• Clinical science
  • Clinician

Acute cholecystitis

Summary

Acute cholecystitis refers to the acute inflammation of the gallbladder, which is typically due to cystic duct obstruction by a gallstone (acute calculous cholecystitis). Acalculous cholecystitis is less common and is seen predominantly in critically ill patients. RUQ pain, a positive Murphy sign, and fever are the characteristic clinical features of acute cholecystitis. RUQ ultrasound is the preferred initial imaging modality, which would show gallbladder distension, edema, and pericholecystic fluid. Empiric antibiotic therapy and laparoscopic cholecystectomy are the mainstays of treatment. Laparoscopic cholecystectomy should be performed as soon as possible, preferably within 72 hours of admission, unless operative and anesthesia risks outweigh the benefits of urgent surgery. In high-risk patients with severe cholecystitis, a temporizing gallbladder drainage procedure (e.g., percutaneous cholecystostomy, endoscopic gallbladder stenting) should be performed and elective interval cholecystectomy scheduled after the resolution of acute symptoms. Complications of acute cholecystitis include gangrenous cholecystitis, emphysematous cholecystitis, gallbladder perforation, biliary-enteric fistula, gallstone ileus, and pyogenic liver abscess. Chronic cholecystitis may result from recurrent attacks of acute cholecystitis or due to chronic cholelithiasis. Chronic gallbladder inflammation increases the risk of gallbladder carcinoma.

See also “Cholelithiasis”, “Choledocholithiasis”, and “Acute cholangitis.”

Epidemiology

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Approximately 90% of acute cholecystitis is caused by cholelithiasis. Acalculous cholecystitis accounts for the remaining 10%. [3]

Clinical features

Acute cholecystitis should always be suspected in a patient with a history of gallstones who presents with RUQ pain, fever, and leukocytosis

Subtypes and variants

Acute acalculous cholecystitis [6][7][2][8]

Suspect acalculous cholecystitis in any critically ill patient with fever and RUQ tenderness.

Emphysematous cholecystitis (EC) [10][11][7]

Diagnostics

The diagnosis of acute cholecystitis is based on characteristic clinical features, systemic signs of inflammation (leukocytosis, CRP),; and evidence of gallbladder inflammation on imaging.

Approach

Diagnostic criteria for acute cholecystitis [10]
Local signs of inflammation
Systemic signs of inflammation
Imaging findings
  • Any imaging finding characteristic of acute cholecystitis (see ''Imaging'' section)
Interpretation

Laboratory studies [10][13]

Imaging [10][9]

RUQ transabdominal ultrasound

Hepatoiminodiacetic acid scintigraphy (HIDA scan) [9][18][2]

  • Indications: : preferred confirmatory test for suspected uncomplicated acute cholecystitis if ultrasound findings are inconclusive [9]
  • Procedure: The radioactive tracer 99mTc-hepatic iminodiacetic acid is injected intravenously → selective uptake by hepatocytes → subsequent excretion into bilebile with radiotracer enters the gallbladder if the cystic duct is patent → visualization of tracer within the gallbladder via a gamma camera [2]
  • Advantages
  • Disadvantages
    • Time-consuming
    • Cannot identify complications of acute cholecystitis, if present
    • Cannot be used to evaluate for potential differential diagnoses
    • May not be widely available
  • Characteristic findings

MRI abdomen without and with IV contrast [9][17][20]

CT abdomen with IV contrast [7][2]

Severity grading [10][21]

Severity grading of acute cholecystitis [10]
Grades of severity Grading criteria

Grade I

(Mild acute cholecystitis)

Grade II

(Moderate acute cholecystitis)

  • No evidence of organ dysfunction
  • Presence of at least one of the following signs of severe gallbladder disease:
    • Symptom duration > 72 hours
    • WBC count > 18,000/mm3
    • Palpable tender RUQ mass
    • Signs of significant local inflammation on imaging studies

Grade III

(Severe acute cholecystitis)

  • Dysfunction of at least one organ system

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

Empiric antibiotic therapy and cholecystectomy are the mainstays of treatment for acute cholecystitis after initial supportive therapy. Laparoscopic cholecystectomy should be performed as soon as possible unless operative and anesthesia risks outweigh the benefits of urgent surgery; . In grade II–III acute cholecystitis, or patients at high risk of surgical complications, a temporizing gallbladder drainage procedure can be performed and elective interval cholecystectomy scheduled for when operative and anesthesia risks are minimized.

Approach [22][14][21]

Initial medical management [22][21]

Definitive management [23][22][21][24]

Grade I acute cholecystitis

Grade II acute cholecystitis

Patients with grade II acute cholecystitis should be managed in a specialized/advanced medical center with expert surgeons trained in difficult laparoscopic cholecystectomy.

Grade III acute cholecystitis

Patients with grade III acute cholecystitis should be managed in an advanced healthcare facility with ICU care and expert laparoscopic surgeons.

In patients with suspected/confirmed concurrent choledocholithiasis, either preoperative or postoperative stone extraction should be performed (see ''Treatment'' in “Choledocholithiasis” for more information).

Procedures

Laparoscopic cholecystectomy

  • Indication: gold standard of treatment for acute calculous cholecystitis [21]
  • Timing: depends on surgical and anesthesia risks, disease severity, and symptom duration
    • Early laparoscopic cholecystectomy: performed within 10 days of symptom onset; preferably within the initial 24–72 hours [21][23]
      • Indication: symptom duration of ≤ 10 days in patients with low surgical and anesthesia risk(s) [21]
      • Contraindications
        • High surgical or anesthesia risks
        • Symptom duration > 10 days
    • Interval laparoscopic cholecystectomy (delayed lap. chole): performed 45 days after resolution of symptoms [21]
      • Indications
        • High surgical or anesthesia risk
        • Symptom duration > 10 days

Gallbladder drainage

Disposition [22]

All patients with acute cholecystitis require inpatient management.

Antibiotic therapy for acute biliary infection

General principles [14]

Recommended empiric regimen [14]

Empiric antibiotic therapy for acute biliary infection
Class of infection Severity of infection

Suggested single-agent empiric regimen

Suggested combination empiric regimen

Community-acquired biliary infection

Grade I

Grade II

Grade III

Healthcare-associated biliary infection

(any grade)

  • Same as grade III community-acquired biliary infection [33]
Suspected multi-drug resistant organism infection
  • Same as grade III community-acquired biliary infection
  • PLUS any one of the following, depending on the suspected infection:

Many ESBL-producing gram-negative organisms are resistant to fluoroquinolones.

Resistance of E. coli to ampicillin-sulbactam is becoming more common, especially in North America. Consider local resistance rates carefully before choosing an empiric antibiotic regimen.

Acute management checklist

Complications

Gangrenous cholecystitis [34][7][35]

Gallbladder perforation [7][36][35]

  • Definition: break in the continuity of the gallbladder wall, typically as a consequence of ischemic necrosis
  • Clinical features: variable; symptoms typically progress rapidly
    • May be indistinguishable from uncomplicated acute cholecystitis
    • Potentially accompanied by a palpable RUQ mass and/or signs of generalized peritonitis
  • Imaging : focal defect in the gallbladder wall; extraluminal stone may be visualized
  • Treatment: emergency laparoscopic cholecystectomy and empiric antibiotic therapy for biliary infection

Cholecystoenteric fistula [7][37][35]

Gallbladder empyema (suppurative cholecystitis) [7]

Chronic cholecystitis [3][7][43]

Chronic gallbladder inflammation increases the risk of gallbladder carcinoma, especially when porcelain gallbladder is present.

Other [7]

We list the most important complications. The selection is not exhaustive.

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last updated 07/17/2020
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