How do acute cholecystitis and chronic cholecystitis differ in presentation and management?

Acute vs Chronic Cholecystitis: Presentation and Management

Acute and chronic cholecystitis differ fundamentally in their clinical presentation, imaging findings, and management approach, with acute cholecystitis requiring urgent surgical intervention within 72 hours to 10 days while chronic cholecystitis presents with recurrent symptoms and allows for elective cholecystectomy. 1, 2

Clinical Presentation Differences

Acute Cholecystitis

• Right upper quadrant pain occurs in 72-93% of patients, typically continuous and sharp, aggravated by inhalation and eating 2
• Fever is present in only 36-74% of cases, with temperature >38°C in merely 6.4-10% of patients 2
• Vomiting or food intolerance occurs in 38-48% of affected individuals 2
• Murphy's sign has a positive likelihood ratio of 2.8 but low sensitivity (43-48%); its absence does not exclude disease 2
• Leukocytosis is documented in 41-59% of cases, with C-reactive protein >75 mg/L strongly supporting the diagnosis 2
• Results from cystic duct obstruction by gallstones in 90-95% of cases 3

Chronic Cholecystitis

• Associated with gallstones in 95% of cases and results from single or multiple recurrent episodes of acute cholecystitis 1
• Presents with chronic right upper quadrant pain and nausea or vomiting without acute inflammatory signs 4
• Leukocyte count and liver function tests are typically normal 4
• Chronic inflammation causes the gallbladder to become thickened and fibrotic 1

Diagnostic Imaging Distinctions

Acute Cholecystitis Imaging

• Ultrasound is the mandatory first-line imaging test with 81-88% sensitivity and 80-83% specificity 2, 3
• At least 2 ultrasound findings are required: gallstones/sludge, wall thickening >3mm, pericholecystic fluid, gallbladder distension, sonographic Murphy's sign, or impacted stones 2
• CT with IV contrast demonstrates gallbladder wall enhancement and adjacent liver parenchymal hyperemia (an early finding) 1
• MRI shows T2 signal hyperintensity in the gallbladder wall due to edema and perihepatic contrast enhancement 1
• If ultrasound is equivocal, hepatobiliary scintigraphy (HIDA scan) has 97% sensitivity and 90% specificity 2

Chronic Cholecystitis Imaging

• CT shows absence of adjacent liver parenchymal hyperemia and pericholecystic inflammatory change 1
• MRI demonstrates gallbladder wall thickening with low signal intensity (fibrosis) rather than T2 hyperintensity 1
• Abnormal gallbladder function noted by radionuclide hepatobiliary scan or cholecystography in 75% of cases 4
• Diagnosis is difficult to make at imaging; chronic inflammation and fibrosis are the hallmark pathologic features 1

Management Algorithms

Acute Cholecystitis Management

• Early laparoscopic cholecystectomy within 72 hours to 7-10 days of symptom onset is the definitive treatment, reducing complications and hospital stay 1, 2, 3
• Laparoscopic cholecystectomy performed before 3 days following symptom onset has a 27% conversion rate versus 59.5% after 3 days 5
• Early surgery (within 1-3 days) versus late surgery (after 3 days) results in fewer postoperative complications (11.8% vs 34.4%), shorter hospital stay (5.4 vs 10.0 days), and lower costs 3
• Antibiotic therapy should be initiated with amoxicillin/clavulanate, eravacycline, or tigecycline for 2-4 days if source control is adequate 2
• Medical management before surgery includes fasting, intravenous fluid infusion, antimicrobial therapy, and analgesics 6

High-Risk and Critically Ill Patients

• Cholecystostomy (percutaneous or endoscopic gallbladder drainage) should be performed in critically ill patients or those with multiple comorbidities unfit for surgery 1
• However, percutaneous cholecystostomy is associated with higher postprocedural complications (65%) compared with laparoscopic cholecystectomy (12%) 3
• In elderly patients over 65 years, laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared with nonoperative management (29.3%) 3
• Urgent cholecystostomy with or without delayed laparoscopic cholecystectomy is the correct approach for elderly, critically ill patients unfit for surgery 1

Chronic Cholecystitis Management

• Elective laparoscopic cholecystectomy is the treatment of choice 7
• In patients not eligible for early surgery, delay cholecystectomy at least 6 weeks after clinical presentation 6
• Cholecystectomy has approximately 0.5% overall mortality rate in all age groups 7
• All patients with chronic cholecystitis who underwent cholecystectomy had complete resolution of symptoms 4

Critical Complications Requiring Immediate Intervention

Gallbladder Perforation

• Occurs in 2-11% of acute cholecystitis cases with mortality as high as 12-16% 1
• Early diagnosis and immediate surgical intervention substantially decrease morbidity and mortality 1
• Type I (free perforation with generalized peritonitis) and Type II (pericholecystic abscess) require prompt surgical intervention 1
• CT scan is more reliable than ultrasound in demonstrating the defect in the gallbladder wall, pericholecystic collection, and free intraperitoneal fluid 1

Special Populations

• During pregnancy, early laparoscopic cholecystectomy is associated with lower maternal-fetal complications (1.6% vs 18.4% for delayed management) and is recommended during all trimesters 3
• In transplant patients, acute cholecystitis frequently occurs with acalculous disease in 40% of cases; operative management is safer than conservative treatment 1

Common Pitfalls to Avoid

• Do not exclude acute cholecystitis based on absence of fever or leukocytosis; no single clinical or laboratory finding has sufficient diagnostic power 2
• Do not delay surgery beyond 72 hours to 10 days from symptom onset, as this increases conversion rates and complications 1, 5
• Do not rely solely on ultrasound if equivocal; proceed to HIDA scan for definitive diagnosis 2
• Do not assume elderly or high-risk patients cannot tolerate surgery; laparoscopic cholecystectomy has better outcomes than nonoperative management in most cases 3
• Do not perform delayed cholecystectomy between 10 days and 6 weeks after symptom onset, as this is associated with higher morbidity 6