What are the typical presentation, diagnosis, management, and complications of cholecystitis (inflammation of the gallbladder)?

Cholecystitis: Presentation, Diagnosis, Management, and Complications

Acute cholecystitis is best diagnosed through a combination of clinical features (right upper quadrant pain, fever, and leukocytosis) and ultrasound findings, and should be treated with early laparoscopic cholecystectomy within 7 days of hospital admission and 10 days of symptom onset for optimal outcomes. 1, 2

Typical Presentation (Signs and Symptoms)

Clinical Features

• Right upper quadrant pain: Most common presenting symptom
• Fever: Common accompanying sign
• Nausea and vomiting: Frequently associated with eating
• Anorexia: Loss of appetite
• Murphy's sign: Inspiratory arrest during deep palpation of the right upper quadrant
• Leukocytosis: Elevated white blood cell count 1, 3

Differential Diagnosis

• Acute hepatitis
• Peptic ulcer disease
• Acute pancreatitis
• Right lower lobe pneumonia
• Perforated duodenal ulcer
• Appendicitis (especially retrocecal)
• Hepatic abscess
• Biliary colic without cholecystitis
• Acute cholangitis
• Biliary dyskinesia 4

Investigation

First-Line Imaging

• Ultrasonography: First choice for suspected cholecystitis with sensitivity of ~81% and specificity of ~83% 1, 3
  • Key findings:
    • Gallstones (in 90-95% of cases)
    • Gallbladder wall thickening (>3mm)
    • Pericholecystic fluid
    • Distended gallbladder
    • Positive sonographic Murphy's sign 1, 2

Second-Line Imaging

• Hepatobiliary scintigraphy (HIDA scan): Gold standard when ultrasound is inconclusive, with higher sensitivity and specificity than ultrasound 1, 3
• CT scan with IV contrast: Useful for detecting complications, fluid collections, and vascular injuries 2
• CE-MRCP: For precise visualization of bile duct injuries 2

Laboratory Tests

• Complete blood count (leukocytosis)
• Liver function tests (may show mild elevation)
• Inflammatory markers (elevated C-reactive protein)

Management

Surgical Management

• Early laparoscopic cholecystectomy: First-line treatment for most patients
  • Should be performed within 7 days of hospital admission and within 10 days of symptom onset
  • Associated with shorter recovery time, shorter hospital stay, and lower costs compared to delayed cholecystectomy 1, 2, 3
• Open cholecystectomy: May be necessary in cases of severe inflammation, adhesions, or anatomical variations 1
• Mini laparotomy cholecystectomy: May be appropriate in resource-constrained settings 1

Non-Operative Management

• Percutaneous cholecystostomy: For critically ill patients or those with multiple comorbidities unfit for surgery
  • Note: Associated with higher rates of postprocedural complications (65%) compared to laparoscopic cholecystectomy (12%) 2, 3

Antibiotic Therapy

• First-line options for community-acquired infections:

  • Beta-lactam/beta-lactamase inhibitor combinations:
    • Amoxicillin/Clavulanate
    • Piperacillin/Tazobactam
  • Cephalosporin-based regimens:
    • Ceftriaxone + Metronidazole
    • Cefepime + Metronidazole
  • For beta-lactam allergy:
    • Ciprofloxacin + Metronidazole
    • Levofloxacin + Metronidazole
    • Moxifloxacin 2

• Duration: 3-5 days for uncomplicated cases 2

Pain Management

• NSAIDs as first-line therapy
• Acetaminophen as alternative or adjunct 2

Complications

Direct Complications

• Gangrenous cholecystitis: Necrosis of gallbladder wall due to ischemia
• Emphysematous cholecystitis: Gas-forming bacterial infection of gallbladder wall
• Gallbladder perforation: Leading to localized abscess or generalized peritonitis
• Hemorrhagic cholecystitis: Bleeding into gallbladder lumen 5

Secondary Complications

• Choledocholithiasis: Common bile duct stones (10-20% of cases)
• Cholangitis: Infection of the biliary tree
• Gallstone pancreatitis: Inflammation of pancreas due to gallstone obstruction
• Gallstone ileus: Bowel obstruction due to large gallstone 5, 4

Mortality Considerations

• Higher mortality in acalculous cholecystitis (45.2%) compared to calculous cholecystitis (21.2%)
• Mortality rates increase with:
  • Male gender
  • Advanced age
  • Severe systemic disease
  • Common bile duct exploration 2
• Perforation carries a mortality rate of 12-16% 2

Special Populations

Elderly Patients

• Laparoscopic cholecystectomy associated with lower 2-year mortality (15.2%) compared to non-operative management (29.3%) 3

Pregnant Patients

• Early laparoscopic cholecystectomy recommended during all trimesters
• Lower risk of maternal-fetal complications (1.6%) compared to delayed management (18.4%) 3

Early diagnosis and appropriate management are crucial for preventing complications and reducing mortality in patients with acute cholecystitis.