Acute Cholecystitis Essentials of Diagnosis Steady, severe pain and tenderness in the right hypochondrium or epigastrium.

. Nausea and vomiting. Fever and leukocytosis. General Considerations Cholecystitis is associated with gallstones in over 90% of cases. It occurs when a stone becomes impacted in the cystic duct and inflammation develops behind the obstruction. Acalculous cholecystitis should be considered when unexplained fever or right upper quadrant pain occurs within 24 weeks of major surgery or in a critically ill patient who has had no oral intake for a prolonged period; multiorgan failure is often present. Acute cholecystitis caused by infectious agents (eg, cytomegalovirus, cryptosporidiosis, or microsporidiosis) may occur in patients with AIDS. Clinical Findings Symptoms and Signs The acute attack is often precipitated by a large or fatty meal and is characterized by the sudden appearance of steady pain localized to the epigastrium or right hypochondrium, which may gradually subside over a period of 1218 hours. Vomiting occurs in about 75% of patients and in half of instances affords variable relief. Right upper quadrant abdominal tenderness (often with Murphy sign, or inhibition of inspiration by pain on palpation of the right upper quadrant) is almost always present and is usually associated with muscle guarding and rebound tenderness (Table 167). A palpable gallbladder is present in about 15% of cases. Jaundice is present in about 25% of cases and, when persistent or severe, suggests the possibility of choledocholithiasis. Fever is typical. Laboratory Findings The white blood cell count is usually high (12,00015,000/mcL). Total serum bilirubin values of 14 mg/dL may be seen even in the absence of bile duct obstruction. Serum aminotransferase and alkaline phosphatase are often elevatedthe former as high as 300 units/mL, or even higher when associated with ascending cholangitis. Serum amylase may also be moderately elevated. Imaging Plain films of the abdomen may show radiopaque gallstones in 15% of cases (see x-ray). 99mTc hepatobiliary imaging (using iminodiacetic acid compounds), also known as the hepatic iminodiacetic acid (HIDA) scan, is useful in demonstrating an obstructed cystic duct, which is the cause of acute cholecystitis in most patients. This test is reliable if the bilirubin is under 5 mg/dL (98% sensitivity and 81% specificity for acute cholecystitis). False-positive results can occur with prolonged fasting, liver disease, and chronic cholecystitis, and the specificity can be improved by intravenous administration of morphine, which induces spasm of the sphincter of Oddi. Right upper quadrant abdominal ultrasound, which is often performed first, may show the presence of gallstones (see ultrasound) but is not as sensitive for acute cholecystitis (67% sensitivity, 82% specificity); findings suggestive of acute cholecystitis are gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign. Differential Diagnosis The disorders most likely to be confused with acute cholecystitis are perforated peptic ulcer, acute pancreatitis, appendicitis in a high-lying appendix, perforated colonic carcinoma or diverticulum of the hepatic flexure, liver abscess, hepatitis, pneumonia with pleurisy on the right side, and even myocardial ischemia. Definite localization of pain and tenderness in the right hypochondrium, with radiation around to the infrascapular area, strongly favors the diagnosis of acute cholecystitis. True cholecystitis without stones suggests the rare possibility of polyarteritis nodosa affecting the cystic artery. Complications Gangrene of the Gallbladder

Continuation or progression of right upper quadrant abdominal pain, tenderness, muscle guarding, fever, and leukocytosis after 2448 hours suggests severe inflammation and possible gangrene of the gallbladder, resulting from ischemia due to splanchnic vasoconstriction and intravascular coagulation. Necrosis may occasionally develop without definite signs in the obese, diabetic, elderly, or immunosuppressed patient. Gangrene may lead to gallbladder perforation, usually with formation of a pericholecystic abscess and rarely to generalized peritonitis. Other serious acute complications include emphysematous cholecystitis (secondary infection with a gas-forming organism) and empyema. Chronic Cholecystitis and Other Complications Chronic cholecystitis results from repeated episodes of acute cholecystitis or chronic irritation of the gallbladder wall by stones and is characterized pathologically by varying degrees of chronic inflammation of the gallbladder. Calculi are usually present. In about 45% of cases, the villi of the gallbladder undergo polypoid enlargement due to deposition of cholesterol that may be visible to the naked eye ("strawberry gallbladder," cholesterolosis). In other instances, hyperplasia of all or part of the gallbladder wall may be so marked as to give the appearance of a myoma (adenomyomatosis). Hydrops of the gallbladder results when acute cholecystitis subsides but cystic duct obstruction persists, producing distention of the gallbladder with a clear mucoid fluid. Occasionally, a stone in the neck of the gallbladder may compress the bile duct and cause jaundice (Mirizzi syndrome). Xanthogranulomatous cholecystitis is a rare variant of chronic cholecystitis characterized by grayishyellow nodules or streaks, representing lipid-laden macrophages, in the wall of the gallbladder. Cholelithiasis with chronic cholecystitis may be associated with acute exacerbations of gallbladder inflammation, bile duct stone, fistulization to the bowel, pancreatitis and, rarely, carcinoma of the gallbladder. Calcified (porcelain) gallbladder has generally been thought to have a high association with gallbladder carcinoma and to be an indication for cholecystectomy, although the risk of gallbladder cancer may be higher when calcification is mucosal rather than intramural. Treatment Acute cholecystitis will usually subside on a conservative regimen (withholding of oral feedings, intravenous alimentation, analgesics, and intravenous antibioticsgenerally a second- or thirdgeneration cephalosporin such as cefoperazone, 1-2 g intravenously every 12 hours, with the addition of metronidazole, 500 mg intravenously every 6 hours); in severe cases, a fluoroquinolone such as ciprofloxacin, 250 mg intravenously every 12 hours, plus metronidazole may be given Morphine or meperidine may be administered for pain. Because of the high risk of recurrent attacks (up to 10% by 1 month and over 30% by 1 year), cholecystectomygenerally laparoscopicallyshould generally be performed within 24 days after hospitalization. If nonsurgical treatment has been elected, the patient (especially if diabetic or elderly) should be watched carefully for recurrent symptoms, evidence of gangrene of the gallbladder, or cholangitis. In high-risk patients, ultrasound-guided aspiration of the gallbladder, if feasible, percutaneous cholecystostomy, or endoscopic insertion of a stent into the gallbladder may postpone or even avoid the need for surgery. Immediate cholecystectomy is mandatory when there is evidence of gangrene or perforation. Surgical treatment of chronic cholecystitis is the same as for acute cholecystitis. If indicated, cholangiography can be performed during laparoscopic cholecystectomy. Choledocholithiasis can also be excluded by either preoperative or postoperative ERCP or MRCP. Prognosis The overall mortality rate of cholecystectomy is < 0.2%, but hepatobiliary tract surgery is a more formidable procedure in the elderly, in whom mortality rates are higher. A technically successful surgical procedure in an appropriately selected patient is generally followed by complete resolution of symptoms. When to Admit All patients with acute cholecystitis should be hospitalized.