Acute inflammation of the gallbladder is usually caused by cystic duct obstruction by an impacted stone. Inflammatory response is evoked by (1) mechanical inflammation from increased intraluminal pressure; (2) chemical inflammation from release of lysolecithin; (3) bacterial inflammation, which plays a role in 50-85% of pts with acute cholecystitis.
Approximately 90% calculous; 5-10% acalculous. Acalculous cholecystitis is associated with higher complication rate and acute illness (i.e., burns, trauma, major surgery), fasting, hyperalimentation leading to gallbladder stasis, vasculitis, carcinoma of gallbladder or CBD, some gallbladder infections (Leptospira, Streptococcus, Salmonella, or Vibrio cholerae), but in >50% of cases an underlying explanation is not found.
(1) Biliary colic (RUQ or epigastric pain) that progressively worsens; (2) nausea, vomiting, anorexia; and (3) fever. Examination typically reveals RUQ tenderness; palpable RUQ mass found in 20% of pts. Murphy's sign is present when deep inspiration or cough during palpation of the RUQ produces increased pain or inspiratory arrest.
Mild leukocytosis; serum bilirubin, alkaline phosphatase, and aspartate aminotransferase (AST) may be mildly elevated.
Ultrasonography is useful for demonstrating gallstones and signs of gallbladder inflammation. Radionuclide scans (HIDA, DIDA, DISIDA, etc.) may identify cystic duct obstruction.
Includes acute pancreatitis, appendicitis, pyelonephritis, PUD, hepatitis, and hepatic abscess.
Empyema, hydrops, gangrene, perforation, fistula formation, gallstone ileus, porcelain gallbladder.
| TREATMENT | ||
Acute CholecystitisNo oral intake, nasogastric suction, IV fluids and electrolytes, analgesia (meperidine or NSAIDs), and antibiotics guided by the most common gram-negative organisms and anaerobes (piperacillin+tazobactam, ceftriaxone+metronidazole, levofloxacin+metronidazole); anaerobic coverage should be added if gangrenous or emphysematous cholecystitis is suspected; imipenem/meropenem covers the spectrum of bacteria causing ascending cholangitis but should be reserved for the most life-threatening infections when other antibiotics have failed. Optimal timing of surgery depends on pt stabilization and pts with acute uncomplicated cholecystitis should undergo laparoscopic cholecystectomy ideally within 48-72 hours of diagnosis. Urgent cholecystectomy is appropriate in most pts with a suspected or confirmed complication. Delayed surgery is reserved for pts with high risk of emergent surgery and where the diagnosis is in doubt. |