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North Am. 201 0;28:103-1 18.

Acute Cholecystitis

Casey Glass, MD

Key Points

• Biliary co lic frequently presents with epigastric or right

upper quadrant pain that resolves in a few hours and is

not associated with fever or leukocytosis.

• Acute cholecystitis cannot be established or excluded

based on history and examination alone.

INTRODUCTION

Acute cholecystitis can be a challenging diagnosis because

the spectrum of disease ranges from biliary colic, a selflimited condition, to emphysematous cholecystitis or gallbladder perforation with sepsis. Additionally, no single

historical feature, exam finding, or test result is adequate to

exclude the disease in its early stages.

When a gallstone moves into the gallbladder neck, cystic

duct, or common bile duct, it causes obstruction. Obstruc ­

tion in turn causes an increase in luminal pressure in the

gallbladder or common bile duct. In biliary colic, the

obstruction is intermittent, and symptoms resolve when

the blockage is relieved. If obstruction is persistent, there is

a resulting increase in mucosal inflammation and irritation. Ultimately this leads to ischemia of the gallbladder

wall and bacterial invasion.

Biliary colic is pain due to transient gallbladder neck

blockage with a gallstone. Acute cholecystitis is inflarumation of the gallbladder due to persistent obstruction from

gallstones and is sometimes associated with infection.

Acalculous cholecystitis accounts for 2-1 5% of cases of

acute cholecystitis and occurs in the absence of gallstones.

Acalculous cholecystitis is believed to be secondary to gallbladder ischemia and is more common in diabetics, the

elderly, and the critically ill and carries a higher mortality

rate. Emphysematous cholecystitis is acute cholecystitis

1 2 1

• Antibiotics should be admin istered early in il l-appearing

patients when acute cholecystitis is suspected.

with superinfection by gas-forming bacteria and has a

more severe course and poorer prognosis. When gallstones

become lodged in the common bile duct, the condition is

referred to as choledocholithiasis. Choledocholithiasis is

associated with ascending cholangitis and pancreatitis.

Gallstones are present in 10--15% of the population in

the United States, but only 10--20% of persons with asymptomatic stones will develop complications over a 20-year

period, and only 1-3% will develop acute cholecystitis each

year. When patients do develop acute cholecystitis, the mortality rate is approximately 4%. The mortality rate for

emphysematous cholecystitis is approximately 20%.

CLINICAL PRESENTATION