Acute cholecystitis

Acute cholecystitis refers to inflammation of the gallbladder and classically presents as a syndrome of right upper quadrant pain, fever, and leucocytosis.

Gallstones are present in 7% of the population, and more common in women and with increasing age. Gallstones can cause biliary colic, acute cholecystitis and chronic cholecystitis. Approximately 20% will become symptomatic within 15 years of follow-up, 1-2% will develop other complications and the majority of these complications will occur in patients with biliary colic. In a systematic review, it was seen in 6-11% of patients with symptomatic gallstones over a median follow-up of 7 to 11 years. Acalculous cholecystitis is clinically identical to acute cholecystitis but is not associated with gallstones and usually occurs in critically ill patients. It accounts for approximately 10% of cases of acute cholecystitis and is associated with high morbidity and mortality rates.

Step 1: Pathway Entry

RUQ / epigastric pain, around the waist, or to the back, scapula, or right shoulder, left upper back.

Fever may be present.

Risk factors:

  • increased age

  • female

  • parity

  • obesity

  • diabetes mellitus

  • profound weight loss

  • fasting

  • cystic fibrosis

  • malabsorption syndromes

  • familial

  • various medication (oral contraceptive pill and clofibrate).

Uncommonly, acute cholecystitis may present even if the patient has had a cholecystectomy.

Step 2: Is the patient stable?

Initiate resuscitation if unstable. If the patient has severe sepsis, initiate the sepsis pathway.

Consideration of other life threatening diagnoses - acute pancreatitis, septic shock from other intraabdominal source or right sided pneumonia, perforated viscus (in particular perforated peptic ulcer, ruptured ectopic pregnancy in women of childbearing age), cardiac ischaemia.

Step 3: Initial assessment

Detailed history and examination. Positive Murphy's sign is 97% sensitive and 48% specific.

ECG to exclude cardiac ischaemia.

Blood tests should include FBC, EUC, LFT, lipase (and blood cultures if febrile), beta-HCG in women of childbearing age.

Step 4: Imaging

AXR not useful in diagnosing gallstones (only 20% radiopaque). If done it may detect air in the biliary tract or gallbladder wall caused by emphysematous cholecystitis, cholangitis, or cholecystic-enteric fistula (however other imaging modalities are more useful).

CXR if possible pneumonia, perforated viscus.

Bedside ultrasound:

Formal ultrasound (sensitivity 94%, specificity 78%).

CT (sensitivity 95%, specificity 96%), useful when ultrasound equivocal and to exclude differentials and complications of acute cholecystitis.

Step 5: Management

IV antibiotics: ampicillin and gentamicin. (Click here to view the eTG Therapeutic Guidelines)

Supportive care:

  • NBM, IV fluids

  • Monitor fluid input / output

  • Analgesia (opiates, NSAIDS).

Step 6: Seek and treat complications

  • Gangrene

  • Perforation

  • Cholecystoenteric fistula

  • Gallstone ileus

  • Emphysematous cholecystitis.

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