DESCRIPTION 
Cholecystitis is defined as inflammation of the gallbladder.
ETIOLOGY
- Acute calculous cholecystitis:
- Owing to bile stasis secondary to prolonged obstruction by a gallstone (see "Cholelithiasis") in the gallbladder neck, cystic duct, or common bile duct
- Leads to increased intraluminal pressure and mucosal damage
- Release of inflammatory mediators results in distention, edema, and increased vascularity.
- Coliforms and anaerobes lead to infection—primary causal role is controversial.
- Acalculous cholecystitis:
- 10% of cases
- Underlying critical illness leads to biliary stasis and mucosal ischemia.
- Subsequent mucosal inflammation and infection
Pediatric Considerations
- Acute calculous cholecystitis extremely rare in childhood (see "Cholelithiasis")
- Acalculous cholecystitis more common than calculous form in children:
- Associated with systemic bacterial infections, scarlet fever, Kawasaki disease, and parasitic infections
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SIGNS AND SYMPTOMS
History
- Acute calculous cholecystitis:
- Dull, aching, epigastric, or right upper quadrant (RUQ) pain
- Radiation to tip of right scapula, acromion, or thoracic spine
- Duration > 6 hr more suggestive of cholecystitis than uncomplicated biliary colic
- As inflammation progresses, parietal peritoneal irritation leads to sharp, localized pain.
- Nausea, vomiting, fever, and chills often reported, but absent in most cases
- Jaundice in 20%
- History of prior attacks of biliary colic or known gallstones favors diagnosis.
- Acalculous cholecystitis:
- Occurs in critically ill patients (burns, sepsis, trauma, or postoperative)
- Localized pain and tenderness frequently absent
- Often presents with symptoms of generalized sepsis of unknown source
Physical Exam
- Localized parietal peritoneal signs:
- Percussion tenderness
- Rebound
- Found as the disease progresses
- Murphy sign:
- Inspiratory arrest with gentle palpation of RUQ owing to increased pain
- Found in most cases
ESSENTIAL WORKUP
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC:
- WBC > 12,000 cells/mm3 supports diagnosis, but may be normal in more than half of cases
- LFTs:
- Transaminases, bilirubin, amylase, and lipase may be minimally elevated, but are generally normal.
- Disproportionate elevation of direct bilirubin and alkaline phosphatase compared with transaminases suspicious for common duct obstruction or cholangitis
Imaging
- US:
- Generally the 1st-line imaging procedure
- Positive findings include gallbladder wall thickening (> 5 mm) or pericolic fluid—sensitivity, 90%; specificity, 80%.
- Optimal if patient NPO > 8 hr
- Radionuclide scanning (HIDA):
- Most useful when clinical suspicion remains high despite equivocal findings on US or when acalculous cholecystitis suspected
- Positive when tracer seen in small bowel but inflamed gallbladder fails to visualize
- Sensitivity, > 95%; specificity, 90%
- False-positive results increase in nonfasting state.
- Addition of IV morphine induces Sphincter of Oddi contraction which improves gallbladder filling and reduces false-positive scan results.
- CT scanning:
- Exclude intestinal perforation or obstruction
- Air in the gallbladder wall consistent with emphysematous cholecystitis
- Gallstones radiopaque in up to 20%
DIFFERENTIAL DIAGNOSIS
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PRE-HOSPITAL
Establish IV access for patients with vomiting or severe pain.
INITIAL STABILIZATION/THERAPY
- IV, oxygen, cardiac monitoring until myocardial ischemic cause excluded
- Initiate IV fluid therapy for dehydration, hemodynamic compromise, or sepsis.
ED TREATMENT/PROCEDURES
- Broad-spectrum antibiotics for coliforms, anaerobes, and enterococcus:
- Alternative antibiotics for penicillin allergic:
- NPO
- IV fluid replacement and maintenance
- Antiemetics (ondansetron) if vomiting
- Nasogastric (NG) suctioning if refractory vomiting or ileus
- Narcotic analgesics (hydromorphone) with antiemetic (ondansetron):
- Administer for refractory pain once diagnosis is reasonably established.
- Morphine sulfate may lead to spasm at sphincter of Oddi (clinical significance not well established).
- Anticholinergics (glycopyrrolate) of no proven benefit for acute biliary pain.
- Surgical consultation
MEDICATION
- Ampicillin/sulbactam: 3 g (peds: 200 mg/kg/24h) IV piggyback (IVPB) q6h
- Clindamycin: 600–900 mg (peds: 25–40 mg/kg/24h) IVPB q6–q8h
- Gentamicin: 1.5–2 mg/kg (peds: 6–7 mg/kg/24h) IVPB q8h; follow levels
- Levaquin: 500 mg IVPB q24h; contraindicated in peds
- Hydromorphone: 0.5–2 mg IV (0.01–0.02 mg/kg), titrated to pain relief.
- Metronidazole: 500 mg (peds: 30 mg/kg/24h) IVPB q6h
- Piperacillin/tazobactam: 3.375 mg (peds: 300 mg/kg/24h) IVPB q6h
- Ondansetron: 4–8 mg IV (peds: 0.15–0.3 mg/kg) IV (not to exceed 8 mg/dose IV), q4h PRN vomiting
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DISPOSITION
Admission Criteria
- All cases of cholecystitis should be admitted for parenteral antibiotics, analgesia, fluid replacement, and cholecystectomy in 24–72 hr.
- Unstable patients (gallbladder perforation or sepsis) require immediate surgery.
Discharge Criteria
None
Issues for Referral
General surgery consult for patients with cholecystitis. GI consult if choledocholisthiasis or cholangitis suspected.
FOLLOW-UP RECOMMENDATIONS
Inpatient admission for antibiotics and surgical evaluation.
[Outline]
- Barie PS, Eachempati SR. Acute acalculous cholecystitis. Gastroenterol Clin North Am. 2010;39:243–357.
- Silen W, ed. Cholecystitis and other causes of acute pain in the right upper quadrant of the abdomen. Cope's Early Diagnosis of the Acute Abdomen. 22nd ed. Oxford, UK: Oxford University Press; 2010:131–141.
- Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis. 2010;50:997; 133–164.
- Strasberg SM. Acute calculous cholecystitis. N Eng J Med. 2008;358:2804–2811.
- Yusuf TE, Baron TH, AIDS cholangiopathy. Curr Treat Options Gastroenterol. 2004;7:111–117.
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