in a phrase "fair, fertile, fat female" indicating a few of the risk factors including obesity, pregnancy and the female gender. However, other risk factors include advanced age, a history of liver transplant, Northern European descent, and use of birth control pills or hormone replacement drugs. Acute cholecystitis may occur without gallstones and is common in patients who have HIV, diabetes, and those who have been receiving treatment in an ICU for a long time.

Although cholecystitis which does not progress to severe complications rarely causes death; if it progresses to complications such as perforation and death of the gallbladder tissue, or obstruction of the bile duct or pancreatic duct, death may occur. Complications are more commonly seen amongst diabetics and patients with severe underlying diseases.

The condition presents with a sudden sharp pain at the center of the upper part of the abdomen called the epigastrium or the right upper part of the abdomen. This pain is often very severe and continuous, occurring for several hours. Low-grade fever, vomiting, nausea, loss of appetite and weakness are other common symptoms of this disease.

Laboratory investigations necessary in the diagnosis of acute cholecystitis include a white blood cell count and liver function tests, which show the level of certain critical chemicals which change with diseases of the liver and gallbladder. However, imaging studies are used to confirm a diagnosis of acute cholecystitis. An ultrasound scan is the preferred modality, while cholescintigraphy, an imaging study which employs nuclear medicine, is the second choice. These imaging studies reveal features in the gallbladder which indicate inflammation.

The initial treatment of acute cholecystitis basically involves antibiotics and pain relief medications. In patients who are hospitalized, fluids and antibiotics would be administered intravenously and the patient is prohibited from taking anything by mouth for a given period of time. Surgery is the standard treatment for acute cholecystitis. Surgery may be done early, that is within 2 days of onset of symptoms or of presentation of the patient especially in those who have developed serious complications. However, it may be delayed by up to 6 weeks in those with no complications after the symptoms have subsided.

Self-assessment

References

  1. Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008 Jun 26. 358(26):2804-11.
  2. Sheng R, Ramirez CB, Zajko AB, Campbell WL. Biliary stones and sludge in liver transplant patients: a 13-year experience. Radiology. 1996 Jan. 198(1):243-7.
  3. Yeatman TJ. Emphysematous cholecystitis: an insidious variant of acute cholecystitis. Am J Emerg Med. 1986 Mar. 4(2):163-6.
  4. Montini M, Gianola D, Pagani MD, et al. Cholelithiasis and acromegaly: therapeutic strategies. Clin Endocrinol (Oxf). 1994 Mar. 40(3):401-6.
  5. Park HZ, Lee SP, Schy AL. Ceftriaxone-associated gallbladder sludge. Identification of calcium-ceftriaxone salt as a major component of gallbladder precipitate. Gastroenterology. 1991 Jun. 100(6):1665-70.
  6. Eskelinen M, Ikonen J, Lipponen P. Diagnostic approaches in acute cholecystitis; a prospective study of 1333 patients with acute abdominal pain. Theor Surg. 1993;8:15–20.
  7. Brewer BJ, Golden GT, Hitch DC, Rudolf LE, Wangensteen SL. Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. Am J Surg. 1976 Feb;131(2):219-23.
  8. Telfer S, Fenyö G, Holt PR, de Dombal FT. Acute abdominal pain in patients over 50 years of age. Scand J Gastroenterol Suppl. 1988;144:47-50.
  9. Hickman MS, Schwesinger WH, Page CP. Acute cholecystitis in the diabetic. A case-control study of outcome. Arch Surg. 1988 Apr. 123(4):409-11.
  10. Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. 1996 Sep. 28(3):267-72.
  11. Fidler JL, Knudsen JM, Collins DA, et al. Prospective assessment of dynamic CT and MR cholangiography in functional biliary pain. AJR Am J Roentgenol. 2013 Aug. 201(2):W271-82.
  12. Takada T, Strasberg SM, Solomkin JS, et al. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013 Jan. 20(1):1-7.
  13. Gruber PJ, Silverman RA, Gottesfeld S, Flaster E. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med. 1996 Sep. 28(3):273-7.

  • A comparison of laparoscopic and open treatment of acute cholecystitis - SW Unger, G Rosenbaum, HM Unger, DS Edelman - Surgical endoscopy, 1993 - Springer
  • Acute acalculous cholecystitis - RJ Howard - The American Journal of Surgery, 1981 - Elsevier
  • Chest pain in children and adolescents - SRV Reddy, HR Singh - Pediatrics in Review, 2010 - Am Acad Pediatrics
  • Acute cholecystitis - SM Cohen, AI Kim, TW Faust - 2008 - pier.acponline.org
  • Years after removal of the gallbladder: observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis - M Vetrhus, T Berhane, O Søreide - Journal of gastrointestinal , 2005 - Springer
  • Diseases of the liver and biliary system - S Sherlock, J Dooley - 2002 - Wiley Online Library
  • Acute acalculous cholecystitis: complication of other illnesses in childhood - JL Ternberg, JP Keating - Archives of Surgery, 1975 - Am Med Assoc
  • Biliary‐type pain as a manifestation of genital tract infection: The Curtis–Fitz‐Hugh syndrome - JJ Wood, JP Bolton, SR Cannon, A Allan - British Journal of , 1982 - Wiley Online Library
  • Acute primary diaphragmitis (Hedblom's syndrome) - M Joannides - CHEST Journal, 1946 - journal.publications.chestnet.org
  • International classification of causes of sickness and death - J Bertillon - 1910 - books.google.com
  • A test for patency of the cystic duct in acute cholecystitis. - EA Eikman, JL Cameron, M Colman - Annals of internal , 1975 - ncbi.nlm.nih.gov
  • Acute cholecystitis following the surgical treatment of unrelated disease - F Glenn - Annals of surgery, 1947 - ncbi.nlm.nih.gov
  • Adult intussusception. - T Azar, DL Berger - Annals of surgery, 1997 - ncbi.nlm.nih.gov
  • Acute abdominal pain - C Dang, MDP Aguilera, MDA Dang - , 2002 - geriatrics.modernmedicine.com
  • ABC of diseases of liver, pancreas, and biliary system: Gallstone disease - IJ Beckingham - BMJ: British Medical Journal, 2001 - ncbi.nlm.nih.gov
  • A history of the dissolution of retained choledocholithiasis - E Kelly, JD Williams, CH Organ - The American journal of surgery, 2000 - Elsevier
  • Acute acalculous cholecystitis. An increasing entity. - F Glenn, CG Becker - Annals of surgery, 1982 - ncbi.nlm.nih.gov
  • Acute biliary septic shock - TJ Liu - HPB Surgery, 1990 - hindawi.com
  • Years after removal of the gallbladder: observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis - M Vetrhus, T Berhane, O Søreide - Journal of gastrointestinal , 2005 - Springer
  • A test for patency of the cystic duct in acute cholecystitis. - EA Eikman, JL Cameron, M Colman - Annals of internal , 1975 - ncbi.nlm.nih.gov
  • A survey of the timing and approach to the surgical management of cholelithiasis in patients with acute biliary pancreatitis and acute cholecystitis in the UK - PSP Senapati, D Bhattarcharya - Annals of the Royal , 2003 - ingentaconnect.com
  • Acute cholecystitis. - KW Sharp - The Surgical clinics of North America, 1988 - ukpmc.ac.uk
  • Acute cholecystitis due to gas‐producing organisms - WA Wilson - British Journal of Surgery, 1958 - Wiley Online Library
  • Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. - BJ Brewer, GT Golden, DC Hitch - American journal of , 1976 - ncbi.nlm.nih.gov
  • Acute emphysematous cholecystitis: A case report and review of the world literature - A Edinburgh, A Geffen - The American Journal of Surgery, 1958 - Elsevier
  • Acute abdominal pain - MH Flasar, E Goldberg - Medical Clinics of North , 2006 - medicina.iztacala.unam.mx
  • Abdominal actinomycosis - M Davies, NC Keddie - British Journal of Surgery, 1973 - Wiley Online Library
  • Acalculous cholecystitis: ascariasis as an unusual cause - MA Kuzu, Y Öztürk, H Özbek, A Soran - Journal of gastroenterology, 1996 - Springer
  • Acute non-traumatic spinal epidural hemorrhage - LI Kaplan, PG Denker - The American Journal of Surgery, 1949 - Elsevier
  • Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis - AJ Singer, G McCracken, MC Henry, HC Thode - Annals of emergency , 1996 - Elsevier
  • Aortic dissection: investigations - PS Ramrakha, KP Moore, A Sam - ohacmed.oxfordtextbookofmedicine.
  • Acute cholecystitis--room for improvement? - IC Cameron, C Chadwick, J Phillips - Annals of The Royal , 2002 - ncbi.nlm.nih.gov
  • Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction - A Prasad, A Lerman, CS Rihal - American heart journal, 2008 - intranet.santa.lt
  • Acute acalculous cholecystitis in the critically ill patient - R Orlando, E Gleason, AD Drezner - The american journal of surgery, 1983 - Elsevier
  • Acute cholecystitis complicating operation for other diseases - JW Thompson III, DO Ferris, AH Baggenstoss - Annals of surgery, 1962 - ncbi.nlm.nih.gov
  • Biliary colic treatment and acute cholecystitis prevention by prostaglandin inhibitor - G Goldman, PJ Kahn, R Alon, T Wiznitzer - Digestive diseases and , 1989 - Springer
  • Acute abdominal pain: value of non-contrast enhanced ultra-low-dose multi-detector row CT as a substitute for abdominal radiographs - UK Udayasankar, J Li, DA Baumgarten, WC Small - Emergency , 2009 - Springer
  • Years after removal of the gallbladder: observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis - M Vetrhus, T Berhane, O Søreide - Journal of gastrointestinal , 2005 - Springer
  • Changes in gastric acidity in peptic ulcer, cholecystitis and other diseases: analyzed with the help of a new and accurate technic - FR Vanzant, WC ALVAREZ, J Berkson - Archives of Internal , 1933 - Am Med Assoc
  • Abdominal pain in the ED: stability and change over 20 years - RD Powers, AT Guertler - The American journal of emergency medicine, 1995 - Elsevier
  • Acute cholecystitis complicating trauma. - RW DuPriest Jr, SC Khaneja, RA Cowley - Annals of surgery, 1979 - ncbi.nlm.nih.gov
  • Cholescintigraphy in acute cholecystitis: use of intravenous morphine. - D Choy, EC Shi, RG McLean, R Hoschl, IP Murray - , 1984 - radiology.rsna.org
  • A primer on anaerobic bacteria and anaerobic infections for the uninitiated - I Olsen, CO Solberg, SM Finegold - Infection, 1999 - Springer
  • Acute fatty liver of pregnancy - MM Kaplan - New England Journal of Medicine, 1985 - Mass Medical Soc
  • Agenesis of the gallbladder without extrahepatic biliary atresia - RS Bennion, JE Thompson Jr, RK Tompkins - Archives of Surgery, 1988 - Am Med Assoc
  • Acalculous cholecystitis in burned patients - AM Munster, MN Goodwin, BA Pruitt - The American Journal of Surgery, 1971 - Elsevier
  • A risk score for conversion from laparoscopic to open cholecystectomy - NA Kama, M Kologlu, M Doganay, E Reis, M Atli - The American journal of , 2001 - Elsevier
  • Years after removal of the gallbladder: observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis - M Vetrhus, T Berhane, O Søreide - Journal of gastrointestinal , 2005 - Springer
  • Acute cholecystitis in the elderly: a surgical emergency - DJ Morrow, J Thompson, SE Wilson - Archives of Surgery, 1978 - Am Med Assoc
  • Acute fatty liver of pregnancy: A cryptic disease threatening mother and child - H Reyes - Clinics in Liver Disease, 1999 - Elsevier
  • Acute abdominal pain - MH Flasar, E Goldberg - Medical Clinics of North , 2006 - medicina.iztacala.unam.mx
  • Abnormal liver function tests in acute cholecystitis; the predicting of common duct stones. - H Järvinen - Annals of clinical research, 1978 - ukpmc.ac.uk
  • Years after removal of the gallbladder: observations from two randomized controlled trials of symptomatic, noncomplicated gallstone disease and acute cholecystitis - M Vetrhus, T Berhane, O Søreide - Journal of gastrointestinal , 2005 - Springer
  • Acute abdominal disease in the elderly: experience from two series in Stockholm - G Fenyö - The American Journal of Surgery, 1982 - Elsevier
  • Acalculous cholecystitis - AM Munster, JR Brown - The American Journal of Surgery, 1967 - Elsevier
  • Factors effecting the complications in the natural history of acute cholecystitis. - A Bedirli, O Sakrak, EM Sözüer, M Kerek - Hepato- , 2001 - ukpmc.ac.uk
  • Dietary factors in the aetiology of gall stones: a case control study. - F Pixley, J Mann - Gut, 1988 - gut.bmj.com
  • Acute acalculous cholecystitis as the initial presentation of primary Epstein-Barr virus infection - A Prassouli, J Panagiotou, M Vakaki, I Giannatou - Journal of pediatric , 2007 - Elsevier
  • Acute gall-bladder disease and the common duct - AM Boyden - Archives of Surgery, 1955 - Am Med Assoc
  • A comparative appraisal of emphysematous cholecystitis. - RM Mentzer Jr, GT Golden, JG Chandler - American journal of , 1975 - ukpmc.ac.uk
  • Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis - AJ Singer, G McCracken, MC Henry, HC Thode - Annals of emergency , 1996 - Elsevier
  • Acalculous cholecystitis in critically III patients - TN Long, DM Heimbach, CJ Carrico - The American Journal of Surgery, 1978 - Elsevier
  • Acute acalculous cholecystitis following trauma - P Herlin, M Ericsson, T Holmin - British Journal of , 1982 - Wiley Online Library
Self-assessment