-IBIS-1.5.0-
tx
digestive system
cholecystitis
diagnoses

definition and etiology

definition:
an acute or chronic inflammation of the gallbladder

etiology:
In 95% of patients, the cause is obstruction of the gallbladder outlet or cystic duct by a calculus. Other causes include chemical irritation and digestive factors (e.g. high fat foods, pork, onions and eggs). Cholecystitis is generally regarded to be a disease of the four "f's": female, fat, forty, and fertile (non-menopausal). Chronic cholecystitis is the most common illness associated with the gallbladder, and is defined as a chronic inflammatory reaction. It is almost always secondary to gallstones, and it is thought to be caused by persistent bouts of acute or subacute cholecystitis or from mechanical irritation by the stone(s). It may also develop insidiously without any acute attacks, although the patient will eventually present with symptoms similar to acute cholecystitis.

signs and symptoms

signs and symptoms: acute
• pain in the acute disease often begins as biliary colic which gets progressively worse
• approximately 60-70% of patients will have histories of previous attacks that cleared spontaneously
• pain is usually in the right upper quadrant, although radiation can occur in the epigastric area and to the tip of the right scapula
• pain often begins at night or in the early morning, with a sudden or gradual onset; the pain can be quite severe, and is usually constant
• vomiting of a bilious nature is common, as well as anorexia, nausea, and flatulence
• slight icterus may be present, especially in severe cases
• fever, if present, is usually slight (around 101° F): a high fever leads to a suspicion of cholangitis
• marked guarding and rigidity in the right upper quadrant of the abdomen
• localized tenderness, a tender liver edge and inspiratory arrest on deep palpation (Murphy's sign)
• gallbladder is palpable in 50% of cases, and thus can be a key to diagnosis

lab findings:
• increased ESR
• moderate leukocytosis (10,000 - 15,000 cu mm, if > 15,000 suspect empyema or perforation) with a slight shift to the left
• serum amylase and lipase values will be elevated in approximately 15% of patients
• serum bilirubin levels commonly reach 3-4 mg/dl; higher levels may indicate cholelithiasis or pancreatitis
• X-rays: plain film may identify some gallstones; cholecystogram is much more reliable; negative finding doesn't rule out cholecystitis, as a marked number of patients presenting with the disease will not have discernible calculi
• ultrasound is accurate and reliable, especially in the acute condition
• intervenous cholangiography can be helpful by showing the bile ducts, although the gallbladder will not be visualized
• radionuclide scanning with labeled HIDA is a highly sensitive and specific test and is extremely useful in gathering functional information concerning cystic duct patency; alone it can reliably confirm or rule out the diagnosis
• serum AST elevated in 75% of patients

course and prognosis

complications of acute cholecystitis:
• gangrene: total necrosis of one or many areas of the gallbladder, usually due to venous stasis and the loss of arterial blood flow following edema of the GB
• perforation: usually a result of gangrene, it occurs in about 10% of patients presenting with acute cholecystitis; it is a medical emergency requiring surgery and carries high morbidity and mortality rates
• empyema: frank infection of the gallbladder which contains thick purulent material, most commonly caused by E. coli; surgery is mandatory
• postoperative acute cholecystitis: a type of acute cholecystitis that can occur following any type of abdominal surgery; the cause is unknown and the morbidity and mortality are extremely high.
• internal biliary fistula: communication of the bile ducts or gallbladder with the surrounding hollow viscera
• gallstone ileus: mechanical obstruction of the intestinal tract from the passage of a large gallstone into the bowel lumen
• porcelain gallbladder: from calcium salt deposition in the walls of a chronically inflamed and irritated gallbladder; it has a high association with gallbladder cancer; cholecystectomy is indicated

Conventional treatment of the acute and chronic disease may initially be pharmacologic, but usually ends in cholecystectomy, as attacks frequently recur. 25% of patients treated conventionally without surgery will have a recurrence within one year; 60% will have a recurrence within 6 years.

differential diagnosis

• biliary colic
• inflamed or leaking duodenal ulcer
• rupture of gallbladder or a biliary duct
• torsion of the gallbladder
• peptic ulcer
• pancreatitis or pancreatic cancer
• hepatitis
• renal pain or colic
• appendicitis
• pleurisy or pleuropneumonia
• myocardial ischemia
• intestinal obstruction or disease


footnotes