cholecystitis

Introduction

Inflammation of the gall bladder.

Etiology

• obstruction of the cystic duct by gallstones (90%)
• can occur without gallstones in hospitalized patients (see acalculous cholecystitis)
• infection of gall bladder by gram negative bacteria.

Pathology

• peritoneal irritation

Clinical manifestations

• tenderness & intermittent epigastric pain or right upper quadrant pain referred to right shoulder or scapula
• rebound tenderness
• bowel sounds often absent or hypoactive when severe
• no peritoneal signs
• nausea/vomiting
• intolerance to dietary fat
  • may present as acute chest pain (non-positional) after eating (especially high-fat meal i.e. pizza)
• fever
• Murphy's sign
• average duration of cholecystitis without surgery is 7-10 days

Laboratory

• modest increased in serum transaminases
  • a marked increase in transaminases suggests another diagnosis
• marked increase in serum alkaline phosphatase
• marked increase in serum gamma-glutamyltransferase (serum GGT)
• increased prothrombin time (PT) suggests another diagnosis
• serum bilirubin > 4 mg/dL suggests cholangitis

Diagnostic procedures

• endoscopic retrograde cholangiopancreatography in patients with concomitant acute cholangitis

Radiology

• abdominal ultrasound (diagnostic)
  • thickened gall bladder wall
  • gas or stones in gall bladder
  • pericholecystic fluid
  • gall stones may be not be visualized with acalculous cholecystitis
  • common bile duct dilation suggests complication
• magnetic resonance cholangiopancreatography if common bile duct dilation & no stomes seen in common bile duct on abdominal ultrasound
• cholescintigraphy (HIDA scan)
  • visualization of the gall bladder & biliary tree
  • diagnosis of acute cholecystitis
  • slightly more accurate than ultrasound, but less available

Complications

• choledocholithiasis with common bile duct obstruction & cholangitis
  • dilated common bile duct on ultrasound (> 6 mm)
  • elevated serum bilirubin, serum AST, serum ALT & serum alkaline phosphatase
• pancreatitis
• ileus
• gallbladder empyema, perforation & peritonitis
• cholecystoenteric fistula
  • Mirizzi syndrome or Bouveret syndrome
• gallbladder cancer
• in patients who have undergone cholecystectomy, retained common bile duct stones may complicate the postoperative course

Differential diagnosis

• cholangitis
  • serum bilirubin > 4 mg/dL
• acute acalculous cholecystitis
  • occurs in critically ill, septic patients
  • right upper quadrant pain, Murphy's sign & fever may be absent

Management

• hospitalization
• intravenous fluids
• broad spectrum antibiotics
  • target gram-positive & gram-negative aerobic & facultative anaerobic bacteria (E. coli, Enterobacteriaceae, Streptococci)
  • Enterococcal coverage generally not needed, except in some immunocompromised patients, especially liver transplant patients
  • mild to moderate infections:
    • cefazolin, cefuroxime, ceftriaxone
    • anaerobic coverage not indicated
  • high risk (elderly, immunocompromised) or severe infection
    • combination of
      • metronidazole plus
      • beta-lactam/beta-lactamase inhibitor or 3rd generation cephalosporin
      • imipenem-cilastatin, meropenem, doripenem, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or cefepime
    • alternative regimen
      • aztreonam plus
      • metronidazole, plus
      • gram-positive cocci coverage
  • acute cholecystitis following bilio-enteric anastomosis
    • target gram-positive & gram-negative aerobic & facultative bacteria (E. coli, Enterobacteriaceae, Streptococci)
    • also requires anaerobic coverage (metronidazole)
    • combination of
      • metronidazole plus
      • imipenem-cilastatin, meropenem, doripenem, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or cefepime
  • older regimens
    • ampicillin plus aminoglycoside
    • cephalosporins
    • penicillinase-resistant penicillin
      • Unasyn (ampicillin sulbactam)
      • Zosyn (piperacillin tazobactam)
    • trovafloxacin (alatrovafloxacin, Trovan IV)
• nothing by mouth
• meperidine or pentazocine for analgesia
  • less spasm of the sphincter of Oddi than morphine (may not be true)
  • opiates not recommended
• cholecystectomy
  • within 24-48 hours of diagnosis during index hospitalization; within 72 hours
  • laparoscopic cholecystectomy is the procedure of choice
    • can be safely performed during pregnancy, epecially in the 2nd trimester
  • recurrence is inevitable without surgery
  • cholecystostomy tubes may be used in patients not improving or at unacceptably high risk for cholecystectomy
• patients with high surgical risk
  • aspiration of fluid visualized by ultrasound (1 time procedure
  • percutaneous cholecystostomy (ultrasound-guided catheter placement to allow fluid to drain for weeks to months)
• choice of cholecystectomy vs percutaneous cholecystotomy is not clear cut

More general terms

• gallbladder disease
• inflammation

More specific terms

• acalculous cholecystitis
• porcelain gallbladder

Additional terms

• cholelithiasis (gallstones)

Patient information

cholecystitispatient information