10/15/2015

CholecystitisClinicalPresentation:History,PhysicalExamination

CholecystitisClinicalPresentation
Author:AlanABloom,MDChiefEditor:JulianKatz,MDmore...
Updated:Apr01,2014

History
Themostcommonpresentingsymptomofacutecholecystitisisupperabdominal
pain.Signsofperitonealirritationmaybepresent,andinsomepatients,thepain
mayradiatetotherightshoulderorscapula.Frequently,thepainbeginsinthe
epigastricregionandthenlocalizestotherightupperquadrant(RUQ).Althoughthe
painmayinitiallybedescribedascolicky,itbecomesconstantinvirtuallyallcases.
Nauseaandvomitingaregenerallypresent,andpatientsmayreportfever.
Mostpatientswithacutecholecystitisdescribeahistoryofbiliarypain.Some
patientsmayhavedocumentedgallstones.Acalculousbiliarycolicalsooccurs,most
commonlyinyoungtomiddleagedfemales.Thepresentationisalmostidenticalto
calculousbiliarycolicwiththeexceptionofreferencerangelaboratoryvaluesandno
findingsofcholelithiasisonultrasound.Cholecystitisisdifferentiatedfrombiliary
colicbythepersistenceofconstantseverepainformorethan6hours.
Patientswithacalculouscholecystitismaypresentsimilarlytopatientswith
calculouscholecystitis,butacalculouscholecystitisfrequentlyoccurssuddenlyin
severelyillpatientswithoutapriorhistoryofbiliarycolic.Often,patientswith
acalculouscholecystitismaypresentwithfeverandsepsisalone,withouthistoryor
physicalexaminationfindingsconsistentwithacutecholecystitis.

Cholecystitisinelderlypersons
Elderlypatients(especiallypatientswithdiabetes)maypresentwithvague
symptomsandwithoutmanykeyhistoricalandphysicalfindings.Painandfever
maybeabsent,andlocalizedtendernessmaybetheonlypresentingsign.Elderly
patientsmayalsoprogresstocomplicatedcholecystitisrapidlyandwithoutwarning.

Cholecystitisinchildren
Thepediatricpopulationmayalsopresentwithoutmanyoftheclassicfindings.
Childrenwhoareathigherriskfordevelopingcholecystitisincludepatientswith
sicklecelldisease,seriouslyillchildren,thoseonprolongedTPN,thosewith
hemolyticconditions,andthosewithcongenitalandbiliaryanomalies. [8]Formore
information,seetheMedscapeReferencearticlePediatricCholecystitis.

Complications
Bacterialproliferationwithintheobstructedgallbladderresultsinempyemaofthe
organ.Patientswithempyemamayhaveatoxicreactionandmayhavemore
markedfeverandleukocytosis. [9,10]Thepresenceofempyemafrequentlyrequires
conversionfromlaparoscopictoopencholecystectomy. [11]
Inrareinstances,alargegallstonemayerodethroughthegallbladderwallintoan
adjacentviscus,usuallytheduodenum.Subsequently,thestonemaybecome
impactedintheterminalileumorintheduodenalbulband/orpylorus,causinga
gallstoneileus.
Emphysematouscholecystitisoccursinapproximately1%ofcasesandisnotedby
thepresenceofgasinthegallbladderwallfromtheinvasionofgasproducing
organisms,suchasEscherichiacoli,Clostridiaperfringens,andKlebsiellaspecies.
Thiscomplicationismorecommoninpatientswithdiabetes,hasamale
predominance,andisacalculousin28%ofcases.Becauseofahighincidenceof
gangreneandperforation,emergencycholecystectomyisrecommended.
Perforationoccursinupto15%ofpatients. [12,10]Formoreinformation,seethe
MedscapeReferencearticleEmphysematousCholecystitis.
Othercomplicationsincludesepsisandpancreatitis. [13]

PhysicalExamination
Thephysicalexaminationmayrevealfever,tachycardia,andtendernessintheRUQ
orepigastricregion,oftenwithguardingorrebound.TheMurphysign,whichis
specificbutnotsensitiveforcholecystitis,isdescribedastendernessandan
inspiratorypauseelicitedduringpalpationoftheRUQ.Apalpablegallbladderor
fullnessoftheRUQispresentin3040%ofcases.Jaundicemaybenotedin
approximately15%ofpatients.
Theabsenceofphysicalfindingsdoesnotruleoutthediagnosisofcholecystitis.
ManypatientspresentwithdiffuseepigastricpainwithoutlocalizationtotheRUQ.
PatientswithchroniccholecystitisfrequentlydonothaveapalpableRUQmass
secondarytofibrosisinvolvingthegallbladder.
Elderlypatientsandpatientswithdiabetesfrequentlyhaveatypicalpresentations,
includingabsenceoffeverandlocalizedtendernesswithonlyvaguesymptoms.
DifferentialDiagnoses

ContributorInformationandDisclosures
Author

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10/15/2015

CholecystitisClinicalPresentation:History,PhysicalExamination

AlanABloom,MDAssociateClinicalProfessorofMedicine,AlbertEinsteinCollegeofMedicineAttending
Physician,DepartmentofGastroenterology,VeteransAffairsHospital,Bronx
AlanABloom,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,American
GastroenterologicalAssociation,AmericanMedicalAssociation,AmericanSocietyforGastrointestinal
Endoscopy,NewYorkAcademyofMedicine,NewYorkAcademyofSciences
Disclosure:Nothingtodisclose.
ChiefEditor
JulianKatz,MDClinicalProfessorofMedicine,DrexelUniversityCollegeofMedicine
JulianKatz,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,
AmericanCollegeofPhysicians,AmericanGastroenterologicalAssociation,AmericanGeriatricsSociety,
AmericanMedicalAssociation,AmericanSocietyforGastrointestinalEndoscopy,AmericanSocietyofLaw,
Medicine&Ethics,AmericanTraumaSociety,AssociationofAmericanMedicalColleges,PhysiciansforSocial
Responsibility
Disclosure:Nothingtodisclose.
Acknowledgements
ClintonSBeverly,MDClinicalAssistantProfessor,DepartmentofSurgery,MercerUniversitySchoolof
Medicine
ClintonSBeverly,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeonsand
SocietyofAmericanGastrointestinalandEndoscopicSurgeons
Disclosure:Nothingtodisclose.
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserve
UniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAcademyofEmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeof
EmergencyPhysicians,AmericanCollegeofPhysicians,AmericanHeartAssociation,AmericanThoracic
Society,ArkansasMedicalSociety,NewYorkAcademyofMedicine,NewYorkAcademyofSciences,and
SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
JackADiPalma,MDDirector,DivisionofGastroenterology,Professor,DepartmentofInternalMedicine,
UniversityofSouthAlabamaCollegeofMedicine
JackADiPalma,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterologyand
AmericanSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
DonGladden,DOStaffPhysician,DepartmentofEmergencyMedicine,SetonMedicalCenterWilliamson
DonGladden,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
Disclosure:Nothingtodisclose.
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
SamuelMKeim,MDAssociateProfessor,DepartmentofEmergencyMedicine,UniversityofArizonaCollegeof
Medicine
SamuelMKeim,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanCollegeofEmergencyPhysicians,AmericanMedicalAssociation,AmericanPublicHealth
Association,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
AlexandreFMigala,DOStaffPhysician,DepartmentofEmergencyMedicine,DentonRegionalMedicalCenter
AlexandreFMigala,DOisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanCollegeofEmergencyPhysicians,AmericanOsteopathicAssociation,AssociationofMilitary
OsteopathicPhysiciansandSurgeons,andTexasMedicalAssociation
Disclosure:Nothingtodisclose.
AnilMinocha,MD,FACP,FACG,AGAF,CPNSSProfessorofMedicine,DirectorofDigestiveDiseases,
MedicalDirectorofNutritionSupport,MedicalDirectorofGastrointestinalEndoscopy,InternalMedicine
Department,UniversityofMississippiMedicalCenterClinicalProfessor,UniversityofMississippiSchoolof
Pharmacy
AnilMinocha,MD,FACP,FACG,AGAF,CPNSSisamemberofthefollowingmedicalsocieties:American
AcademyofClinicalToxicology,AmericanAssociationfortheStudyofLiverDiseases,AmericanCollegeof
ForensicExaminers,AmericanCollegeofGastroenterology,AmericanCollegeofPhysicians,American
FederationforClinicalResearch,AmericanGastroenterologicalAssociation,andAmericanSocietyof
GastrointestinalEndoscopy
Disclosure:Nothingtodisclose.
TusharPatel,MB,ChBProfessorofMedicine,OhioStateUniversityMedicalCenter
TusharPatel,MB,ChBisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheStudyof
LiverDiseasesandAmericanGastroenterologicalAssociation
Disclosure:Nothingtodisclose.
RahulSharma,MD,MBA,FACEPMedicalDirectorandAssociateChiefofService,NYULangoneMedical
Center,TischHospitalEmergencyDepartmentAssistantProfessorofEmergencyMedicine,NewYorkUniversity

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CholecystitisClinicalPresentation:History,PhysicalExamination

SchoolofMedicine
RahulSharma,MD,MBA,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians,AmericanCollegeofPhysicianExecutives,PhiBetaKappa,andSocietyforAcademic
EmergencyMedicine
Disclosure:Nothingtodisclose.
PeterADSteel,MA,MBBSAttendingPhysician,DepartmentofEmergencyMedicine,JoanandSanfordI
WeillCornellMedicalCenter,NewYorkPresbyterianHospital
PeterADSteel,MA,MBBSisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,BritishMedicalAssociation,EmergencyMedicineResidentsAssociation,andSocietyforAcademic
EmergencyMedicine
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
AlanBRThomson,MDProfessorofMedicine,DivisionofGastroenterology,UniversityofAlberta,Canada
AlanBRThomson,MDisamemberofthefollowingmedicalsocieties:AlbertaMedicalAssociation,American
CollegeofGastroenterology,AmericanGastroenterologicalAssociation,CanadianAssociationof
Gastroenterology,CanadianMedicalAssociation,CollegeofPhysiciansandSurgeonsofAlberta,andRoyal
CollegeofPhysiciansandSurgeonsofCanada
Disclosure:Nothingtodisclose.
JefferyWolff,DOConsultingStaff,DepartmentofGastroenterology,BrookeArmyMedicalCenterStaff
Gastroenterologist,LandstuhlRegionalMedicalCenter
JefferyWolff,DO,isamemberofthefollowingmedicalsocieties:AmericanCollegeofGastroenterology,
AmericanGastroenterologicalAssociation,andAmericanSocietyforGastrointestinalEndoscopy
Disclosure:Nothingtodisclose.

References
1. HuffmanJL,SchenkerS.Acuteacalculouscholecystitisareview.ClinGastroenterolHepatol.2009Sep
9.[Medline].
2. DonovanJM.Physicalandmetabolicfactorsingallstonepathogenesis.GastroenterolClinNorthAm.1999
Mar.28(1):7597.[Medline].
3. SitzmannJV,PittHA,SteinbornPA,etal.Cholecystokininpreventsparenteralnutritioninducedbiliary
sludgeinhumans.SurgGynecolObstet.1990Jan.170(1):2531.[Medline].
4. CullenJJ,MaesEB,AggrawalS,etal.Effectofendotoxinonopossumgallbladdermotility:amodelof
acalculouscholecystitis.AnnSurg.2000Aug.232(2):2027.[Medline].
5. ForbesLE,BajajM,McGinnT,etal.Perihepaticabscessformationindiabetes:acomplicationofsilent
gallstones.AmJGastroenterol.1996Apr.91(4):7868.[Medline].
6. HuangJ,ChangCH,WangJL,KuoHK,LinJW,ShauWY,etal.Nationwideepidemiologicalstudyof
severegallstonediseaseinTaiwan.BMCGastroenterol.2009Aug22.9:63.[Medline].[FullText].
7. LeeSW,YangSS,ChangCS,YehHJ.ImpactoftheTokyoguidelinesonthemanagementofpatients
withacutecalculouscholecystitis.JGastroenterolHepatol.2009Aug3.[Medline].
8. McEvoyCF,SuchyFJ.Biliarytractdiseaseinchildren.PediatrClinNorthAm.1996Feb.43(1):7598.
[Medline].
9. GruberPJ,SilvermanRA,GottesfeldS,etal.Presenceoffeverandleukocytosisinacutecholecystitis.
AnnEmergMed.1996Sep.28(3):2737.[Medline].
10. NidimusiliAJ,AlraiesMC,EisaN,AlraiyesAH,ShaheenK.Leukocytosisofunknownorigin:gangrenous
cholecystitis.CaseRepMed.2013.2013:418014.[Medline].[FullText].
11. LioliosA,OropelloJM,BenjaminE.Gastrointestinalcomplicationsintheintensivecareunit.ClinChest
Med.1999Jun.20(2):32945,viii.[Medline].
12. ChiuHH,ChenCM,MoLR.Emphysematouscholecystitis.AmJSurg.2004Sep.188(3):3256.[Medline].
13. MoscatiRM.Cholelithiasis,cholecystitis,andpancreatitis.EmergMedClinNorthAm.1996Nov.
14(4):71937.[Medline].
14. YatesMR3rd,BaronTH.Biliarytractdiseaseinpregnancy.ClinLiverDis.1999.3:131147.
15. SingerAJ,McCrackenG,HenryMC,etal.Correlationamongclinical,laboratory,andhepatobiliary
scanningfindingsinpatientswithsuspectedacutecholecystitis.AnnEmergMed.1996Sep.28(3):26772.
[Medline].
16. [Guideline]KatzDS,RosenMP,BlakeMA,etalandExpertPanelonGastrointestinalImaging.ACR
AppropriatenessCriteriarightupperquadrantpain.[onlinepublication].Reston(VA):AmericanCollegeof
Radiology(ACR)2010.[FullText].
17. TowfighS,McFaddenDW,CortinaGR,etal.Porcelaingallbladderisnotassociatedwithgallbladder
carcinoma.AmSurg.2001Jan.67(1):710.[Medline].
18. StephenAE,BergerDL.Carcinomaintheporcelaingallbladder:arelationshiprevisited.Surgery.2001
Jun.129(6):699703.[Medline].
19. BingenerJ,SchwesingerWH,ChopraS,etal.Doesthecorrelationofacutecholecystitisonultrasound
andatsurgeryreflectamirrorimage?.AmJSurg.2004Dec.188(6):7037.
20. JangT,AubinC,NaunheimR.Minimumtrainingforrightupperquadrantultrasonography.AmJEmerg
Med.2004Oct.22(6):43943.[Medline].

http://emedicine.medscape.com/article/171886clinical

3/4

10/15/2015

CholecystitisClinicalPresentation:History,PhysicalExamination

21. RoeJ.Evidencebasedemergencymedicine.Clinicalassessmentofacutecholecystitisinadults.Ann
EmergMed.2006Jul.48(1):1013.[Medline].
22. RosenCL,BrownDF,ChangY,etal.Ultrasonographybyemergencyphysiciansinpatientswithsuspected
cholecystitis.AmJEmergMed.2001Jan.19(1):326.[Medline].
23. RubensDJ.Hepatobiliaryimaginganditspitfalls.RadiolClinNorthAm.2004Mar.42(2):25778.
[Medline].
24. ShahK,WolfeRE.Hepatobiliaryultrasound.EmergMedClinNorthAm.2004Aug.22(3):66173,viii.
[Medline].
25. KimYK,KwakHS,KimCS,HanYM,JeongTO,KimIH,etal.CTfindingsofmildformsorearly
manifestationsofacutecholecystitis.ClinImaging.2009JulAug.33(4):27480.[Medline].
26. SahaiAV,MauldinPD,MarsiV,etal.Bileductstonesandlaparoscopiccholecystectomy:adecision
analysistoassesstherolesofintraoperativecholangiography,EUS,andERCP.GastrointestEndosc.1999
Mar.49(3Pt1):33443.[Medline].
27. SiddiquiT,MacDonaldA,ChongPS,etal.Earlyversusdelayedlaparoscopiccholecystectomyforacute
cholecystitis:ametaanalysisofrandomizedclinicaltrials.AmJSurg.2008Jan.195(1):407.[Medline].
28. CoxMR,WilsonTG,LuckAJ,etal.Laparoscopiccholecystectomyforacuteinflammationofthe
gallbladder.AnnSurg.1993Nov.218(5):6304.[Medline].
29. LoCM,LiuCL,FanST,etal.Prospectiverandomizedstudyofearlyversusdelayedlaparoscopic
cholecystectomyforacutecholecystitis.AnnSurg.1998Apr.227(4):4617.[Medline].
30. [Guideline]OverbyDW,ApelgrenKN,RichardsonW,FanelliR.SAGESguidelinesfortheclinical
applicationoflaparoscopicbiliarytractsurgery.SurgEndosc.2010Oct.24(10):236886.[Medline].
31. WilsonE,GurusamyK,GluudC,DavidsonBR.Costutilityandvalueofinformationanalysisofearly
versusdelayedlaparoscopiccholecystectomyforacutecholecystitis.BrJSurg.2010Feb.97(2):2109.
[Medline].
32. TarragunAV,AzagraJS,LensV,ManzoniD,FabianoP,GoergenM.TwoStagedMinimallyInvasive
TreatmentforAcuteCholecystitisinHighRiskPatients.Hepatogastroenterology.2013May1.60(123):
[Medline].
33. BinenbaumSJ,TeixeiraJA,ForresterGJ,HarveyEJ,AfthinosJ,KimGJ,etal.Singleincision
laparoscopiccholecystectomyusingaflexibleendoscope.ArchSurg.2009Aug.144(8):7348.[Medline].
34. WuCH,ChenCC,WangCJ,etal.Discriminationofgangrenousfromuncomplicatedacutecholecystitis:
AccuracyofCTfindings.AbdomImaging.2011Apr.36(2):1748.[Medline].
35. SilberfeinEJ,ZhouW,KougiasP,etal.Percutaneouscholecystostomyforacutecholecystitisinhighrisk
patients:experienceofasurgeoninitiatedinterventionalprogram.AmJSurg.2007Nov.194(5):6727.
[Medline].
36. MutignaniM,IacopiniF,PerriV,etal.Endoscopicgallbladderdrainageforacutecholecystitis:technical
andclinicalresults.Endoscopy.2009Jun.41(6):53946.[Medline].
37. LiM,LiN,JiW,QuanZ,WanX,WuX,etal.PercutaneousCholecystostomyIsaDefinitiveTreatmentfor
AcuteCholecystitisinElderlyHighriskPatients.AmSurg.2013May.79(5):5247.[Medline].
38. LeeSS,ParkdoH,HwangCY,etal.EUSguidedtransmuralcholecystostomyasrescuemanagementfor
acutecholecystitisinelderlyorhighriskpatients:aprospectivefeasibilitystudy.GastrointestEndosc.2007
Nov.66(5):100812.[Medline].
39. GreenwaldJA,McMullenHF,CoppaGF,etal.Standardizationofsurgeoncontrolledvariables:impacton
outcomeinpatientswithacutecholecystitis.AnnSurg.2000Mar.231(3):33944.[Medline].
40. GuttCN,EnckeJ,KningerJ,HarnossJC,WeigandK,KipfmllerK,etal.Acutecholecystitis:early
versusdelayedcholecystectomy,amulticenterrandomizedtrial(ACDCstudy,NCT00447304).AnnSurg.
2013Sep.258(3):38593.[Medline].
41. LowenfelsA.Isearlysurgerybetterforacutecholecystitis?MedscapeMedicalNews.November6,2013.
Availableathttp://www.medscape.com/viewarticle/813363.Accessed:December2,2013.

MedscapeReference2011WebMD,LLC

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