ACUTE CHOLECYSTITIS

The most common cause of acute cholecystitis is obstruction of the cystic duct by gallstones,
resulting in acute inflammation. Approximately 90 percent of cases of acute cholecystitis are
associated with cholelithiasis. The clinical features of acute cholecystitis may include symptoms
of local inflammation (e.g., right upper quadrant mass, tenderness) and systemic toxicity (e.g.,
fever, leukocytosis). Most patients with acute cholecystitis have had previous attacks of biliary
pain. The pain of acute cholecystitis typically lasts longer than three hours and, after three hours,
shifts from the epigastrium to the right upper quadrant. This sequence of clinical features
includes visceral pain from ductal impaction by stones, progressing to inflammation of the
gallbladder with parietal pain.

In elderly patients, localized tenderness may be the only presenting sign; pain and fever may be
absent.7 In 30 to 40 percent of patients, the gallbladder and adherent omentum can be perceived
as a palpable mass. Jaundice is noted in approximately 15 percent of patients with acute
cholecystitis, even without choledocholithiasis. The pathogenesis may involve edema and
inflammation secondary to the impacted stone in the cystic duct. This leads to the compression
of the common hepatic duct or the common bile duct (Mirizzi's syndrome).

In the event of delayed diagnosis in the setting of acute cholecystitis, the cystic duct remains
obstructed, and the lumen may become distended with clear mucoid fluid (hydrops of the
gallbladder). Although rare, a large gallstone in the gallbladder will sometimes erode through the
gallbladder wall into an adjacent viscus, usually the duodenum. Subsequently, the stone may
become impacted in the terminal ileum (small bowel obstruction) or in the duodenal bulb/pylorus,
causing gastric outlet obstruction (Bouveret's syndrome). Patients with chronic cholecystitis
usually have had repeated attacks of biliary pain or acute cholecystitis. This results in a
thickened and fibrotic gallbladder that may not be palpable in these patients.

Cholecystitis the cystic duct remains obstructed hydrops of the gallbladder

gallstone in the gallbladder erode through the gallbladder wall duodenum stone may
become impacted in the terminal ileum (small bowel obstruction) or in the duodenal
bulb/pylorus gastric outlet obstruction (Bouveret's syndrome)

Acute cholecystitis may present as an acalculous disorder in 5 to 10 percent of patients.

Acalculous cholecystitis typically affects critically ill, older men in the setting of major surgery,
critical illness, total parenteral nutrition, extensive trauma or burn-related injury. The
pathogenesis probably involves a combination of biliary stasis, chemical inflammation and
ischemia. Complications develop more frequently in acalculous cholecystitis than in calculous
cholecystitis.

Rarely, infectious agents can cause acute cholecystitis. Cytomegalovirus and cryptosporidia can
result in cholecystitis and cholangitis in immunocompromised persons. Salmonella can colonize
the gallbladder epithelium without eliciting inflammation, creating a carrier state.

CHOLEDOCHOLITHIASIS
Acute suppurative cholangitis is a common complication of choledocholithiasis. The usual clinical
presentation, occurring in 70 percent of the cases of choledocholithiasis, consists of pain,
jaundice and chills (i.e., Charcot's triad). Refractory sepsis characterized by altered mentation,
hypotension and Charcot's triad constitutes Raynold's pentad. Depending on the progression of
the illness, endotoxemia with shock or multiple liver abscesses may be noted. On the other hand,
cholangitis may be a short, self-limited illness complicating choledocholithiasis. The most
commonly found organisms are Escherichia coli, Klebsiella, Pseudomonas and enterococci, with
a 15 percent contribution by anaerobes.

Acute biliary pancreatitis is another potential complication of choledocholithiasis. 8 Differentiating

acute pancreatitis from cholecystitis can be difficult because both conditions produce tenderness
in an overlapping area. Although acute cholecystitis alone can be associated with
hyperamylasemia, pancreatitis often has higher enzyme levels. Also, cholecystitis and
pancreatitis may coexist.

Diagnostic Studies
A wide array of laboratory and radiologic studies is used for the evaluation of gallstones located
in the gallbladder and the common bile duct. There are strengths and limitations to each
diagnostic test.

LABORATORY TESTS
In uncomplicated biliary colic, there are usually no accompanying changes in hematologic and
biochemical tests. In acute cholecystitis, leukocytosis with a left shift is usually observed.
Serum aminotransferase, alkaline phosphatase, bilirubin and amylase levels may also be
elevated. The most reliable indicator of gallstones as the cause of acute pancreatitis is an
elevation of alanine aminotransferase levels greater than 2.5 times above normal. 8

ULTRASONOGRAPHY
Ultrasonography should be a routine examination for the confirmation or exclusion of gallstone
disease. Ultrasonography provides more than 95 percent sensitivity and specificity for the
diagnosis of gallstones greater than 2 mm in diameter. Ultrasonography of the gallbladder should
follow a fast of at least eight hours because gallstones are visualized better in a distended, bile-
filled gallbladder.

Ultrasonography is less sensitive for the diagnosis of choledocholithiasis and may document only
one half of common bile duct stones.9 Ultrasound scans may indicate dilatation of intrahepatic or
extrahepatic bile ducts, which is highly suggestive of distal obstruction, with a sensitivity of 76
percent. Ultrasonographic findings that are suggestive of acute cholecystitis include the following:
pericholecystic fluid (in the absence of ascites); gallbladder wall thickening greater than 4 mm (in
the absence of hypoalbuminemia); and sonographic Murphy's sign (abrupt arrest of breathing
during the inspiration phase secondary to pain elicited by placing the ultrasound probe in the
right upper quadrant).

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Endoscopic retrograde cholangiopancreatography (ERCP) is the best method for determining a
diagnosis of choledocholithiasis.10 ERCP provides diagnostic and therapeutic options, and has a
sensitivity and specificity of 95 percent for the detection of common bile duct stones.

BILE MICROSCOPY
It is essential that gallbladder bile (induced by cholecystokinin), rather than hepatic or ductal bile,
be obtained to maximize sensitivity for detecting sludge. A bile sample may be obtained by
aspiration through the catheter during ERCP. Bile must be centrifuged and examined under
polarizing or light microscopy for detection of precipitates.

COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING

The latest computer technology, processing computed tomographic (CT) and magnetic
resonance imaging (MRI) data into a three-dimensional image of the bile duct, is now
comparable to the ERCP in terms of diagnostic accuracy.11,12 Although CT and MRI provide the
advantage of noninvasiveness, they offer no therapeutic options.

HEPATOBILIARY SCINTIGRAPHY
Hepatobiliary scintigraphy can confirm or exclude the diagnosis of acute cholecystitis with a high
degree of sensitivity and specificity.13 After a two- to four-hour fast, the patient is given an
intravenous injection of a technetium-99mlabeled iminodiacetic acid derivative (IDA agent) that
is excreted into the bile ducts and sequentially imaged under a gamma camera.

In a normal study, images of the gallbladder, common bile duct and small bowel appear within 30
to 45 minutes.14 A normal Tc-99m-IDA scan virtually rules out the diagnosis of acute cholecystitis
in patients who present with abdominal pain. An abnormal or positive Tc-99m-IDA scan can be
defined as non-visualization of the gallbladder with preserved excretion into the common bile
duct and small bowel. Failure to image the gallbladder within 90 minutes despite adequate views
of the liver, common bile duct and small bowel strongly suggests acute obstruction of the cystic
duct. False-positive findings can result from nonfasting or prolonged fasting states, 14 chronic
alcoholism and chronic cholecystitis. Repeat scanning after four or more hours decreases the
false-positive rate.

In patients with acute acalculous cholecystitis, prolonged fasting may result in viscous
(concentrated) bile and a false-positive hepatobiliary scan. Alternatively, patients with acalculous
cholecystitis may not have an obstructed cystic duct, resulting in a false-negative hepatobiliary
scan. False-positive results occur more frequently than false-negative results. The hepatobiliary
scan has a sensitivity greater than 90 percent, but the lack of specificity in fasting, critically ill
patients limits the use of the hepatobiliary scan to exclusion of acute acalculous cholecystitis
rather than confirmation of the diagnosis.

Management
Cholelithiasis can be diagnosed in a variety of clinical circumstances. A patient can be
asymptomatic, have a history of one or more uncomplicated biliary pain episodes or have
complications of acute cholecystitis, gangrene, jaundice or even gallbladder cancer.

ASYMPTOMATIC GALLSTONES
It is estimated that 60 to 80 percent of all gallstones are asymptomatic at some point. 15 Adult
patients with silent or incidental gallstones should be observed and managed expectantly,
including patients with diabetes.16 In diabetic patients, the natural history of gallstones is
generally benign, and there is low risk of a major complication.15 There is no evidence to suggest
that prophylactic cholecystectomy prolongs life expectancy. However, prophylactic
cholecystectomy should be performed in patients at high risk of gallbladder carcinoma (Figure 1).
The specific groups at high risk of gallbladder cancer include patients with asymptomatic
gallstones who are Pima Indians or who have a calcified gall-bladder, gallbladder polyps greater
than 10 mm, gallstones greater than 2.5 cm or anomalous pancreaticobiliary ductal junction, and
carriers of Salmonella typhosa.

SYMPTOMATIC GALLSTONES

Once an episode of biliary colic has occurred, there is a high risk of repeated
pain attacks. Cohort studies with follow-up of patients with symptomatic
gallstones indicate a 38 to 50 percent incidence rate of recurrent biliary pain
per year.17 Patients with symptomatic gallstones are more likely to develop
biliary complications.18 The risk of developing biliary complications is estimated
to be 1 to 2 percent per year.

As many as 30 percent of patients who are observed for several years do not
have further problems. Therefore, a management plan is dependent on the
patient's decision and surgical candidacy. For patients who do not want to risk
the possibility of a future attack, a laparoscopic cholecystectomy is
recommended.

In the 1980s, considerable interest was generated in the evaluation of

nonsurgical treatment strategies for gallstone disease. Nonoperative therapy is
costly and time-consuming, and should be reserved for use in the symptomatic
patient who declines surgery or has a high operative risk19,20

ACUTE CHOLECYSTITIS

Most physicians agree that early laparoscopic cholecystectomy (within 24 to

48 hours) is indicated once the diagnosis of acute cholecystitis is secure and
the patient is hemodynamically stable. Use of this surgical technique is
supported by large randomized trials conclusively demonstrating its clinical
superiority over open cholecystectomy.21 The potential advantages of
laparoscopic cholecystectomy include a marked reduction in postoperative
pain, a shorter hospital stay and a more rapid return to work and usual
activities. A percutaneous cholecystostomy or transpapillary endoscopic
cholecystostomy should be considered in patients with acute cholecystitis who
are at excessive risk for surgery22,2
A glossary of the complications of cholelithiasis
1. Acute cholecystitis is the most frequent complication of symptomatic
cholelithiasis and is characterised by inflammation of the gallbladder
wall.6 The risk of this is increased in patients with larger gallstones that are
more likely to be trapped within the gallbladder. Gangrenous cholecystitis
and perforation of the gallbladder are serious complications of acute
cholecystitis.13 In severe cases acute cholecystitis can be fatal.
2. Chronic cholecystitis is also common and results from recurrent or
relapsing bouts of acute cholecystitis. Rare but serious complications of
chronic cholecystitis include:
o Mirizzi syndrome, which is an unusual cause of obstructive
jaundice occurring when a large stone becomes impacted in
Hartmans pouch causing extrinsic compression and eventual
erosion of the common hepatic duct
o Gallstone ileus, which occurs when there is mechanical
obstruction due to the impaction of a large gallstone at the
ileocaecal valve, often after spontaneously eroding into the small
bowel via a cholecystoenteric fistula
o Gallbladder cancer, which in most cases develops from long-
term cholelithiasis and chronic cholecystitis. Patients are often
asymptomatic until the cancer develops. Most early gallbladder
cancers are diagnosed incidentally following cholecystectomy for
cholelithiasis.
b. Choledocholithiasis is the migration of gallstones from the gallbladder into
the common biliary duct. This is more likely to occur in patients with small
gallstones because these can pass with greater ease through the cystic
duct.6 There are three main clinical consequences of choledocholithiasis:
o Obstructive jaundice, which occurs when a bile duct stone
obstructs the flow of bile into the duodenum. Patients will typically
present with biliary colic accompanied by jaundice, dark urine, pale
stools and pruritus.
o Acute pancreatitis, which is caused by temporary obstruction to
the pancreatic duct during passage of a bile duct stone through the
ampulla of Vater into the duodenum. It can range in severity from
mild and transient to life-threatening.
o Ascending cholangitis, which occurs when bile in an obstructed
bile duct becomes infected, often from bacteria embedded in the
matrix of a gallstone within the bile duct.10
(Genc, et al., 2011) (AHMED, CHEUNG, & KEEFFE, 2000 )

Bibliography
ABRAHAM, S., RIVERO, H. G., ERLIKH, I. V., & GRIFFITH, L. F. (2014). Surgical and
Nonsurgical Management of Gallstones. American Academy of
Family Physicians.

AHMED, A., CHEUNG, R. C., & KEEFFE, E. B. (2000 ). Management of Gallstones

and Their Complications. Am Fam Physician , 15;61(6):1673-
1680.

Chemmanur, A. T. (2016, Juny 03). Biliary Disease Treatment & Management.

Retrieved 11 16, 13, from
http://emedicine.medscape.com/article/171386-treatment

Genc, V., Sulaimanov, M., Cipe, G., Basceken, S. I., Erverdi, N., Gurel, M., et al.
(2011). What necessitates the conversion to open
cholecystectomy? A retrospective analysis of 5164 consecutive
laparoscopic operations. CLINICS , 66(3):417-420.

Bibliography
ABRAHAM, S., RIVERO, H. G., ERLIKH, I. V., & GRIFFITH, L. F. (2014). Surgical and
Nonsurgical Management of Gallstones. American Academy of
Family Physicians.

AHMED, A., CHEUNG, R. C., & KEEFFE, E. B. (2000 ). Management of Gallstones

and Their Complications. Am Fam Physician , 15;61(6):1673-
1680.

Chemmanur, A. T. (2016, Juny 03). Biliary Disease Treatment & Management.

Retrieved 11 16, 13, from
http://emedicine.medscape.com/article/171386-treatment

Genc, V., Sulaimanov, M., Cipe, G., Basceken, S. I., Erverdi, N., Gurel, M., et al.
(2011). What necessitates the conversion to open
cholecystectomy? A retrospective analysis of 5164 consecutive
laparoscopic operations. CLINICS , 66(3):417-420.

(Chemmanur, 2016)

(Abraham, Rivero, Erlikh, & Grifith, 2014)