Acute Cholecystitis

By Natnael Habtamu, C2

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Outline
• Introduction
• Pathogenesis
• Clinical Manifestations
• Laboratory Evaluation
• Diagnosis
• Complications
• Treatment

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Introduction
• Definition
• Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever,
and leukocytosis associated with gallbladder inflammation

• Etiology
Calculous Acalculous

• 90% • 10%
• Gallstone • Cause is unknown
obstructing cystic but theories?
duct • Primarily in critically
ill patients (ICU pts)
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Pathogenesis • Duct obstruction  increased intraluminal
pressure  compression of vasculature 
Mechanical Ischemia +/- necrosis & perforation
Inflammation
• In contrast to biliary colic, the
development of acute
cholecystitis is not fully explained • Phospholipases (from gall bladder mucosa) act
by cystic duct obstruction alone on lecithin in bile  release of lysolecithin
(Mechanical Inflammation) Chemical • Elevated levels of Prostaglandins
Inflammation

• 50-80% of patients
• Commonest etiologies: E.coli (41%),
Bacterial Enterococcus (12%), Klebsiella (11%)
Infection

Inflammatory responses evoked by three factors are

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important
Pathogenesis
• Histologic changes
• Ranges from mild edema & acute inflammation to necrosis & gangrene
• Rarely Hydrops of Gall bladder
• Prolonged impaction of a stone in the cystic duct can lead to a distended
gallbladder that is filled with colorless, mucoid fluid.
• Mechanism  absence of bile entry into the gallbladder and absorption of all
the bilirubin within the gallbladder.

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Clinical Manifestations acute calculous cholecystitis

• History
• Risk factors for cholelithiasis
• Symptoms
• Pain  Similar to biliary colic but more severe & prolonged (> 6hrs)
• Fever
• + Nausea, vomiting & Anorexia
• Physical Examination
• Pt lies still on the examining table
• Fever, Tachycardia
• Guarding (don’t forget to rule out Perforation)
• Murphy’s sign and Boas’ sign
• Signs related with complications (e.g. Sepsis if gangrenous cholecystitis)
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 Clinical Manifestations acute calculous cholecystitis

• Murphy’s sign
• Performed in supine or sitting
position
• Sudden inspiratory arrest during
RUQ palpation
• Sensitivity  ~97%
• Lower sensitivity if elderly
• Specificity  ~48 %

Source: Singer AJ, McCracken G, Henry MC, et al. Correlation among

clinical, laboratory, and hepatobiliary scanning findings in patients
with suspected acute cholecystitis. Ann Emerg Med 1996; 28:267.

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Clinical Manifestations acute calculous cholecystitis

• Boas’ Sign
• An area of hyperesthesia b/n 9th and 11th ribs posteriorly on the right side
• Cause
• Increased/Altered sensitivity below the right scapula due to phrenic nerve irritation

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Clinical Manifestations acute acalculous cholecystitis

• Alert Patients
• Similar to acute calculous cholecystitis

• Sedated or Unconscious patients

• Most clinical manifestations are masked
• If uncomplicated, in most cases we find Fever thus additional diagnostic
modalities are needed

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Laboratory Evaluation
• Elevated Inflammatory Markers
• Leukocytosis with increased # of band forms (left shift)
• Elevated CRP
• Normal or mild elevations of Serum Bilirubin & ALP
• If markedly elevated, rule out cholangitis, choledocholithiasis….etc specially if
the patient is jaundiced!

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 Ultrasound Sensitivity & Specificity
• Sensitivity: 84%
Diagnosis • Specificity: 99%

Source: Shea JA, Berlin JA, Escarce JJ, et al. Revised

estimates of diagnostic test sensitivity and
• Requires Imaging!!! specificity in suspected biliary tract disease. Arch
Intern Med 1994; 154:2573.
• Ultrasound
• Findings
• More specificity for Acute cholecystitis (Diagnostic)
• Gall bladder wall thickening (> 4 – 5 mm) or Double Wall Sign (edema)
• Sonographic Murphy’s Sign (higher specificity and sensitivity than murphy’s sign)
• Non-specific but somewhat suggestive findings acute cholecystitis
• Enlargement of gallbladder
• Presence of gall stones (~90% of cases)
• Findings of complications of acute cholecystitis
• E.g. Air in gall bladder wall or lumen  Emphysematous cholecystitis
• If U/S is not diagnostic, then do Cholescintigraphy
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 HIDA Scan Sensitivity & Specificity
• Sensitivity: 90 - 97%
Diagnosis • Specificity: 71 - 90%

Source: Shea JA, Berlin JA, Escarce JJ, et al. Revised

estimates of diagnostic test sensitivity and
• Cholescintigraphy (HIDA scan) specificity in suspected biliary tract disease. Arch
Intern Med 1994; 154:2573.

The gallbladder
Taken up If the cystic duct
can visualized
selectively by is patent, the
IV HIDA injected within 30 – 60
hepatocytes & tracer will enter
minutes by
excreted in to bile the gallbladder
gamma camera

• Said to be positive if gall bladder isn’t visualized

• Fasle positive if severe liver disease, Total parentral nutrition patients, Biliary sphincterotomy
& Hyperbilirubinemia
• Can be minimized if we use Morphine Cholescintigraphy
• False Negative is very rare (if present suspect incomplete cystic duct obstruction)

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Diagnosis
• Abdominal Computed Tomography (CT)
• It is unnecessary in the diagnosis of acute cholecystitis,
• Although it can easily demonstrate gallbladder wall edema associated with acute
cholecystitis it may fail to detect gall stones
• CT is useful when complications of acute cholecystitis are suspected
• E.g. Pericholecystic stranding/fluid  Perforation (Gold standard to detect perforation)

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Diagnosis
• To diagnose acute acalculous cholecystitis all the following must be
present:
• Clinical & Lab suggestive findings: Fever, abdominal pain, leukocytosis and/or
elevated liver tests
• Risk factors for acalculous cholecystitis
• Radiologic features suggestive of acalculous cholecystitis (eg, gallbladder wall
thickening, sonographic Murphy’s sign, pericholecystic fluid)
• No evidence of other conditions that could elicit the clinical and radiographic
findings

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Complications
1. Gangrene
2. Perforation
3. Emphysematous Cholecystitis
4. Cholecytoenteric fistula
5. Gallstone ileus

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Complications
1. Gangrene
• Most common complication (present in up to 20% of cases of Acute Ch.)
• Risk factor: Old age, DM pt & Delay in seeking treatment
• Clinically features: Ranges from absent clinical signs to sepsis signs and
symptoms
2. Perforation
3. Emphysematous Cholecystitis
4. Cholecytoenteric fistula
5. Gallstone ileus

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Complications
1. Gangrene
2. Perforation
• Cause  Gangrene
• Results in Pericholecystic Abscess or rarely perforation in to peritoneum
• Dx  CT is gold standard
3. Emphysematous Cholecystitis
4. Cholecytoenteric fistula
5. Gallstone ileus

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Complications
1. Gangrene
2. Perforation
3. Emphysematous Cholecystitis
• Cause  secondary infection of the gallbladder wall with gas-forming
organisms (such as Clostridium welchii)
• Risk factor  Elderly, DM, Male
• Clinical Feature  Acute cholecystitis signs, No peritoneal signs, Crepitus in
the abdomen (rare)
• Outcome  Early gangrene & Perforation
• Dx  Air in Gall bladder wall or lumen (mimics overlying bowel gas)
4. Cholecytoenteric fistula
5. Gallstone ileus 18
Treatment of Acute Cholecystitis
• Approach to the patient diagnosed with acute cholecystits

Admit the Start supportive Selection & Timing

patient care of Definitive therapy

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Supportive Care
• Elements of supportive care are
• Pain control
• IV fluid therapy & correction of electrolytes
• Antibiotics
• Others when indicated

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Supportive Care
• Elements of supportive care are
• Pain control
• NSAID or Opioid
• Progression of pain despite adequate analgesia is an indicator of clinical progression
• IV fluid therapy & correction of electrolytes
• Antibiotics
• Others when indicated

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Supportive Care
• Elements of supportive care are
• Pain control
• IV fluid therapy & correction of electrolytes
• KEEP THE PATIENT NPO!!!
• Antibiotics
• Others when indicated

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Supportive Care
• Elements of supportive care are
• Pain control
• IV fluid therapy & correction of electrolytes
• Antibiotics
• Which pts receive antibiotics is a debate
o Antibiotics only when infection is suspected clinically (e.g. Temp > 38.5oc, lab findings (e.g
WBC # > 12,500/mm3) or on imaging (e.g. gall bladder rupture/necrosis)
 Reason: Rate of empyema & percholecystic abscess is low plus antibiotics haven’t made
any difference in the development of emypyema & pericholecystic abscess
o Routine administration to all pts
 Reason: Pts can easily develop life threatening sepsis from uncomplicated acute
cholecystitis despite rate of empyema & percholecystic abscess being low

• Others when indicated

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Supportive Care
• Elements of supportive care are
• Pain control
• IV fluid therapy & correction of electrolytes
• Antibiotics
• Antibiotics regimen

• Others when indicated

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Supportive Care
• Elements of supportive care are
• Pain control
• IV fluid therapy & correction of electrolytes
• Antibiotics
• How long to administer
o Either
 Until it resolves clinically
 Gall bladder is removed
 Post-op usually till 5 days (usually done for severe cases)
o Generally depends on the status of the patient!!!
• Others when indicated

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Supportive Care
• Elements of supportive care are
• Pain control
• IV fluid therapy & correction of electrolytes
• Antibiotics
• Others when indicated
• NG tube placement if patient is vomiting

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Selection & Timing of Definitive Therapy
• Medical Risk Assessment
• American Society of Anesthesiologists (ASA) physical status classification is
commonly used to stratify the risk of surgery
• Based on ASA assessment we can classify patients in to
• Low Risk Patients  ASA class I & II
• High Risk Patients  ASA class III, IV & V

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Selection & Timing of Definitive Therapy
• Low Risk Patients
• Definitive Therapy  Surgery
• Surgical Approach
• Gold standard  Laparascopic Cholecystectomy
• Other options if high risk of complication or inability to access using laparascopic
approach
• Open cholecystectomy
• Subtotal cholecystectomy
• i.e. living the dome of the gallbladder adherent to the liver fossa in situ
• Still there is risk of biliary leaks but it can generally be managed conservatively.
• Gall bladder drainage

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Selection & Timing of Definitive Therapy

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Selection & Timing of Definitive Therapy
• Low Risk Patients
• Timing of Surgery
• Better to do it Early (<7 days of admission) than Delayed (> 7 days of admission)
cholecystectomy
• Reason: Reduced Post-op morbidity & mortality in some patients; Reduced length of hospital
stay & cost

• Best to do it with in 72 hours onset of symptoms (i.e. after the patient is adequately
resuscitated)
• Reason: local inflammation increases 72 hours after the initial onset of symptoms, making
dissection less precise, increasing the severity of surgical complications, and making open
conversion more likely

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Selection & Timing of Definitive Therapy
• Low Risk Patients
• Timing of Surgery
• Indications to do delayed intervention
• Pt’s overall medical condition imposes an unacceptable risk for early surgery
• Pts in whom acute cholecystitis is in doubt

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Selection & Timing of Definitive Therapy
• High Risk Patients
• Definitive therapy approach for patients who don’t have complications

Antibiotic
Therapy Key:

If clinical Improvement

NPO If no clinical improvement

(Cut-off point ~ 3days)

Cholecystectomy Gall bladder drainage then

cholecystectomy if possible
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Selection & Timing of Definitive Therapy
• High Risk Patients
• Definitive therapy approach for patients who have complications is
Emergency Cholecystectomy
• Reason: The burden of the ongoing systemic effects of cholecystitis is deemed to be
greater than the risk of surgery.

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Selection & Timing of Definitive Therapy
• High Risk Patients
• Gall bladder drainage
• Goal of drainage  To direct purulent material away from the obstructed gallbladder
• This also allows for resolution of edema, which often “opens” up the obstructed cystic duct.
• Approaches to drainage
• Percutaneous Cholecystostomy
• Endoscopic gallbladder drainage
• Surgical gallbladder drainage
• Generally they all help decompress the gall bladder to resolve both local & systemic
inflammation

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Selection & Timing of Definitive Therapy
• High Risk Patients
• Gall bladder drainage
• Percutaneous Cholecystostomy
o Indications:
 Contraindications to general anesthesia
 Severe cholecystitis
 Late presentation (>72 hours after onset of
symptoms)
 Failure of medical (antibiotic) therapy

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Selection & Timing of Definitive Therapy
• High Risk Patients
• Gall bladder drainage
• Percutaneous Cholecystostomy
o Effectiveness  Resolves acute cholecystitis in ~90% of cases
o Clinical Improvement  symptomatic relief within 24 – 48 hours is expected
o Timing of cholecystectomy after drainage:
 Ranges from ‘After clinical improvement’ to ‘After 8 weeks’
o Complications (Generally are minor)
 Bleeding, Catheter blockage and dislodgement, and failure to resolve the acute
cholecystitis
 Failure to resolve is usually due to thick sludge or pus affecting the drainage thus
irrigate the gall bladder content manually with normal saline through the catheter.

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Selection & Timing of Definitive Therapy
• High Risk Patients
• Gall bladder drainage
• Endoscopic gallbladder drainage
o Indication: When percutaneous approaches are either
 Contraindicated, or
 Are not anatomically feasible (ie, advanced liver disease, ascites, or coagulopathy)
o Techniques:
 Transpapillary drainage
 Transmural drainage

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Selection & Timing of Definitive Therapy
• High Risk Patients
• Gall bladder drainage
• Surgical gallbladder drainage
o i.e. doing Open cholecystostomy tube placement through a limited laparotomy in the OR

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Selection & Timing of Definitive Therapy
• High Risk Patients
• Gall bladder drainage
• Subsequent care following drainage depends on whether there is
• Effective Drainage (i.e. clinical symptoms resolve after gallbladder drainage has been accomplished)
o Reassess the risk for surgery and if
 Candidate for surgery  Laparascopic cholecystectomy
 Not candidate for surgery  Remove the cholecystostomy tube & avoid surgery
• Ineffective Drainage
o It usually suggests that the gallbladder may have progressed to gangrene
o Thus do Laparascopic cholecystectomy.

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 Are any one of the following present on Abdominal Imaging
1. Gall bladder necrosis
2. Emphysematous gall bladder
3. Gall bladder perforation

Approach to
Yes No
management
of acute Emergency
Cholecystectomy
Percutaneous
Gallbladder drainage
acalculus
cholecystitis Failure to improve at
24 – 48 hours

Yes No

Emergency Continue Antibiotics to complete

Cholecystectomy treatment course and Do Abdominal
Ultrasound for stones or sludge
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 Continue Antibiotics to complete treatment course and do
Abdominal Ultrasound for stones or sludge

Approach to
Gall stones on U/S No Gall stones on U/S
management
of acute
Remove
acalculus Emergency
cholecystectomy in cholecystostomy tube
cholecystitis surgical candidates when minimal
drainage

Cholecystectomy not
required
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