From the Guidelines
Cholecystitis typically presents with right upper quadrant abdominal pain, fever, and leukocytosis, and is often diagnosed using a combination of clinical features, laboratory tests, and imaging studies, such as ultrasound, which shows pericholecystic fluid, a distended gall bladder, an edematous gallbladder wall, and gall stones 1. The clinical presentation of cholecystitis can vary, but common features include:
- Right upper quadrant abdominal pain that may radiate to the right shoulder or back
- Fever
- Leukocytosis
- Nausea and vomiting
- Anorexia
- Murphy's sign (pain with deep inspiration during palpation of the right upper quadrant) is characteristic Laboratory findings commonly include:
- Leukocytosis
- Mildly elevated liver enzymes
- Occasionally elevated bilirubin The diagnosis of acute cholecystitis is made on the basis of clinical features and is supported by findings from relevant imaging studies, such as ultrasound, which is the first-choice imaging investigation for patients with suspected acute cholecystitis due to its relatively low cost, lack of invasiveness, and high accuracy for gallbladder stones 1. The use of a combination of detailed history, complete clinical examination, laboratory tests, and imaging investigations is recommended for the diagnosis of acute cholecystitis, with ultrasound being the investigation of choice 1. In elderly patients, the presentation may be atypical with minimal pain but significant systemic symptoms like altered mental status or sepsis. Acalculous cholecystitis, occurring without gallstones, is less common and typically affects critically ill patients. Complications of untreated cholecystitis include gallbladder perforation, empyema, and rarely, gallstone ileus. The management of cholecystitis typically involves surgical intervention, with early cholecystectomy being preferable to delayed cholecystectomy as it results in a shorter recovery time and hospitalization compared to delayed cholecystectomy 1.
From the Research
Clinical Presentation of Cholecystitis
- The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness 2.
- Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis 2.
- Approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically in the setting of severe critical illness 2.
Diagnosis of Cholecystitis
- Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis 2.
- When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy (a nuclear medicine study that includes the intravenous injection of a radiotracer excreted in the bile) is the gold standard diagnostic test 2.
Treatment and Management of Cholecystitis
- Early (performed within 1-3 days) vs late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications and a shorter length of hospital stay 2.
- The use of antibiotic agents in patients undergoing cholecystectomy for gallbladder disease is recommended for patients undergoing laparoscopic cholecystectomy for acute cholecystitis, but not for low-risk patients undergoing elective laparoscopic cholecystectomy 3.
- The empirical use of first-generation cephalosporins for mild-to-moderate acute cholecystitis without gallbladder perforation was not inferior to using second-generation cephalosporin for prophylaxis against postoperative infection 4.
- A meta-analysis showed no significant benefit of extended antibiotic therapy in reducing surgical site infections after cholecystectomy for mild and moderate acute cholecystitis 5.