From the Guidelines
Surrounding pericholecystic echogenic fat is a strong indicator of acute cholecystitis, and management should involve early laparoscopic cholecystectomy, as it is a safe and effective treatment that results in shorter recovery time and hospitalization compared to delayed cholecystectomies 1.
Diagnosis and Treatment
The diagnosis of acute cholecystitis is made on the basis of clinical features such as right upper quadrant pain, fever, and leukocytosis, and is supported by findings from relevant imaging studies, including ultrasound, which typically shows pericholecystic fluid, distended gall bladder, oedematous gallbladder wall, and gall stones, and Murphy’s sign can be elicited on ultrasound examination 1.
- Key findings on ultrasound include:
- Pericholecystic fluid
- Distended gall bladder
- Oedematous gallbladder wall
- Gall stones
- Murphy’s sign
Management Approach
Early laparoscopic cholecystectomy is the recommended treatment for acute cholecystitis, as it is a safe and effective treatment that results in shorter recovery time and hospitalization compared to delayed cholecystectomies 1.
- The treatment approach should involve:
- Early laparoscopic cholecystectomy
- Antibiotics such as piperacillin-tazobactam or ceftriaxone plus metronidazole for 3-5 days
- Pain control using NSAIDs or opioids as needed
- Fasting and IV fluids
- Further imaging like HIDA scan if diagnosis is uncertain
Special Considerations
- In critically ill patients or those with multiple comorbidities, cholecystostomy may be a safe and effective treatment option 1.
- Early diagnosis of gallbladder perforation and immediate surgical intervention may substantially decrease morbidity and mortality rates 1.
From the Research
Surrounding Pericholecystic Echogenic Fat
- Pericholecystic echogenic fat is a sonographic finding that can be associated with acute cholecystitis, as mentioned in the study 2.
- The presence of echogenic pericholecystic fat is considered a helpful sonographic finding of acute cholecystitis, along with other signs such as a dilated gallbladder, increased intraluminal pressures, and wall hyperemia 2.
- A study published in 2022 found that patients with gangrenous cholecystitis were more likely to have echogenic pericholecystic fat, mucosal discontinuity, and frank perforation on imaging 3.
- The positive likelihood ratio for gangrenous cholecystitis with echogenic fat was found to be 4.6, and with mucosal discontinuity, it was 14.4, indicating that these sonographic findings can be useful in identifying gangrenous cholecystitis 3.
- Echogenic pericholecystic fat and mucosal discontinuity are considered early sonographic findings that may help identify gangrenous cholecystitis prior to late findings of frank perforation 3.
Diagnosis and Treatment of Acute Cholecystitis
- Acute cholecystitis is typically diagnosed using ultrasonography, which has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis 4.
- Early laparoscopic cholecystectomy is considered the best treatment for acute cholecystitis, and it is recommended to be performed within 1-3 days of diagnosis 5, 4.
- Percutaneous gallbladder drainage with or without cholecystostomy tube placement is a safe and effective management technique for surgically high-risk patients with multiple medical conditions 6.
Clinical Presentation and Imaging
- 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 4, 6.
- Imaging studies such as ultrasonography, computed tomography, and magnetic resonance imaging are helpful in the diagnosis and management of acute cholecystitis, and can help identify complications such as cholescintigraphy 2, 6.