ACUTE CHOLECYSTITIS

ACUTE CHOLECYSTITIS

ACUTE CHOLECYSTITIS

Acute cholecystitis is inflammation of the gallbladder.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 2–4 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 may be caused by infectious agents (eg, cytomegalovirus, cryptosporidiosis, microsporidiosis) in patients with AIDS or by vasculitis (eg, polyarteritis nodosa, Henoch-Schönlein purpura).

Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. The cystic duct is the main opening of the gallbladder.

The gallbladder is a small pear-shaped organ that stores and concentrates bile used for digestion of fats. Bile is a compound composed mainly of cholesterol, bile salts and bilirubin, produced by the liver and stored in the gallbladder during fasting states. When food is consumed, it is partially digested by the stomach and enters the small intestine, where bile is released by the gallbladder to aid in the breakdown of fats. Gallstones develop when the components of bile, such as cholesterol and bilirubin, remain in the gallbladder and solidify into “pebble-like” material. Gallstones may lodge in the bile ducts and block the release of bile causing a backup. 

Signs and symptoms

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 12–18 hours.

Vomiting occurs in about 75% of patients and in half of instances affords variable relief.

Fever is typical.

Right upper quadrant abdominal tenderness (often with a 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.

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.

Diagnosis

The white blood cell count is usually high (12,000–15,000/mcL [12–15 ×109/L]). Total serum bilirubin values of 1–4 mg/dL (17.1–68.4 mcmol/L) may be seen even in the absence of bile duct obstruction. Serum aminotransferase and alkaline phosphatase levels are often elevated—the former as high as 300 units/mL, and even higher when associated with acute cholangitis. Serum amylase may also be moderately elevated.

Plain films of the abdomen may show radiopaque gallstones in 15% of cases. 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 (85.5 mcmol/L) (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 ultrasonography, which is often performed first, may show gallstones but is not as sensitive for acute cholecystitis (67% sensitivity, 82% specificity); findings suggestive of acute cholecystitis are gallbladder wall thick­ening, pericholecystic fluid, and a sonographic Murphy sign. CT may show complications of acute cholecystitis, such as perforation or gangrene.

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 myocardial ischemia. Definite localization of pain and tenderness in the right upper quadrant, with radiation around to the infrascapular area, strongly favors the diag­nosis of acute cholecystitis. True cholecystitis without stones suggests acalculous cholecystitis.

Treatment

Acute cholecystitis usually subsides on a conservative regimen, including withholding oral feedings, intrave­nous alimentation, analgesics, and intravenous antibiotics (generally a second- or third-generation cephalosporin such as ceftriaxone 1 g intravenously every 24 hours, with the addition of metronidazole, 500 mg intravenously every 6 hours), although the need for antibiotics has been questioned in patients undergoing immediate cholecystectomy.

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 20% by 1 year), cholecystectomy—generally laparoscopically—should be performed within 24 hours of admission to the hospital for acute cholecystitis. Compared with delayed surgery, surgery within 24 hours is associated with a shorter length of stay, lower costs, and greater patient satisfaction. 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 or EUS-guided cholecystostomy, or endo­scopic insertion of a stent or nasobiliary drain 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 MRCP or ERCP.

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