II. Definition

  1. Gallbladder inflammation resulting from cystic duct blockage by Gallstones

III. Precautions

  1. Acute Cholecystitis may present cryptically yet requires emergent management
  2. Fever and chills are frequently absent
    1. Fever or chills are only present in a third of patients with Acute Cholecystitis
  3. Right upper quadrant pain or tenderness may be absent
    1. As many as a quarter of Acute Cholecystitis cases do not have RUQ findings

IV. Symptoms

  1. Biliary Colic with additional characteristics below
    1. Acute Cholecystitis is typically preceded by at least one Biliary Colic episode
  2. Characteristics
    1. Starts as dull visceral poorly localized pain
    2. Develops into sharp parietal focal RUQ Pain
  3. Timing
    1. Pain persists beyond typical 5-6 hours
  4. Associated Symptoms
    1. Fever is present in only 35% of Acute Cholecystitis
    2. Chills are present in only 13% of Acute Cholecystitis

V. Signs

  1. Appearance
    1. Toxic appearance in moderate to severe discomfort
    2. Tachycardia
  2. Non-specific gastrointestinal findings
    1. RUQ Abdominal tenderness
      1. Test Sensitivity: 77%
      2. Test Specificity: 54%
    2. Hypoactive bowel sounds
  3. Peritoneal Signs
    1. Localized irritation is comon
    2. Generalized signs (rare) suggests perforation
  4. Murphy Sign positive
    1. Examiner palpates the abdominal RUQ while the patient takes a deep breath
    2. Positive test if the patient suddenly halts their inspiration due to pain

VI. Labs

  1. Complete Blood Count
    1. Leukocytosis with Left Shift
    2. Normal WBC Count does not rule out Acute Cholecystitis
    3. Very high WBC Count may suggest gallbladder gangrene or perforated gallbladder
  2. Liver Function Tests (LFTs)
    1. Serum Bilirubin elevated (typically mild)
    2. Serum Alkaline Phosphatase elevated
    3. Serum Aminotransferases normal
  3. Pancreatic Studies (for gallstone Pancreatitis)
    1. Serum Lipase (some also obtain Serum Amylase)
  4. Urine Studies
    1. Urinalysis
    2. Urine HCG

VII. Imaging: First-Line

  1. RUQ Ultrasound (preferred)
    1. See Gallbladder Ultrasound for diagnostic criteria
  2. Abdominal CT
    1. Indicated for non-diagnostic Ultrasound
    2. Evaluation of Cholecystitis complications (Ascending Cholangitis, gallstone Pancreatitis, post-operative findings)
  3. Hepatobiliary Iminodiacetic Acid Scan (HIDA Scan)
    1. Acute Cholecystitis evaluation for cystic duct obstruction
    2. Normal gallbladder visualization on HIDA Scan has high Negative Predictive Value (99%)
  4. Magnetic Resonance Cholangiopancreatography (MRCP)
    1. Indicated for suspected Common Duct Stone (Choledocholithiasis)

VIII. Imaging: Other

  1. XRay Abdomen
    1. Test Sensitivity for Gallstones: 10-20%
    2. Most stones are Cholesterol (radiolucent)
  2. Chest XRay
    1. Assess for Right Lower Lobe Pneumonia
    2. Assess for Pleural Effusion (seen in Pancreatitis)
    3. Assess for free air under the diaphragm

IX. Management

  1. Intravenous fluid hydration
  2. Nasogastric suction
  3. Antibiotics
    1. Initial antibiotic regimen (see Cholecystectomy)
      1. Cefazolin 1 gram IV within 1 hour of skin incision
    2. Consider broadening antibiotics for severe cases
      1. Ampicillin with Gentamicin
      2. Ampicillin-Sulbactam
      3. Piperacillin-Tazobactam
  4. Laparoscopic Cholecystectomy
    1. Recommended within first 72 hours
    2. Immediate Cholecystectomy is safe and preferred
    3. Stevens (2006) Am J Surg 192:756-61 [PubMed] (or open in [QxMD Read])
  5. Percutaneous cholecystostomy drainage (with delayed Cholecystectomy)
    1. Indicated for older or critically ill patients with gallbladder empyema (and associated Sepsis)
  6. Alternatives to surgery
    1. Extracorporeal Shock Wave Lithotripsy (ESWL)
    2. Oral Dissolution Therapy

X. Course

  1. Spontaneous resolution in 60% of cases

XI. Complications

  1. Acute Pancreatitis
  2. Ascending Cholangitis
  3. Gallbladder Empyema
  4. Gallbladder Gangrene (Emphysematous Cholecystitis)

Images: Related links to external sites (from Google)

Ontology: Cholecystitis (C0008325)

Definition (NCI) An acute or chronic inflammation involving the gallbladder wall. It may be associated with the presence of gallstones.
Definition (NCI) A disorder characterized by inflammation involving the gallbladder. It may be associated with the presence of gallstones.
Definition (MSH) Inflammation of the GALLBLADDER; generally caused by impairment of BILE flow, GALLSTONES in the BILIARY TRACT, infections, or other diseases.
Definition (CSP) inflammation of the gallbladder; generally caused by impairment of bile flow, gallstones in the biliary tract, infections, or other diseases.
Concepts Disease or Syndrome (T047)
MSH D002764
ICD9 575.10
ICD10 K81 , K81.9
SnomedCT 197414008, 76581006
French CHOLECYSTITE, Cholécystite SAI, Cholécystite, Inflammation de la vésicule biliaire
English CHOLECYSTITIS, GALL BLADDER INFLAMMATION, INFLAMMATION GALL BLADDER, Cholecystitis, NOS, Cholecystitis, unspecified, Cholecystitis NOS, GALLBLADDER DISEASE 1, GBD1, GALLBLADDER INFLAMM, Cholecystitis, cholecystitis (diagnosis), cholecystitis, Cholecystitis NOS (disorder), Cholecystitis [Disease/Finding], gall bladder inflammation, gallbladder inflammation, Gallbladder inflammation, Inflammation gallbladder, Gallbladder Inflammation, Inflammation, Gallbladder, Cholecystitis (disorder), gallbladder; inflammation, inflammation; gallbladder
Portuguese COLECISTITE, Inflamação da vesícula biliar, Colecistite NE, Colecestite, Colecistite, Inflamação da Vesícula Biliar
Spanish COLECISTITIS, Colecistitis NEOM, Inflamación de la vesícula biliar, colecistitis (trastorno), colecistitis, SAI (trastorno), colecistitis, SAI, colecistitis, Colecistitis, Inflamación de la Vesícula Biliar, Inflamacion de la Vesicula Biliar
German CHOLEZYSTITIS, Gallenblasenentzuendung, Cholezystitis NNB, Entzuendung, Gallenblase, Cholezystitis, nicht naeher bezeichnet, Cholezystitis
Dutch cholecystitis NAO, galblaasontsteking, onsteking galblaas, galblaas; ontsteking, ontsteking; galblaas, Cholecystitis, niet gespecificeerd, cholecystitis, Cholecystitis, Galblaasontsteking
Italian Colecistite NAS, Infiammazione della colecisti, Infiammazione della vescica biliare, Colecistite
Japanese 胆嚢の炎症, 胆嚢炎NOS, タンノウエンNOS, タンノウエン, タンノウノエンショウ, 胆嚢炎, 胆嚢膿腫, 胆嚢蓄膿, 胆のう炎, 蓄膿-胆嚢
Swedish Gallblåseinflammation
Czech zánět žlučníku, cholecystitida, žlučník - zánět, Zánět žlučníku, Cholecystitida NOS, Cholecystitida
Finnish Sappirakkotulehdus
Korean 상세불명의 담낭염, 담낭염
Polish Zapalenie pęcherzyka żółciowego
Hungarian Cholecystitis, Cholecystitis k.m.n., Epehólyag-gyulladás, Epehólyag gyulladás

Ontology: Cholecystitis, Acute (C0149520)

Definition (MSH) Acute inflammation of the GALLBLADDER wall. It is characterized by the presence of ABDOMINAL PAIN; FEVER; and LEUKOCYTOSIS. Gallstone obstruction of the CYSTIC DUCT is present in approximately 90% of the cases.
Concepts Disease or Syndrome (T047)
MSH D041881
ICD9 575.0
ICD10 K81.0
SnomedCT 155827009, 197411000, 197409009, 65275009, 197408001
English CHOLECYSTITIS, ACUTE, Acute cholecystitis NOS, Acute cholecystitis unspecif., Acute cholecystitis unspecified, CHOLECYSTITIS ACUTE, acute cholecystitis (diagnosis), acute cholecystitis, Cholecystitis acute NOS, Acute cholecystitis NOS (disorder), Acute cholecystitis unspecified (disorder), Cholecystitis, Acute [Disease/Finding], Acute Cholecystitis, Cholecystitis, Acute, Cholecystitis acute, Acute cholecystitis, Acute cholecystitis (disorder), cholecystitis; acute, acute; cholecystitis
Dutch acute cholecystitis, cholecystitis acuut NAO, acuut; cholecystitis, cholecystitis; acuut, Acute cholecystitis, cholecystitis acuut, Cholecystitis, acute, Galblaasontsteking, acute
French Cholécystite aiguë SAI, Cholécystite aiguë, Cholécystite aigüe
German Cholezystitis akut NNB, akute Cholezystitis, Akute Cholezystitis, Cholezystitis, akute
Italian Colecistite acuta NAS, Colecistite acuta
Portuguese Colecistite aguda NE, Colecistite aguda, Colecestite aguda, Colecistite Aguda
Spanish Colecistitis aguda NEOM, Acute cholecystitis, colecistitis aguda (trastorno), colecistitis aguda no especificada (trastorno), colecistitis aguda no especificada, colecistitis aguda, SAI (trastorno), colecistitis aguda, SAI, colecistitis aguda, Colecistitis aguda, Colecistitis Aguda
Japanese 急性胆嚢炎NOS, キュウセイタンノウエンNOS, キュウセイタンノウエン, 急性胆嚢炎, 胆嚢炎-急性
Swedish Gallblåseinflammation, akut
Czech cholecystitida akutní, Akutní cholecystitida, Akutní cholecystitida NOS
Finnish Äkillinen sappirakkotulehdus
Korean 급성 담낭염
Polish Zapalenie pęcherzyka żółciowego ostre
Hungarian Acut cholecystitis, Heveny epehólyag-gyulladás, Acut cholecystitis k.m.n.