Acute calculous cholecystitis. Inflammation of the gallbladder is associated with gallstones in more than 90% of cases. It is a common problem, presenting as an acute abdomen, especially in middle-aged women. Acute calculous cholecystitis is caused by obstruction of the cystic duct either by an impacted stone or by the edema and inflammation caused by the passage of a stone to the common bile duct and duodenum. The obstructed gallbladder becomes distended, and the walls become edematous, ischemic, and inflamed. Secondary infection with enteric organisms complicates the inflammation and may lead to cholangitis and sepsis.
Clinical presentation. The pain of acute cholecystitis usually starts in the right upper quadrant or epigastrium as a colicky pain followed by local signs and symptoms of inflammation. It may radiate to the flanks, intrascapular regions, and right shoulder. Nausea and vomiting are also common. Physical examination reveals a tender right upper quadrant, especially at the tip of the ninth costal cartilage during inspiration (Murphy’s sign). The gallbladder may be palpable. Abdominal rigidity represents peritoneal inflammation. Fever, tachycardia, and tachypnea are common. Jaundice suggests obstruction of the common bile duct and may be present in one third of the patients.
The differential diagnosis includes acute appendicitis, pancreatitis, hepatitis, pneumonia, pyelonephritis, perforated peptic ulcer, and myocardial infarction.
Laboratory studies. Leukocytosis of 10,000 to 15,000/ВµL with a shift to the left usually accompanies acute cholecystitis. Elevation of the serum amylase is not uncommon without the presence of concomitant pancreatitis. Elevation of alkaline phosphatase and bilirubin levels usually suggests obstruction of the common bile duct due to either an impacted stone or edema and inflammation as a result of the passage of a stone. Alanine aminotransferase (alanine aminotransferase) and aspartate aminotransferase (aspartate aminotransferase) elevations suggest concomitant parenchymal cholangitis.
Ultrasonography is the test of choice in demonstrating gallstones, thickening of the gallbladder wall, and pericystic fluid. If the common bile duct is obstructed, dilatation of the biliary tract may be present.
Biliary scintigraphy (i.e., dimethylphenylcarbamylmethyliminodiacetic acid (HIDA) or PIPIDA scan) uses technetium 99m-labeled derivatives of iminodiacetic acid excreted in the bile. In healthy individuals, scans obtained 15 to 30 minutes after intravenous (intravenous) injection demonstrate the filling of the bile ducts and the gallbladder and passage of the radionuclide to the common bile duct and small intestine. In acute cholecystitis due to an obstructed cystic duct, the gallbladder does not fill. Parenchymal liver disease and high bile duct obstruction may lead to failure of imaging of the extrahepatic biliary tract. False-positive scans may occur in chronic cholecystitis, and false-negative scans have been reported in acalculous cholecystitis. In general, the sensitivity of this test is very high.
The patient should be admitted to the hospital. Oral intake should be stopped and, in those with severe nausea and vomiting, a nasogastric sump tube should be inserted to aspirate gastric contents with low suction. intravenous fluid and electrolytes should be provided. Antibiotic therapy to cover enteric organism may be used if secondary infection is suspected after appropriate cultures are obtained.
Cholecystectomy is the definitive treatment for acute cholecystitis. Most patients can be treated with laparoscopic cholecystectomy. Extensive previous laparotomy with scarring may render laparoscopy impossible in some cases. Controversy as to the timing of the surgery still exists for uncomplicated cases; however, most surgeons prefer early intervention, within 5 days of onset of symptoms, rather than waiting 6 to 8 weeks. In elderly patients with other systemic diseases, such as congestive heart failure, the operation may need to be delayed. Preoperative endoscopic retrograde cholangiopancreatography may be performed in selected patients if common bile duct stones are suspected. Sphincterotomy and stone extraction eliminate the need for operative common bile duct exploration. Cholecystectomy should be performed acutely in cases of emphysematous cholecystitis in which the gallbladder walls and bile ducts contain gas. The infective organisms are the gas-forming bacteria, such as Clostridium, E. coli, and other anaerobes.
Cholecystostomy. In severe illness, when laparotomy is contraindicated, a cholecystostomy may be performed. Cholecystostomy involves evacuation of the gallbladder of the stones and infected bile and placement of a Foley catheter into the gallbladder for drainage to outside the body. When the patient is stable, a tube cholangiogram should be performed to assess the patency of the biliary system and the presence of possible residual stones. If these abnormalities are detected, cholecystectomy should be performed when possible.
Perforation is the most serious complication of acute cholecystitis. It may be localized or may extend into the peritoneal cavity with subsequent peritonitis or into an adjacent hollow organ, such as the stomach, duodenum, or colon with formation of a cholecystenteric fistula. Surgical intervention is necessary in all cases.
Gallstone ileus is a form of mechanical intestinal obstruction caused by the impaction of a large gallstone that has entered into the intestine from a cholecystenteric fistula. The obstruction may be intermittent as the stone moves along the intestine until permanent obstruction occurs. Most obstructions occur in the ileum. Colonic obstruction is rare except at sites of previous narrowing due to another disease process, such as diverticular or inflammatory bowel disease. Gallstone ileus requires prompt diagnosis and laparotomy.
Mirrizzi syndrome. Rarely, a gallstone impacted in the cystic duct or the neck of the gallbladder may cause a localized obstruction of the common hepatic duct from direct pressure or inflammatory changes around the duct. The obstruction can cause right upper quadrant pain, jaundice, recurrent cholangitis, and possibly a fistula between the two ducts.
Ultrasound examination may show dilated ducts above the point of obstruction as well as the stone. endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography (percutaneous transhepatic cholangiography) confirms the site of obstruction. computed tomography scan may be helpful in defining the stone and differentiating it from tumor or mass. Surgery is required in most instances.
Acute acalculous cholecystitis is a particularly severe form of inflammation of the gallbladder that occurs in the absence of cholelithiasis. There is a high incidence of necrosis, gangrene, and perforation of the gallbladder in this group of patients. The mortality may be as high as 50% if diagnosis is delayed and prompt therapy not instituted.
Most of the patients are elderly or debilitated as a result of coexisting disease or trauma. The condition is also seen in patients of all ages in the intensive care unit, after surgery, or on total parenteral nutrition. Absence of oral intake associated with gallbladder stasis, sludge formation, and increased biliary pressure due to narcotic drugs that increase the tone at the sphincter of Oddi may contribute to its pathogenesis.
- Clinical presentation. Bile is usually infected with enteric bacteria, which may lead to sepsis. The clinical presentation may be nonspecific, and the diagnosis requires a high index of suspicion. Most patients complain of abdominal pain, nausea, and vomiting. Fever and chills may be present. Serum bilirubin, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase may be elevated. There is usually a moderate leukocytosis (10,000-20,000 cells/ВµL) with a left shift. Serum amylase may be elevated.
- Diagnostic studies. The diagnostic test of choice in acute acalculous cholecystitis is ultrasound of the gallbladder, which identifies a distended gallbladder with thickened walls and biliary sludge. Nuclear scans with HIDA or PIPIDA may give equivocal results in these debilitated patients and are not reliable.
- Treatment. Successful management of acute acalculous cholecystitis requires prompt diagnosis and early surgical intervention. Patients should be treated with antibiotics to cover enteric organisms and enterococci. Cholecystectomy is the surgical procedure of choice. Cholecystostomy is not recommended, because in most cases, the gallbladder is necrotic or gangrenous and its total removal is necessary to prevent perforation and other complications.