Question 1 of 10

    Acute Cholecystitis

    AcuteCholMark[1]

    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.

    cardiovascular
    Chest Pain
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  • musculoskeletal
    Right Shoulder Pain
    • Constant right upper quadrant pain that can radiate to the right shoulder.[radiopaedia.org]
    • Nausea is common and vomiting occurs in 75% of people with cholecystitis. [14] In addition to abdominal pain, right shoulder pain can be present. [13] On physical examination, fever is common. [14] A gallbladder with cholecystitis is almost always tender[en.wikipedia.org]
    Back Pain
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  • gastrointestinal
    Nausea
    • She experienced nausea and 6 bouts of vomiting in the last 2 days.[acupuncturereliefproject.org]
    • Clinical finding Right upper quadrant pain, variable severity, sudden onset, rigidity and rebound tenderness with peritonitis, nausea, vomiting, constipation, fever, slow pulse, Murphy sign; spontaneous remission is not uncommon.[medical-dictionary.thefreedictionary.com]
    • It can lead to fever, pain, nausea, and severe complications.[medicalnewstoday.com]
    • No history of similar kind of pain, no nausea, vomiting or fever.[sonoworld.com]
    • Symptoms include right upper quadrant pain and tenderness, sometimes accompanied by fever, chills, nausea, and vomiting.[merckmanuals.com]
    Vomiting
    • Reduces stimulation of vomiting center.[nurseslabs.com]
    • She experienced nausea and 6 bouts of vomiting in the last 2 days.[acupuncturereliefproject.org]
    • It is episodic, occurs after eating greasy or fatty foods, and leads to nausea and/or vomiting. [13] People who suffer from cholecystitis most commonly have symptoms of biliary colic before developing cholecystitis.[en.wikipedia.org]
    • Clinical finding Right upper quadrant pain, variable severity, sudden onset, rigidity and rebound tenderness with peritonitis, nausea, vomiting, constipation, fever, slow pulse, Murphy sign; spontaneous remission is not uncommon.[medical-dictionary.thefreedictionary.com]
    • No history of similar kind of pain, no nausea, vomiting or fever.[sonoworld.com]
    Colic
    • Laboratory results are usually normal in patients with biliary colic.[aafp.org]
    • colic Laboratory studies in cases of cholelithiasis and gallbladder colic should be completely normal.[emedicine.medscape.com]
    • […] duct with cholecystitis Cholelithiasis with cholecystitis Cholecystitis with cholelithiasis NOS Any condition classifiable to 574.2 with cholecystitis (chronic) 574.2 Calculus of gallbladder without mention of cholecystitis [0-1] Biliary: calculus NOS colic[icd9.chrisendres.com]
    • The most common presentations are biliary colic (56%) and acute cholecystitis (36%) [ 1 ] .[patient.info]
    • The degree of obstruction and the duration of the obstruction determine the progression to acute cholecystitis partial and of short duration obstruction results in biliary colic prolonged, complete obstruction over many hours leads to acute cholecystitis[gpnotebook.co.uk]
    Abdominal Pain
    • Laboratory data: Eosinophilia Gallbladder Polyp 52 year old male with sharp right upper quadrant abdominal pain.[sonoworld.com]
    • Severe abdominal pain may need immediate treatment.[healthline.com]
    • Gallstones alone can cause episodes of crampy abdominal pain without any infection.[drugs.com]
    • Specialty General surgery , gastroenterology Symptoms Right upper abdominal pain , nausea, vomiting , fever [1] Duration Short term or long term [2] Causes Gallstones, severe illness [1] [3] Risk factors Birth control pills , pregnancy , family history[en.wikipedia.org]
    • On the other hand, abdominal pain and accompanying GB wall thickening can be seen in different clinical scenarios such as, pancreatitis, hepatitis, cirrhosis, and congestive heart failure.[clinicaltrials.gov]
    Severe Abdominal Pain
    • Diagnosing acute cholecystitis If you have severe abdominal pain, your GP will probably carry out a simple test called Murphy's sign.[nhs.uk]
    • Severe abdominal pain may need immediate treatment.[healthline.com]
    • When to Call a Professional Call your doctor if you have severe abdominal pain, fever and shaking chills, or jaundice.[drugs.com]
    • Symptoms of peritonitis include: a sudden and very severe abdominal pain vomiting chills a high temperature (fever) of 38C (100.4F) or above rapid heartbeat (tachycardia) feeling thirsty not passing any urine or passing much less urine than normal Peritonitis[hse.ie]
    • abdominal pain, more severely elevated white blood count. [13] Fistula formation and gallstone ileus [ edit ] The inflammation of cholecystitis can lead to adhesions between the gallbladder and other parts of the gastrointestinal tract , most commonly[en.wikipedia.org]
    Abdominal Tenderness
    • Length of symptoms, gender and the degree of abdominal tenderness were not different between the groups.[sages.org]
    • Residual abdominal tenderness may occur.[aafp.org]
    • Drain his gall-bladder if: (1) intense pain persists, (2) swinging fever continues with tachycardia, (3) his abdominal tenderness gets worse, the area of guarding extends, or the mass increases in size, or (4) he has rigors and deepening jaundice, indicating[meb.uni-bonn.de]
    • A diagnosis of Acute Cholecystitis would involve: Physical examination with evaluation of medical history; abdominal tenderness is felt on touch Investigations: Blood amylase and lipase tests Complete blood count may show a higher-than-normal white blood[dovemed.com]
    • Physical exam reveals an obese female with RUQ abdominal tenderness to palpation.[medbullets.com]
    Upper Abdominal Pain
    • Biliary colic is characterized by the sudden onset of intense right upper abdominal pain that may radiate to the shoulder.[aafp.org]
    • The most common presenting symptom of acute cholecystitis is upper abdominal pain.[emedicine.medscape.com]
    • The typical symptoms of cholangitis are fever, right upper abdominal pain, and jaundice.[drugs.com]
    • History The most common presenting symptom of acute cholecystitis is upper abdominal pain.[emedicine.medscape.com]
    • Specialty General surgery , gastroenterology Symptoms Right upper abdominal pain , nausea, vomiting , fever [1] Duration Short term or long term [2] Causes Gallstones, severe illness [1] [3] Risk factors Birth control pills , pregnancy , family history[en.wikipedia.org]
    Epigastric Pain
    • The most common cause is cystic duct obstruction by gallstone(s), and the initial symptom may be epigastric pain.[aafp.org]
    • Many patients present with diffuse epigastric pain without localization to the RUQ.[emedicine.medscape.com]
    • Symptoms include persistent epigastric pain radiating to the back which is relieved by leaning forwards and profuse vomiting.[patient.info]
    • The proportion of patients with right hypochondrial pain and epigastric pain combined is 72–93 %.[link.springer.com]
    Loss of Appetite
    • Hepatic Amebic Abscess 44 year old male patient, 10 days with high fever, pain in right hypochondrium, night sweats and loss of appetite.[sonoworld.com]
    • Some people may have additional symptoms, such as: a high temperature (fever) nausea and vomiting sweating loss of appetite yellowing of the skin and the whites of the eyes (jaundice) a bulge in the abdomen When to seek medical advice See your GP as soon[nhs.uk]
    • Other symptoms of acute cholecystitis include: a high temperature (fever), which is usually mild and no higher than 38C (100.4F) nausea (feeling sick) vomiting (being sick) loss of appetite jaundice, which causes yellowing of the skin and the whites of[hse.ie]
    Clay-Colored Stool
    • You may feel: Sharp, cramping, or dull pain Steady pain Pain that spreads to your back or below your right shoulder blade Other symptoms that may occur include: Clay-colored stools Fever Nausea and vomiting Yellowing of skin and whites of the eyes (jaundice[nlm.nih.gov]
    • Signs and symptoms of Acute Cholecystitis include: Fever Sharp cramping or dull pain over the right upper quadrant of the abdomen, which may sometimes spread to the back Nausea and vomiting Clay-colored stool Yellowing of the skin and eyes (jaundice)[dovemed.com]
    Abdominal Guarding
    • Abdominal guarding in response to deep palpation is common.[aafp.org]
    • Abdominal guarding is noted.[nursingcenter.com]
    • Abdominal examination in gallbladder colic and cholecystitis is remarkable for epigastric or right upper quadrant tenderness and abdominal guarding.[emedicine.medscape.com]
    Abdominal Distension
    • ., constipation and abdominal distension strongly suggest bowel obstruction), whereas others are of little value (i.e, anorexia has little predictive value for appendicitis).[medbullets.com]
    • When a gallstone gets trapped, it can lead to an intestinal obstruction , called gallstone ileus , leading to abdominal pain, vomiting, constipation , and abdominal distension . [13] Causes [ edit ] Cholecystitis occurs when the gallbladder becomes inflamed[en.wikipedia.org]
    Acute Abdomen
    • Review of literature The results of the systematic literature review performed for the EAES Consensus Conference about the laparoscopic approach to the acute abdomen, published in 2012 were entirely considered for this analysis; the literature search[wjes.biomedcentral.com]
    • Clinical presentation of acute abdomen: study of 600 patients.[link.springer.com]
    Tenderness in the Right Upper Quadrant
    • […] in the right upper quadrant, as well as one of the systemic signs of inflammation, such as fever, elevated white blood cell (WBC) count, and elevated C-reactive protein level, are diagnosed as having acute cholecystitis. [22] Imaging findings characteristic[emedicine.medscape.com]
    Fat Intolerance
    • Fat intolerance may develop in a small proportion of patients - and a low-fat diet is recommended.[patient.info]
    Epigastric Tenderness
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  • respiratoric
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  • Entire body system
    Fever
    • Nausea and vomiting are generally present, and patients may report fever.[emedicine.medscape.com]
    • No history of similar kind of pain, no nausea, vomiting or fever.[sonoworld.com]
    • As local inflammation becomes more intense, signs and symptoms of tenderness and a local mass can be complicated by systemic toxicity manifested by fever and leukocytosis.[aafp.org]
    • The presence of high fever and chills may indicate septic complications.[nursingcenter.com]
    • Signs of complications include high fever, shock and jaundice .[en.wikipedia.org]
    Chills
    • Symptoms include right upper quadrant pain and tenderness, sometimes accompanied by fever, chills, nausea, and vomiting.[merckmanuals.com]
    • When to Call a Professional Call your doctor if you have severe abdominal pain, fever and shaking chills, or jaundice.[drugs.com]
    • Other symptoms may include: Abdominal bloating Tenderness on the upper-right hand side of the abdomen Little or no appetite Nausea Vomiting Sweating A slight fever and chills may be present with acute cholecystitis.[medicalnewstoday.com]
    • If he has jaundice, swinging fever, chills and rigors, suspect that his cholecystitis is complicated by cholangitis.[meb.uni-bonn.de]
    • The presence of high fever and chills may indicate septic complications.[nursingcenter.com]
    Rigor
    • If he has jaundice, swinging fever, chills and rigors, suspect that his cholecystitis is complicated by cholangitis.[meb.uni-bonn.de]
    • In severe cases, symptoms can include pain in the RUQ, jaundice and high swinging fevers with rigors and chills (Charcot's triad).[patient.info]
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  • Liver, Gall & Pancreas
    Murphy's Sign
    • The sonographic Murphy's sign is an important finding in suspected acute cholecystitis.[ultrasoundtraining.com]
    • Murphy’s sign, acute cholecystitis and elderly people.[link.springer.com]
    • Evaluate for focal and maximum tenderness over the gallbladder (Murphy's sign) by applying pressure with the transducer in the right costal margin.[med-ed.virginia.edu]
    • Murphy sign and gallstones (without evidence of other pathology) are present.[emedicine.medscape.com]
    • Clinical finding Right upper quadrant pain, variable severity, sudden onset, rigidity and rebound tenderness with peritonitis, nausea, vomiting, constipation, fever, slow pulse, Murphy sign; spontaneous remission is not uncommon.[medical-dictionary.thefreedictionary.com]
    Biliary Colic
    • Laboratory results are usually normal in patients with biliary colic.[aafp.org]
    • Overview Biliary colic and cholecystitis are in the spectrum of biliary tract disease.[emedicine.medscape.com]
    • The most common presentations are biliary colic (56%) and acute cholecystitis (36%) [ 1 ] .[patient.info]
    • The patient's symptoms are those of biliary colic (13.2), but they last more than 24 hours.[meb.uni-bonn.de]
    Jaundice
    • Obstructive jaundice See the separate Jaundice article.[patient.info]
    • Mild jaundice does not always mean that his common duct is obstructed by a stone.[meb.uni-bonn.de]
    • The typical symptoms of cholangitis are fever, right upper abdominal pain, and jaundice.[drugs.com]
    • […] as possible if you develop sudden and severe abdominal pain, particularly if it lasts longer than a few hours or is accompanied by other symptoms, such as jaundice and a fever.[nhs.uk]
    • Signs of complications include high fever, shock and jaundice .[en.wikipedia.org]
    Gallbladder Enlargement
    • Other ultrasonographic findings may include gallbladder enlargement, gallbladder stones, debris echo and gas imaging (Fig. 1 ).[link.springer.com]
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  • 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.

    Laboratory

    Serum
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  • Imaging

    X-ray
    Nonvisualization of the Gallbladder
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  • ECG

    QT, RR, ST Intervals
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  • 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.

    Complications

    Acute Peritonitis
    • Antibiotics are generally withheld in straightforward, uncomplicated cases of acute cholecystitis, but they are ordered in cases of acute peritonitis or sepsis.[nursingcenter.com]
    Ileus
    • Gallstone ileus Gallstone ileus is caused by occlusion of the intestinal lumen as a result of one or more gallstones.[patient.info]
    • Complications include the following: [13] Gangrene Gallbladder rupture Empyema Fistula formation and gallstone ileus Rokitansky-Aschoff sinuses Gangrene and gallbladder rupture [ edit ] Cholecystitis causes the gallbladder to become distended and firm[en.wikipedia.org]
    • Subsequently, the stone may become impacted in the terminal ileum or in the duodenal bulb and/or pylorus, causing gallstone ileus.[emedicine.medscape.com]
    • When gallstones are passed directly through the fistula into the small bowel, if they are greater than 2.5 cm, they can obstruct the ileocecal valve, which causes gallstone ileus.[emedicine.medscape.com]
    • Failure of small bowel activity to progress over time may be indicative of ileus or downstream obstruction.[appliedradiology.com]
    Fever
    • Nausea and vomiting are generally present, and patients may report fever.[emedicine.medscape.com]
    • No history of similar kind of pain, no nausea, vomiting or fever.[sonoworld.com]
    • As local inflammation becomes more intense, signs and symptoms of tenderness and a local mass can be complicated by systemic toxicity manifested by fever and leukocytosis.[aafp.org]
    • The presence of high fever and chills may indicate septic complications.[nursingcenter.com]
    • Signs of complications include high fever, shock and jaundice .[en.wikipedia.org]
    Acute Pancreatitis
    • If you don't find a tense inflamed gall-bladder when you operate, look for acute pancreatitis (13.9), a liver abscess (31.12) or a localised perforation of a peptic ulcer (11.2) etc.[meb.uni-bonn.de]
    • Like cholangitis, acute pancreatitis can be serious.[drugs.com]
    • Pancreatitis See the separate Acute Pancreatitis and Chronic Pancreatitis articles.[patient.info]
    • pancreatitis, MI, acute appendicitis, renal colic, Fitz-Hugh-Curtis Syndrome, PUD, pneumonia Treatment IV antibiotics Fluids Electrolytes Perform early cholecystectomy (within 72 hours) if patient in good health with intra-operative cholangiogram to[medbullets.com]
    • ., Barakat, B. and Bartaccini, B. (1963) Electrocardiographic Abnormalities in Acute Pancreatitis.[dx.doi.org]
    Liver Abscess
    • If you don't find a tense inflamed gall-bladder when you operate, look for acute pancreatitis (13.9), a liver abscess (31.12) or a localised perforation of a peptic ulcer (11.2) etc.[meb.uni-bonn.de]
    • abscess For a more extensive differential, please refer to the article on differential diagnosis of diffuse gallbladder wall thickening . cholecystitis chronic cholecystitis acute acalculous cholecystitis Mirizzi syndrome xanthogranulomatous cholecystitis[radiopaedia.org]
    • These alternative diagnoses include but are not limited to: [14] Perforated peptic ulcer Acute pancreatitis Liver abscess Pneumonia Myocardial ischemia Hiatal hernia Biliary colic Choledocholithiasis Cholangitis Appendicitis Colitis Acute peptic ulcer[en.wikipedia.org]
    • Both benign and malignant liver lesions may manifest as areas of photopenia, such as liver abscesses that could be responsible for patient’s abdominal pain and fever or hepatocellular carcinoma.[appliedradiology.com]
    Jaundice
    • Obstructive jaundice See the separate Jaundice article.[patient.info]
    • Mild jaundice does not always mean that his common duct is obstructed by a stone.[meb.uni-bonn.de]
    • The typical symptoms of cholangitis are fever, right upper abdominal pain, and jaundice.[drugs.com]
    • […] as possible if you develop sudden and severe abdominal pain, particularly if it lasts longer than a few hours or is accompanied by other symptoms, such as jaundice and a fever.[nhs.uk]
    • Signs of complications include high fever, shock and jaundice .[en.wikipedia.org]
    Emphysematous Cholecystitis
    • Complications gangrenous cholecystitis (most common - 20%) 8 gallbladder perforation ( 5%) 8,9 emphysematous cholecystitis pericholecystic abscess cholecystoenteric fistula The differential diagnosis for acute cholecystitis is extensive and includes:[radiopaedia.org]
    • Perforation occurs in up to 15% of patients. [ 11 , 13] For more information, see the Medscape Drugs & Diseases article Emphysematous Cholecystitis .[emedicine.medscape.com]
    • Emphysematous cholecystitis , cholangitis, cholecystic-enteric fistula, or postendoscopic manipulation may show air in the biliary tree.[emedicine.medscape.com]

    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.

    Causes

    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.

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    References

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