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% . 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.
Entire Body System
Acute cholecystitis refers to inflammation of the gallbladder and classically presents as a syndrome of right upper quadrant pain, fever, and leucocytosis. [aci.health.nsw.gov.au]
Associated complaints may include fever, nausea, vomiting, and anorexia. There is often a history of fatty food ingestion one hour or more before the initial onset of pain. [medical-institution.com]
Abdominal pain and fever continued after TAE, with CE-CT showing re-bleeding from the previous pseudoaneurysm. [ncbi.nlm.nih.gov]
Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med 1996; 28: 273. PMID: 8780469 Jain A et al. History, physical examination, laboratory testing and emergency department ultrasonography for the diagnosis of acute cholecystitis. [coreem.net]
The patient also experiences nausea, vomiting, and chills. In chronic cholecystitis the gallbladder often is contracted rather than swollen; its wall is grayish white, tough, and thickened. [britannica.com]
You may also develop indigestion and other digestive upset, nausea, vomiting, fever, chills, chest pain, dark urine, or clay-colored stools. [everydayhealth.com]
Increasingly severe pain, a high fever, and chills suggest pockets of pus (abscesses) in or a tear (perforation) in the gallbladder. Abscesses result from gangrene, which develops when tissue dies. [msdmanuals.com]
Increasing abdominal pain, high fever, and rigors with rebound tenderness or ileus suggest empyema (pus) in the gallbladder, gangrene, or perforation. [msdmanuals.com]
Cholangitis Suspect with significant elevation of bilirubin (total bilirubin >3), rigors, signs of sepsis. Can rapidly progress to shock and death. 2. Pancreatitis Epigastric pain through to the back. Nausea and vomiting. [clinicaladvisor.com]
In severe cases, symptoms can include pain in the RUQ, jaundice and high swinging fevers with rigors and chills (Charcot's triad). Obstructive jaundice See the separate Jaundice article. [patient.info]
- Abdominal Pain
Thus, abdominal pain in a patient with a previous history of breast carcinoma should raise suspicion of gallbladder metastasis. [ncbi.nlm.nih.gov]
Intermittent sever epigastric and RUQ pain; usually asssociated with nausea and vomiting. Tenderness over gall bladder during acute episodes. [armandoh.org]
[…] illness: A 46-year-old female with a history of an aortic arch repair secondary to invasive aspergillosis in addition to a known history of gallstones presented to the emergency department with two days of right upper quadrant pain, fever, nausea and vomiting [jetem.org]
Vomiting is common, as is right subcostal tenderness. [msdmanuals.com]
[…] of present illness: A 46-year-old female with a history of an aortic arch repair secondary to invasive aspergillosis in addition to a known history of gallstones presented to the emergency department with two days of right upper quadrant pain, fever, nausea [jetem.org]
The patient also experiences nausea, vomiting, and chills. In chronic cholecystitis the gallbladder often is contracted rather than swollen; its wall is grayish white, tough, and thickened. [britannica.com]
She experienced nausea and 6 bouts of vomiting in the last 2 days. [acupuncturereliefproject.org]
She had nausea with vomiting. On physical exam, she noted that she stops breathing on deep palpation of the right quadrant. Laboratory studies show an absolute neutrophillic leukocytosis with a left shift. [step2.medbullets.com]
[…] duct (CBD) or common hepatic duct compression) Acute Hepatitis Hepatic abscess Right lower lobe pneumonia Cholangitis Pancreatitis Pyelonephritis Presentation History Right upper quadrant (RUQ) pain History of similar, self-limited pain (biliary colic) Nausea [coreem.net]
- Upper Abdominal Pain
A 61-year-old man presented with upper abdominal pain and jaundice. [ncbi.nlm.nih.gov]
Symptoms include right upper abdominal pain, nausea, vomiting, and occasionally fever. Often gallbladder attacks (biliary colic) precede acute cholecystitis. The pain lasts longer in cholecystitis than in a typical gallbladder attack. [play.google.com]
- Acute Abdomen
Pregnant patients with acute abdomen should be evaluated with open mind. To the best of our knowledge, this is the first published report of the coexistence of 2 different causes of acute abdomen during pregnancy. [ncbi.nlm.nih.gov]
The second part of the article describes the most frequent causes of acute surgical abdomen: peritonitis, ileus, bleeding, acute mesenteric ischemia, cholecystitis, peptic ulcer perforation, acute pancreatitis, appendicitis and diverticulitis. [dlib.si]
Acute cholecystitis Acute cholecystitis is the fourth most common cause of hospital admissions for patients presenting with an acute abdomen , and it is the prime diagnostic concern when a thick-walled gallbladder is found at imaging. [radiologyassistant.nl]
Liver, Gall & Pancreas
- Biliary Colic
Gallstones can cause biliary colic, acute cholecystitis and chronic cholecystitis. [aci.health.nsw.gov.au]
Overview Biliary colic and cholecystitis are in the spectrum of biliary tract disease. [emedicine.medscape.com]
Laboratory results are usually normal in patients with biliary colic. [aafp.org]
Pyelonephritis Presentation History Right upper quadrant (RUQ) pain History of similar, self-limited pain (biliary colic) Nausea/Vomiting Radiation of pain to the tip of the right scapula (referred pain) Physical Examination RUQ/epigastric tenderness [coreem.net]
Between 1% and 4% of these adults become symptomatic in a year (the majority due to biliary colic but a significant proportion due to acute cholecystitis). [cochrane.org]
- Murphy's Sign
Murphy's sign was absent in 3 (10%) of 29 of these patients. A stepwise analysis failed to identify any combination of clinical variables that was associated with a higher probability of a positive HBS. [ncbi.nlm.nih.gov]
Diagnosis: — Murphy’s sign — Patients with acute cholecystitis frequently have a positive “ Murphy’s sign “. The sensitivity and specificity of a positive Murphy’s sign is 97 and 48 percent, respectively. [medical-institution.com]
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%. However, Murphy's sign may not be so sensitive in elderly patients. [symptoma.com]
Murphy sign and gallstones (without evidence of other pathology) are present. [emedicine.medscape.com]
Positive Murphy's sign is 97% sensitive and 48% specific. ECG to exclude cardiac ischaemia. Blood tests should include FBC, EUC, LFT, lipase (and blood cultures if febrile), beta-HCG in women of childbearing age. [aci.health.nsw.gov.au]
- Scleral Icterus
The presence of scleral icterus or frank jaundice makes the diagnosis of acute cholecystitis unlikely. Importantly, approximately 90% of patients with gallstones are asymptomatic. [clinicaladvisor.com]
It results in jaundice, which can be detected by scleral icterus at a concentration as low as 2 mg/dL, and by dark urine. [emedicine.medscape.com]
- Gallbladder Enlargement
Other ultrasonographic findings may include gallbladder enlargement, gallbladder stones, debris echo and gas imaging (Fig. 1 ). Fig. 1 US images of acute cholecystitis. [link.springer.com]
- Chest Pain
A 39-year-old man referred with chest pain and cold sweating and scheduled for coronary artery bypass grafting (CABG) because of severe stenosis in right coronary artery, aneurysm of left circumflex artery, and long-segment muscle bridge in the middle [ncbi.nlm.nih.gov]
She describes mild upper abdominal discomfort but is unable to further localize the pain. There have been no abnormal bowel movements, gastrointestinal bleeding, or chest pain. The patient is febrile (39°C) and appears uncomfortable. [jamaevidence.mhmedical.com]
At treatment 7, the patient experienced a total of 90% reduction in abdominal and scapula pain, with complete resolution of chest pain. [acupuncturereliefproject.org]
Annals of Internal Medicine, 116, 218-220. http://dx.doi.org/10.7326/0003-4819-116-3-218 [ 2 ] Nasir Javed, M., During, S.J., Sweet, J.M. and Cation Lannine, J. (2006) Chest Pain and ST Segment Elevation Attributable to Cholecystitis: A Case Report. [dx.doi.org]
She sat there on her chair going through the computer screen checking the store inventory and all of a sudden she had a pain in her chest. Well, she thought it was a chest pain. [symptomsdiagnosisbook.com]
- Right Shoulder Pain
It is the primary complication of cholelithiasis and the most common cause of acute pain in the right upper quadrant (RUQ). Constant right upper quadrant pain that can radiate to the right shoulder. [radiopaedia.org]
[…] in the upper-right side of the abdomen Pain that radiates towards the right shoulder Pain when taking deep breaths Abdominal pain that is persistent Jaundice Fever Diagnosis of Acute Cholecystitis Before diagnosing acute cholecystitis, your doctor will [marinahospital.com]
Nausea is common and vomiting occurs in 75% of people with cholecystitis. In addition to abdominal pain, right shoulder pain can be present. On physical examination, fever is common. A gallbladder with cholecystitis is almost always tender [en.wikipedia.org]
- Back Pain
Patients typically complain of abdominal pain, most commonly in the right upper quadrant or epigastrium. The pain may radiate to the right shoulder (referred phrenic nerve pain) or back. Pain is typically steady and severe. [medical-institution.com]
pain Liver: hepatomegaly Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection Left low back pain Spleen Kidney: kidney stone (nephrolithiasis), complicated urinary tract infection Low back pain kidney pain (kidney stone, kidney [en.wikipedia.org]
The back pain is moderate upon moderate palpation around the scapula region. Vital signs at first visit were slightly elevated. [acupuncturereliefproject.org]
Pancreatitis Epigastric pain through to the back. Nausea and vomiting. Amylase/lipase levels should be elevated. 3. Peptic ulcer disease Epigastric pain radiating to the back. Pain relieved with eating but then recurs. [clinicaladvisor.com]
Gallstones can cause some very unpleasant symptoms, including abdominal and back pain, fever, chills, nausea, digestive upset, and vomiting. [everydayhealth.com]
- Kidney Failure
Some chronic medical conditions, like kidney failure, coronary heart disease, or certain types of cancer also increase the risk of cholecystitis. [medicalnewstoday.com]
Systemic Diseases Systemic diseases, such as liver dysfunction, heart failure, or kidney failure, may lead to diffuse gallbladder thickening [ 1, 2 ]. [doi.org]
or kidney failure. Chronic hepatitis Acute cases of hepatitis are seen to be resolved well within a six-month period. [en.wikipedia.org]
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 .
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.
- Nonvisualization of the Gallbladder
A positive HBI was one in which there was nonvisualization of the gallbladder up to four hours after the administration of technetium Tc 99m-disofenin. [ncbi.nlm.nih.gov]
A positive HBI was one in which there was nonvisualization of the gallbladder up to four hours after the administration of technetium Tc 99m—disofenin. [doi.org]
Nonvisualization of the gallbladder (within 4 hr) is diagnostic of cystic duct occlusion. (See Figure 2 .) A CCK-HIDA has also been used as a diagnostic test gallbladder and biliary dyskinesia. [clinicaladvisor.com]
Radionuclide hepatobiliary imaging: Nonvisualization of the gallbladder secondary to prolonged fasting. J Nucl Med. 1982;23:1003-1005. Down RH, Arnold J, Goldin A, et al. [appliedradiology.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]
Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation that is usually related to gallstone disease. [medical-institution.com]
Laboratory studies demonstrated leukocytosis with normal liver function tests. A CT of the abdomen was remarkable for a large fluid collection in the right abdomen and no discernible gallbladder in the gallbladder fossa. [ncbi.nlm.nih.gov]
Laboratory studies show an absolute neutrophillic leukocytosis with a left shift. [medbullets.com]
The diagnostic criteria and treatment guidelines for acute cholecystitis has been established in detail in the "Tokyo guidelines" which was published in 2007 . 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 . The diagnosis is confirmed by findings on imaging studies .
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.
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 .
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.
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 . 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 .
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.
Up to 10% of all cases of abdominal pain are caused by acute cholecystitis   . Studies have shown that the incidence of acute cholecystitis is higher in those above the age of 50 .
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.
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.
Acute cholecystitis is the inflammation of the gallbladder. It often develops secondary to obstruction of the gallbladder and cystic duct by gallstones . 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.
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.
- Strasberg SM. Clinical practice. Acute calculous cholecystitis. N Engl J Med. 2008 Jun 26. 358(26):2804-11.
- 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.
- Yeatman TJ. Emphysematous cholecystitis: an insidious variant of acute cholecystitis. Am J Emerg Med. 1986 Mar. 4(2):163-6.
- Montini M, Gianola D, Pagani MD, et al. Cholelithiasis and acromegaly: therapeutic strategies. Clin Endocrinol (Oxf). 1994 Mar. 40(3):401-6.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.