Acute Cholecystitis

Jane Chunwen Teng D.O. 12/5/12
 Acute Cholecystitis: symptoms of RUQ pain, fever, and
leukocytosis associated with gallbladder inflammation that is usually
related to gallstone disease.
 Acalculous Cholecystitis: Clinically identical to acute cholecystitis
but is not associated with gallstones, and usually occurs in critically ill
pts. It accounts for approximately 10 % of cases of acute
cholecystitis and is associated with high morbidity and mortality.
 Chronic inflammatory cell infiltration of the gallballdder seen on
 Almost invariably associated with the presence of gallstones and is
thought to be the result of mechanical irritation or recurrent attacks
of acute cholecystitis leading to fibrosis and thickening of the
 In contrast to biliary colic, the development of acute cholecystitis
is not fully explained by cystic duct obstruction alone.
 Studies in animals have demonstrates that ligation of the cystic
duct does not result in acute cholecystitis.
 However, acute cholecystitis can be produced experimentally by
blockade of the cystic duct followed by deliberate irritation of the
gallbladder mucosa.
 Lysolecithin (normally absent in bile) maybe release following
trauma of the gallbladder wall from an impacted gallstone.
 Inflammatory mediators (e.g. PGE2 and 6 keto PG F1 alpha)
synthesized by inflamed human gallbladder microsomes increased
four times above normal.
 Prolonged impaction of stones in the cystic duct can lead to
 RUQ or epigastrium abdominal pain, may radiate to the right
shoulder or back. Pain is usually steady and sever.
 Nausea, vomiting, and anorexia.
 Hx of fatty food ingestion about one hour or more before the
initial onset of pain.
 Pt usually are ill appearing, febrile, tachycardic and lie still on the
examining table because any movement can aggravate the pain.
 Abdominal exam usually demonstrates voluntary and involuntary
 Positive “Murphy’s sign” While palpating the area of the
gallbladder fossa just beneath the liver edge, the patient is asked to
inspire deeply, causing the gallbladder to descend toward the
examining fingers. Pt with acute cholecystitis commonly experience
increased discomfort and may have associated inspiratory arrest.
 Using cholescintigraphy as the gold standard, the sensitivity and
specificity of a positive Murphy’s sign were 97 and 48 %, respectively.
 Left untreated, symptoms of cholecystitis may abate within 7-10
 Complication can occur at alarmingly high rate, including the
development of gallbladder gangrene (up to 20%) and subsequent
perforation (2%). Other complications include cholecystoenteric
fistula, gallstone ileus, emphysematous cholecystitis.
 Confirmation of the diagnosis must be based upon a combination
of physical findings, laboratory studies, and imaging tests.
 The most accurate physical findings were a positive Murphy sign
(positive likelihood ratio 2.8, 95% CI 0.8 to 8.6) and right upper
quadrant tenderness (negative LR 0.4, 95% CI 0.2 to 1.1)
 Lab: CBC shows leukocytosis with a left shift.
 Elevation in the serum total bilirubin and alkaline phosphatase
concentrations are NOT common in uncomplicated cholecystitis,
since biliary obstruction is limited to the gallbladder; if present, they
should raise the concerns about complicating conditions such as
cholangitis, choledocholithiasis, or the Mirizzi syndrome (a gallstone
impacted in the distal cystic duct causing extrinsic compression of the
common bile duct)
 There have been reports of mild elevation of serum
aminotransferase and amylase, along with hyperbilirubinemia and
jaundice. These abnormalities maybe due to the passage of small
stones, sludge, or pus.
 Ultrasonograpy is usually the first test obtained and can often
establish the diagnosis.
 Nuclear cholescintigraphy may be useful in cases in which the
diagnosis remains uncertain after ultrasounography.
 Gallbladder wall thickening (>4-5 mm) or edema (double wall sign)
 A “sonographic Murphy’s sign”, which is similar to the Murphy’s sign
elicited during abdominal palpation, except that the positive response is
observed during palpation with the ultrasound transducer.
 A particularly informative systematic review summarized the results of
30 studies of ultrasonography for gallstones and acute cholecystitis.
Adjusted sensitivity and specificity for diagnosis of acute cholecystitis
were 88% and 80% respectively.
 Indicated if the diagnosis remain uncertain following
 Technetium labeled hepatic iminodiacetic acid (HIDA) is injected
intravenously and is then taken up selectively by hepatocytes and
excreted into bile.
 If the cystic duct is patent, this agent will enter the gallbladder,
leading to its visualization without the need for concentration.
 HIDA scan is also useful demonstrating patency of the common
bile duct and ampulla.
 Visualization of the contrast within the common bile duct,
gallbladder, and small bowel occurs within 30 to 60 mins.
 The test is positive if the gallbladder does not visualize, which is
invariably due to cystic duct obstruction, usually from edema
associated with acute cholecystitis or an obstructing stone.
 Cholescintigraphy has a sensitivity and specificity of approximately
97 and 90 %, respectively.
 Cystic duct obstruction with a stone or tumor in the absence of
acute cholecystitis can cause a false positive test.
 Other conditions that can cause false positive results include:
- Severe liver disease, Fasting pt receiving TPN, Biliary
sphincterotomy and Hyperbilirubinemia.
 A modified version of the HIDA scan, in which pts are given IV
morphine during the exam.
 Morphine increases sphincter of Oddi pressure, thereby causing a
more favorable pressure gradient for the radioactive tracer to enter the
cystic duct.
 This modification is thought to be particularly useful in critically ill pts,
in whom standard HIDA scans may be associated with false positive
 Noninvasive technique for evaluating the intrahepatic and extrahepatic
bile ducts.
 In a series that included 35 pts with symptoms of acute cholecystitis
who underwent both ultrasound and MR cholangiography prior to
cholecystectomy. MR cholangiography was superior to ultrasound for
detecting stones in the cystic duct (sensitivity 100 vs. 14 %) but was less
sensitive than ultrasound for detecting gallbladder wall thickening
(sensitivity 69 vs. 96 %)
 Abdominal CT is usually unnecessary in the diagnosis of acute cholecystitis,
although it can easily demonstrate gallbladder wall edema associated with acute
 Other CT findings include pericholecystic stranding and fluid, and highattenuation bile.
 However, CT may fail to detect gallstones because many stones are isodense
with bile.
 CT can be useful when complications of acute cholecystitis are suspected or
when other diagnosis are considered.
 Pts diagnosed with acute cholecystitis required hospital admission for IV
hydration, correction of electrolyte disorders, and pain control (IM ketorolac 30-60
mg adjusted for age and renal function).
 Pts should be kept NPO and those who are vomiting may need NGT
 The guidelines of the Infectious Diseases Society of America (IDSA)
recommend that antimicrobial therapy be instituted if infection is suspected on the
basis of lab (>12,5000 WBC) or clinical findings (temp ≥38.5 degree) , and
radiographic findings .
 Routine antibiotics are also recommended in pts of advanced age
or who have diabetes or immunodeficiency, and for prophylaxis in
patients undergoing cholecystectomy to reduce septic complications
even when infection is not suspected.
 Empiric antibiotic therapy should induce activity against the most
common pathogens.
 In a study of 467 pts, including a control group of 42 pts,
including a control group of 42 with normal biliary tress, positive bile
cultures were found in 22 % pts with symptomatic gallstones and 46
& of pts with acute cholecystitis. The most frequent isolates from the
gallbladder or common bile duct were
- E.Coli (12%), Klebsiella (11%) , and Enterobacter (9%).
Empiric antibiotic Treatment for gram negative and anaeronic bateria
1st choice:
Monotherapy with a beta-lactam or beta-lactamase inhibitor (e.g.
pipercillin tazobactam 3.375 or 4.5 g IV q6hr or ticarcillin-clauvulanate 3.1
g q4hr)
Or Combination of 3rd generation cephalosporin PLUS metronidazole
(ceftriaxone 1g q 24 hr or 2g q 12 hr for CNS infection and metronidazole
500mg q8hr)
 The duration of antibiotic therapy is tailored to clinical improvement.
 For pts requiring prompt surgical intervention, antibiotics may be
warranted for 24 to 48 hours following cholecystectomy, although longer
or shorter courses may be appropriate depending on individual
 Pts for whom surgical intervention is initially deferred ay warrant
antibiotic therapy over 48 to 72 hours pending resolution of clinical signs
and symptoms.
 Although there is consensus that incidentally discovered asymptomatic
gallstones should not be treated. Once a pt develops symptoms or complications
related to gallstones (such as biliary colics or acute cholecystis), treatment to
eliminate the gallstones should be recommended, because the likelihood of
subsequent symptoms or complications is high.
 The National Cooperative Gallstone Study, a trial of nonsurgical treatment with
chenodiol for biliary tract pain, demonstrated that the risk for recurrent symptoms
was approximately 70 % during the two yrs following initial presentation.
 The selection of treatment and timing of definitive therapy for
acute cholecystitis depends upon the severity of symptoms and the
pts overall risk of surgery.
 The aim of definitive therapy is to eliminate the precipitating cause
of acute cholecystitis (ie, gallstones in the case of calculous
cholecystitis) to prevent recurrent attacks.
The benefit of prompt surgical intervention was also illustrated in a
subsequent study of 29,818 Medicare pts with acute cholecystitis.
Compared to pts who underwent cholecystectomy in the initial
hospitalization, pts who were discharged without surgery were more
likely to require readmission (38 vs. 4 %) and had higher mortality
(hazard ratio 1.56, 95% CI, 1.47-1.65) over the following two yrs.
 Lows-risk pts - The physical status scale established by the
American Society of Anesthesiologists (ASA) is commonly used to
determine the risk of surgery.
 Although previously considered to be at higher risk, pts with DM
who do not have substantial microvascular or macrovascular disease
have an outcome after acute cholecystitis similar to the nondiabetic
 The ASA physical status classification system is a system for assessing the
fitness of patients before surgery .
A normal healthy patient.
A patient with mild systemic disease.
A patient with severe systemic disease.
A patient with severe systemic disease that is a constant threat to life.
A moribund. patient who is not expected to survive without the surgery
A declared brain-dead patient whose organs are being removed for donor
 Immediate Cholecystectomy is preferred for pts who are at low risk (ASA class I
and II)
 Several studies have indicated that cholecystectomy performed for low surgical
risk pts during the initial hospitalization can reduce morbidity and costs.
 Early Surgery is also easier to perform as local inflammation increases 72 hr past
the initial onset of symptoms making dissection less precise, increasing the severity
of surgical complications, and open conversion more likely.
 High-risk pts - Pts who are in ASA classes III, IV, or V have a surgical mortality
ranging from 5-27%, and are considered high-risk for cholecystectomy.
 This category generally includes pts with severe chronic illnesses, such as
cardiovascular or pulmonary disease, or advanced malignancy.
 High risk pts, or pts who present late in the course of their disease process(>3-5
days), who continue to have severe symptoms and show no appreciable
improvement despite one to two days of medical management require further
 Gallbladder drainage by percutaneous cholecystostomy in
conjunction of antibiotic is the initial treatment of choice for high
risk pts.
 The goal of cholecystostomy is to drain purulent material from the
obstructed gallbladder.
 Tube decompression of the gallbladder allows for resolution of
edema which often “opens” up the obstructed cystic duct.
 Endoscopic transpapillary gallbladder drainage has also been reported
in pts with acute cholecystitis in whom percutaneous approaches are
contraindicated or anatomically impossible.
 A limitation of the technique is that it can be technically challenging to
place a guidewire and drainage tube into the gallbladder.
 In addition, this procedures carries all the inherent complications of
 When the acute cholecystits has resolved, pts who are surgical
candidates should undergo cholecystectomy.
 Surgery may also be required when the pt does not improve following
percutaneous drainage, which suggests that the gallbladder has already
progressed to gangrene.
 Pts who are particularly unstable will benefit from open
cholecystostomy tube drainage achieved through a limited lapratomy.
This can be performed at the bedside in the ICU setting if necessary.
 Pts who stabilize but continue to be at high risk for surgery can be
considered for percutaneous gallstone extraction with or without
mechanical lithotripsy.

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