From the Guidelines
The correct answer is A. 75% associated with stone, as acute cholecystitis is predominantly associated with gallstones, with approximately 90-95% of cases being calculous cholecystitis (stone-related) 1. The statement that it's 75% associated with stones is closest to the truth, though the actual percentage is even higher. Regarding option B, while E. coli can be isolated in some cases of acute cholecystitis, the condition initially begins as a chemical inflammation rather than an infectious process, with bacterial infection occurring secondarily 1. Therefore, not all cases will be positive for organisms. For option C, this is incorrect because HIDA scan is actually one of the most sensitive tests for acute cholecystitis, showing non-visualization of the gallbladder when the cystic duct is obstructed 1. A normal HIDA scan (where the radiotracer fills the gallbladder normally) effectively rules out acute cholecystitis, making this statement false. Some key points to consider in the diagnosis and management of acute cholecystitis include:
- The use of abdominal ultrasonography and hepatobiliary scintigraphy for diagnosis 1
- The importance of early diagnosis and treatment to reduce morbidity and mortality rates 1
- The role of laparoscopic cholecystectomy as a safe and effective treatment for acute cholecystitis 1
- The consideration of cholecystostomy as a treatment option for critically ill patients or those with multiple comorbidities 1
From the Research
Acute Cholecystitis Overview
- Acute cholecystitis is generally associated with the presence of gallstones, with approximately 95% of people with acute cholecystitis having gallstones 2.
- 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 3.
Diagnosis and Treatment
- Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis 3.
- Hepatobiliary scintigraphy (a nuclear medicine study that includes the intravenous injection of a radiotracer excreted in the bile) is the gold standard diagnostic test when an ultrasound result does not provide a definitive diagnosis 3.
- Early laparoscopic cholecystectomy (performed within 1-3 days) is associated with improved patient outcomes, including fewer composite postoperative complications, a shorter length of hospital stay, and lower hospital costs 3.
Specific Considerations
- 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 3.
- For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy 3.
- In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up compared with nonoperative management 3.
Answer to the Question
- Option A (75% associated with stone) is not entirely accurate, as approximately 95% of people with acute cholecystitis have gallstones 2.
- Option B (Positive with organism (E. Coli)) is not directly addressed in the provided evidence.
- Option C (HIDA scan normal even with acute cholecystitis) is not supported by the evidence, as hepatobiliary scintigraphy is considered the gold standard diagnostic test when an ultrasound result does not provide a definitive diagnosis 3.