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cholecystitis

Inflammation of the gall bladder [1]. Etiology: 1) obstruction of the cystic duct by gallstones (90%) [4] 2) can occur without gallstones in hospitalized patients [2] (see acalculous cholecystitis) 3) infection of gall bladder by gram negative bacteria. Pathology: - peritoneal irritation Clinical manifestations: 1) tenderness & intermittent epigastric pain or right upper quadrant pain referred to right shoulder or scapula 2) rebound tenderness 3) bowel sounds often absent or hypoactive when severe 4) no peritoneal signs 4) nausea/vomiting 5) intolerance to dietary fat - may present as acute chest pain (non-positional) after eating (especially high-fat meal i.e. pizza) [17] 6) fever 7) Murphy's sign 8) average duration of cholecystitis without surgery is 7-10 days Laboratory: 1) modest increased in serum transaminases - a marked increase in transaminases suggests another diagnosis 2) marked increase in serum alkaline phosphatase 3) marked increase in serum gamma-glutamyltransferase (serum GGT) 4) increased prothrombin time (PT) suggests another diagnosis 5) serum bilirubin > 4 mg/dL suggests cholangitis Special laboratory: - endoscopic retrograde cholangiopancreatography in patients with concomitant acute cholangitis [14] Radiology: 1) abdominal ultrasound (diagnostic) [4] a) thickened gall bladder wall b) gas or stones in gall bladder c) pericholecystic fluid d) gall stones may be not be visualized with acalculous cholecystitis e) common bile duct dilation suggests complication 2) magnetic resonance cholangiopancreatography if common bile duct dilation & no stomes seen in common bile duct on abdominal ultrasound [22] 3) cholescintigraphy (HIDA scan) a) visualization of the gall bladder & biliary tree b) diagnosis of acute cholecystitis c) slightly more accurate than ultrasound, but less available [11] Complications: 1) choledocholithiasis with common bile duct obstruction & cholangitis a) dilated common bile duct on ultrasound (> 6 mm) [19] b) elevated serum bilirubin, serum AST, serum ALT & serum alkaline phosphatase 2) pancreatitis 3) ileus 4) gallbladder empyema, perforation & peritonitis 5) cholecystoenteric fistula - Mirizzi syndrome or Bouveret syndrome 6) gallbladder cancer 7) in patients who have undergone cholecystectomy, retained common bile duct stones may complicate the postoperative course Differential diagnosis: - cholangitis - serum bilirubin > 4 mg/dL - acute acalculous cholecystitis a) occurs in critically ill, septic patients b) right upper quadrant pain, Murphy's sign & fever may be absent [4] Management: 1) hospitalization 2) intravenous fluids 3) broad spectrum antibiotics a) target gram-positive & gram-negative aerobic & facultative anaerobic bacteria (E. coli, Enterobacteriaceae, Streptococci) b) Enterococcal coverage generally not needed, except in some immunocompromised patients, especially liver transplant patients [10] c) mild to moderate infections: 1] cefazolin, cefuroxime, ceftriaxone 2] anaerobic coverage not indicated d) high risk (elderly, immunocompromised) or severe infection 1] combination of a] metronidazole plus b] beta-lactam/beta-lactamase inhibitor or 3rd generation cephalosporin [4] c] imipenem-cilastatin, meropenem, doripenem, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or cefepime 2] alternative regimen a] aztreonam plus b] metronidazole, plus c] gram-positive cocci coverage e) acute cholecystitis following bilio-enteric anastomosis 1] target gram-positive & gram-negative aerobic & facultative bacteria (E. coli, Enterobacteriaceae, Streptococci) 2] also requires anaerobic coverage (metronidazole) 3] combination of a] metronidazole plus b] imipenem-cilastatin, meropenem, doripenem, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or cefepime f) older regimens 1] ampicillin plus aminoglycoside 2] cephalosporins 3] penicillinase-resistant penicillin a] Unasyn (ampicillin sulbactam) b] Zosyn (piperacillin tazobactam) 4] trovafloxacin (alatrovafloxacin, Trovan IV) 4) nothing by mouth 5) meperidine or pentazocine for analgesia - less spasm of the sphincter of Oddi than morphine (may not be true) - opiates not recommended [18] 6) cholecystectomy a) within 24-48 hours of diagnosis during index hospitalization [4,8,12]; within 72 hours [14] b) laparoscopic cholecystectomy is the procedure of choice [4] - can be safely performed during pregnancy, epecially in the 2nd trimester [4] c) recurrence is inevitable without surgery d) cholecystostomy tubes may be used in patients not improving or at unacceptably high risk for cholecystectomy [4] 7) patients with high surgical risk [7] a) aspiration of fluid visualized by ultrasound (1 time procedure b) percutaneous cholecystostomy (ultrasound-guided catheter placement to allow fluid to drain for weeks to months) [20] 8) choice of cholecystectomy vs percutaneous cholecystotomy is not clear cut [10]

Interactions

disease interactions

Related

cholelithiasis (gallstones)

Specific

acalculous cholecystitis porcelain gallbladder

General

gallbladder disease inflammation

References

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  2. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 363
  3. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 873
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 376-78
  6. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1730-1733
  7. Journal Watch 21(10):82, 2001 Chopra et al AJR Am J Roentgenol 176:1025, 2001
  8. Journal Watch 24(4):31, 2004 Papi C et al, Am J Gastroenterol 99:147, 2004 PMID: 14687156 http://www.blackwell-synergy.com/links/doi/10.1046/j.1572-0241.2003.04002.x/full/
  9. Prescriber's Letter 17(3): 2010 CHART: Antibiotics for Complicated Intra-Abdominal Infections GUIDELINES: Diagnosis and Management of Complicated Intra- abdominal Infections Detail-Document#: 260321 (subscription needed) http://www.prescribersletter.com
  10. Abi-Haidar Y et al. Revisiting percutaneous cholecystostomy for acute cholecystitis based on a 10-year experience. Arch Surg 2012 May; 147:416. PMID: 22785633 http://archsurg.jamanetwork.com/article.aspx?doi=10.1001/archsurg.2012.135
  11. Kiewiet JJS et al. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology 2012 Sep; 264:708 PMID: 22798223
  12. Gutt CN et al. Acute cholecystitis: Early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg 2013 Sep; 258:385 PMID: 24022431 - de Mestral C et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: A population-based propensity score analysis. Ann Surg 2014 Jan; 259:10. PMID: 23979286
  13. Baron TH, Grimm IS, Swanstrom LL. Interventional Approaches to Gallbladder Disease. N Engl J Med 2015; 373:357-365. July 23, 2015 PMID: 26200981 http://www.nejm.org/doi/full/10.1056/NEJMra1411372
  14. NEJM. Knowledge+. Question of the Week. March 14, 2017 https://knowledgeplus.nejm.org/question-of-week/472/
  15. Strasberg SM Acute Calculous Cholecystitis N Engl J Med 2008; 358:2804-2811. June 26, 2008 PMID: 18579815 http://www.nejm.org/doi/full/10.1056/NEJMcp0800929
  16. Yamashita Y, Takada T, Kawarada Y et al Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14(1):91-7. PMID: 17252302 Free PMC Article
  17. Drachman DE, Dudzinski DM, Moy MP Case 27-2017 - A 32-Year-Old Man with Acute Chest Pain. N Engl J Med 2017; 377:874-882. August 31, 2017 PMID: 28854089 http://www.nejm.org/doi/full/10.1056/NEJMcpc1706111
  18. Shalkow J Fast Five Quiz: Test Your Knowledge of Gallstones Medscape. June 12, 2018 https://reference.medscape.com/viewarticle/897845
  19. Chisholm PR, Patel AH, Law RJ et al Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis. Gastrointest Endosc. 2019 May;89(5):977-983.e2. PMID: 30465770
  20. Teoh AYB, Leung CH, Tam TH et al. EUS-guided gallbladder drainage versus laparoscopic cholecystectomy for acute cholecystitis: A propensity score analysis with 1-year follow-up data. Gastrointest Endosc 2020 Jun 29;S0016-5107(20)34532-6 PMID: 32615177 https://www.giejournal.org/article/S0016-5107(20)34532-6/pdf
  21. Gallaher JR, Charles A Acute Cholecystitis. A Review. JAMA. 2022;327(10):965-975. March 8 PMID: 35258527 https://jamanetwork.com/journals/jama/fullarticle/2789654
  22. NEJM Knowledge+ Gastroenterology