Cholecystitis

Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation, which is usually related to gallstone disease (i.e., acute calculous cholecystitis). Complications include the development of gangrene and gallbladder perforation, which can be life threatening.

Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Uncomplicated cholecystitis has an excellent prognosis; the development of complications such as perforation or gangrene renders the prognosis less favorable.

Signs and symptoms

The most common presenting symptom of acute cholecystitis is upper abdominal pain.

The following characteristics may be reported:

• Signs of peritoneal irritation may be present, and the pain may radiate to the right shoulder or scapula
• Pain frequently begins in the epigastric region and then localizes to the right upper quadrant (RUQ)
• Pain may initially be colicky but almost always becomes constant
• Nausea and vomiting are generally present, and fever may be noted
• Patients with acalculous cholecystitis may present with fever and sepsis alone, without history or physical examination findings consistent with acute cholecystitis.

Cholecystitis may present differently in special populations, as follows:

• Elderly (especially diabetics) - May present with vague symptoms and without many key historical and physical findings (e.g., pain and fever), with localized tenderness the only presenting sign; may progress to complicated cholecystitis rapidly and without warning
• Children - May present without many of the classic findings; those at higher risk for cholecystitis include those who have sickle cell disease, serious illness, a requirement for prolonged total parenteral nutrition (TPN), hemolytic conditions, or congenital and biliary anomalies

The physical examination may reveal the following:

• Fever, tachycardia, and tenderness in the RUQ or epigastric region, often with guarding or rebound
• Palpable gallbladder or fullness of the RUQ (30-40 percent of patients)
• Jaundice (~15 percent of patients)
• The absence of physical findings does not rule out the diagnosis of cholecystitis.

Diagnosis

Laboratory tests are not always reliable, but the following findings may be diagnostically useful:

• Leukocytosis with a left shift may be observed
• Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels may be elevated in cholecystitis or with common bile duct (CBD) obstruction
• Bilirubin and alkaline phosphatase assays may reveal evidence of CBD obstruction
• Amylase/lipase assays are used to assess for pancreatitis; amylase may also be mildly elevated in cholecystitis
• Alkaline phosphatase level may be elevated (25 percent of patients with cholecystitis)
• Urinalysis is used to rule out pyelonephritis and renal calculi
• All females of childbearing age should undergo pregnancy testing

Diagnostic imaging modalities that may be considered include the following:

• Radiography
• Ultrasonography
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)

The American College of Radiology (ACR) makes the following imaging recommendations:

• Ultrasonography is the preferred initial imaging test for the diagnosis of acute cholecystitis; scintigraphy is the preferred alternative
• CT is a secondary imaging test that can identify extrabiliary disorders and complications of acute cholecystitis
• CT with intravenous (IV) contrast is useful in diagnosing acute cholecystitis in patients with nonspecific abdominal pain
• MRI, often with IV gadolinium-based contrast medium, is also a possible secondary choice for confirming a diagnosis of acute cholecystitis
• MRI without contrast is useful for eliminating radiation exposure in pregnant women when ultrasonography has not yielded a clear diagnosis
• Contrast agents should not be used in patients on dialysis unless absolutely necessary

Treatment

Once a patient develops symptoms or complications related to gallstones (biliary colic, acute cholecystitis, cholangitis, and/or pancreatitis), definitive therapy (cholecystectomy, cholecystostomy, endoscopic sphincterotomy, medical gallstone dissolution) is recommended. Without treatment to eliminate the gallstones, the likelihood of subsequent symptoms or complications is high. Complications include the development of gangrene and gallbladder perforation, which can be life threatening

Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications.

For acute cholecystitis, initial treatment includes bowel rest, IV hydration, and correction of electrolyte abnormalities, analgesia, and IV antibiotics.

Patients with acute cholecystitis should be admitted to the hospital for supportive care, which includes intravenous fluid therapy, correction of electrolyte disorders, and control of pain.

Antibiotics may also be indicated.

• The selection and timing of definitive therapy depends upon the severity of symptoms and the patient's overall risk for cholecystectomy.
• If gangrene or perforation are suspected, or if the patient develops progressive symptoms and signs such as fever, hemodynamic instability, or intractable pain while on supportive therapy, emergency cholecystectomy or gallbladder drainage may be needed.
• Low-risk patients without emergent indications for intervention generally undergo laparoscopic cholecystectomy preferably during the same admission.
• High-risk patients without emergent indications for intervention are treated with a gallbladder drainage procedure if symptoms do not improve with supportive care. For patients whose medical status can be optimized to allow surgery, cholecystectomy can be considered.

For cases of uncomplicated cholecystitis, outpatient treatment may be appropriate. The following medications may be useful in this setting:

• Levofloxacin and metronidazole for prophylactic antibiotic coverage against the most common organisms
• Antiemetics (e.g., promethazine or prochlorperazine) to control nausea and prevent fluid and electrolyte disorders
• Analgesics (e.g., oxycodone/acetaminophen)
• Surgical and interventional procedures used to treat cholecystitis include the following:
• Laparoscopic cholecystectomy (standard of care for surgical treatment of cholecystitis)
• Percutaneous drainage
• ERCP
• Endoscopic ultrasound-guided transmural cholecystostomy
• Endoscopic gallbladder drainage

Morbidity and Mortality

The overall mortality of a single episode of acute cholecystitis is approximately 3 percent. However, the risk in a given patient depends upon the patient's health and surgical risk. Mortality is less than 1 percent in young, otherwise healthy patients, but approaches 10 percent in high-risk patients, or in those with complications.

A study of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database evaluated outcomes following treatment of acute cholecystitis in 5460 patients with and without diabetes. Mortality among 770 patients with diabetes was significantly higher than in the 4690 patients without diabetes (4.4 versus 1.4 percent). The risk for complications including cardiovascular events and renal failure was also significantly increased.

Srinivas Seela, MD, moved to Orlando after finishing his fellowship in Gastroenterology at Yale University School of Medicine. His interests include advanced and therapeutic endoscopic procedures, colorectal cancer screening, Gastro Esophageal Reflux Disease (GERD), metabolic and other liver disorders.

He is an Assistant Professor at the University of Central Florida School of Medicine, and a teaching attending physician at both the Florida Hospital Internal Medicine Residency and Family Practice Residence (MD and DO) programs. Visit www.dlcfl.com for more.