Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Uncomplicated cholecystitis has an excellent prognosis; the development of complications such as perforation or g

Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Uncomplicated cholecystitis has an excellent prognosis; the development of complications such as perforation or gangrene renders the prognosis less favorable.

Signs and symptoms

The most common presenting symptom of acute cholecystitis is upper abdominal pain. The following characteristics may be reported:

Signs of peritoneal irritation may be present, and the pain may radiate to the right shoulder or scapula

Pain frequently begins in the epigastric region and then localizes to the right upper quadrant (RUQ)

Pain may initially be colicky but almost always becomes constant

Nausea and vomiting are generally present, and fever may be noted

Patients with acalculous cholecystitis may present with fever and sepsis alone, without history or physical examination findings consistent with acute cholecystitis.

Cholecystitis may present differently in special populations, as follows:

Elderly (especially diabetics) May present with vague symptoms and without many key historical and physical findings (eg, pain and fever), with localized tenderness the only presenting sign; may progress to complicated cholecystitis rapidly and without warning

Children May present without many of the classic findings; those at higher risk for cholecystitis include those who have sickle cell disease, serious illness, a requirement for prolonged total parenteral nutrition (TPN), hemolytic conditions, or congenital and biliary anomalies

The physical examination may reveal the following:

Fever, tachycardia, and tenderness in the RUQ or epigastric region, often with guarding or rebound

Palpable gallbladder or fullness of the RUQ (30-40% of patients)

Jaundice (~15% of patients)

The absence of physical findings does not rule out the diagnosis of cholecystitis.

See Presentation for more detail.

Diagnosis

Laboratory tests are not always reliable, but the following findings may be diagnostically useful:

Leukocytosis with a left shift may be observed

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels may be elevated in cholecystitis or with common bile duct (CBD) obstruction

Bilirubin and alkaline phosphatase assays may reveal evidence of CBD obstruction

Amylase/lipase assays are used to assess for pancreatitis; amylase may also be mildly elevated in cholecystitis

Alkaline phosphatase level may be elevated (25% of patients with cholecystitis)

Urinalysis is used to rule out pyelonephritis and renal calculi

All females of childbearing age should undergo pregnancy testing

Diagnostic imaging modalities that may be considered include the following:

Radiography

Ultrasonography

Computed tomography (CT)

Magnetic resonance imaging (MRI)

Hepatobiliary scintigraphy (see the image below)

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Endoscopic retrograde cholangiopancreatography (ERCP)

The American College of Radiology (ACR) makes the following imaging recommendations:

Ultrasonography is the preferred initial imaging test for the diagnosis of acute cholecystitis; scintigraphy is the preferred alternative

CT is a secondary imaging test that can identify extrabiliary disorders and complications of acute cholecystitis

CT with intravenous (IV) contrast is useful in diagnosing acute cholecystitis in patients with nonspecific abdominal pain

MRI, often with IV gadolinium-based contrast medium, is also a possible secondary choice for confirming a diagnosis of acute cholecystitis

MRI without contrast is useful for eliminating radiation exposure in pregnant women when ultrasonography has not yielded a clear diagnosis

Contrast agents should not be used in patients on dialysis unless absolutely necessary

See Workup for more detail.

Management

Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications.

For acute cholecystitis, initial treatment includes bowel rest, IV hydration, correction of electrolyte abnormalities, analgesia, and IV antibiotics. Options include the following:

Sanford guide Piperacillin-tazobactam, ampicillin-sulbactam, or meropenem; in severe life-threatening cases, imipenem-cilastatin

Alternative regimens Third-generation cephalosporin plus metronidazole

Emesis can be treated with antiemetics and nasogastric suction

Because of the rapid progression of acute acalculous cholecystitis to gangrene and perforation, early recognition and intervention are required.

Supportive medical care should include restoration of hemodynamic stability and antibiotic coverage for gram-negative enteric flora and anaerobes if biliary tract infection is suspected.

Daily stimulation of gallbladder contraction with IV cholecystokinin (CCK) may help prevent formation of gallbladder sludge in patients receiving TPN

For cases of uncomplicated cholecystitis, outpatient treatment may be appropriate. The following medications may be useful in this setting:

Levofloxacin and metronidazole for prophylactic antibiotic coverage against the most common organisms

Antiemetics (eg, promethazine or prochlorperazine) to control nausea and prevent fluid and electrolyte disorders

Analgesics (eg, oxycodone/acetaminophen)

Surgical and interventional procedures used to treat cholecystitis include the following:

Laparoscopic cholecystectomy (standard of care for surgical treatment of cholecystitis)

Percutaneous drainage

ERCP

Endoscopic ultrasound-guided transmural cholecystostomy

Endoscopic gallbladder drainage

See Treatment and Medication for more detail.

Cholecystitis is defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Ninety percent of cases involve stones in the cystic duct (ie, calculous cholecystitis), with the other 10% of cases representing acalculous cholecystitis.[1] Risk factors for cholecystitis mirror those for cholelithiasis and include increasing age, female sex, certain ethnic groups, obesity or rapid weight loss, drugs, and pregnancy. Although bile cultures are positive for bacteria in 50-75% of cases, bacterial proliferation may be a result of cholecystitis and not the precipitating factor.

Acalculous cholecystitis is related to conditions associated with biliary stasis, including debilitation, major surgery, severe trauma, sepsis, long-term total parenteral nutrition (TPN), and prolonged fasting. Other causes of acalculous cholecystitis include cardiac events; sickle cell disease; Salmonella infections; diabetes mellitus; and cytomegalovirus, cryptosporidiosis, or microsporidiosis infections in patients with AIDS. (See Etiology.) For more information, see the Medscape Reference article Acalculous Cholecystopathy.

Uncomplicated cholecystitis has an excellent prognosis, with a very low mortality rate. Once complications such as perforation/gangrene develop, the prognosis becomes less favorable. Some 25-30% of patients either require surgery or develop some complication. (See Prognosis.)

The most common presenting symptom of acute cholecystitis is upper abdominal pain. The physical examination may reveal fever, tachycardia, and tenderness in the RUQ or epigastric region, often with guarding or rebound. However, the absence of physical findings does not rule out the diagnosis of cholecystitis. (See Clinical Presentation.)

Delays in making the diagnosis of acute cholecystitis result in a higher incidence of morbidity and mortality. This is especially true for ICU patients who develop acalculous cholecystitis. The diagnosis should be considered and investigated promptly in order to prevent poor outcomes. (See Diagnosis.)

Initial treatment of acute cholecystitis includes bowel rest, intravenous hydration, correction of electrolyte abnormalities, analgesia, and intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy with a single broad-spectrum antibiotic is adequate. Outpatient treatment may be appropriate for cases of uncomplicated cholecystitis. If surgical treatment is indicated, laparoscopic cholecystectomy represents the standard of care. (See Treatment and Management.)

Patients diagnosed with cholecystitis must be educated regarding causes of their disease, complications if left untreated, and medical/surgical options to treat cholecystitis. For patient education information, see the Liver, Gallbladder, and Pancreas Center, as well as Gallstones and Pancreatitis.

For further clinical information, see the Medscape Reference topic Cholecystitis and Biliary Colic.

Ninety percent of cases of cholecystitis involve stones in the cystic duct (ie, calculous cholecystitis), with the other 10% of cases representing acalculous cholecystitis.[1] Acute calculous cholecystitis is caused by obstruction of the cystic duct, leading to distention of the gallbladder. As the gallbladder becomes distended, blood flow and lymphatic drainage are compromised, leading to mucosal ischemia and necrosis.

Although the exact mechanism of acalculous cholecystitis is unclear, several theories exist. Injury may be the result of retained concentrated bile, an extremely noxious substance. In the presence of prolonged fasting, the gallbladder never receives a cholecystokinin (CCK) stimulus to empty; thus, the concentrated bile remains stagnant in the lumen.[2, 3] A study by Cullen et al demonstrated the ability of endotoxin to cause necrosis, hemorrhage, areas of fibrin deposition, and extensive mucosal loss, consistent with an acute ischemic insult.[4] Endotoxin also abolished the contractile response to CCK, leading to gallbladder stasis.

Risk factors for calculous cholecystitis mirror those for cholelithiasis and include the following:

Female sex

Certain ethnic groups

Obesity or rapid weight loss

Drugs (especially hormonal therapy in women)

Pregnancy

Increasing age

Acalculous cholecystitis is related to conditions associated with biliary stasis, to include the following:

Critical illness

Major surgery or severe trauma/burns

Sepsis

Long-term total parenteral nutrition (TPN)

Prolonged fasting

Other causes of acalculous cholecystitis include the following:

Cardiac events, including myocardial infarction

Sickle cell disease

Salmonella infections

Diabetes mellitus[5] Patients with AIDS who have cytomegalovirus, cryptosporidiosis, or microsporidiosis

Patients who are immunocompromised are at increased risk of developing cholecystitis from a number of different infectious sources. Idiopathic cases exist.

An estimated 10-20% of Americans have gallstones, and as many as one third of these people develop acute cholecystitis. Cholecystectomy for either recurrent biliary colic or acute cholecystitis is the most common major surgical procedure performed by general surgeons, resulting in approximately 500,000 operations annually.

Age distribution for cholecystitis

The incidence of cholecystitis increases with age. The physiologic explanation for the increasing incidence of gallstone disease in the elderly population is unclear. The increased incidence in elderly men has been linked to changing androgen-to-estrogen ratios.

Go to Pediatric Cholecystitis for more complete information on this topic.

Sex distribution for cholecystitis

Gallstones are 2-3 times more frequent in females than in males, resulting in a higher incidence of calculous cholecystitis in females. Elevated progesterone levels during pregnancy may cause biliary stasis, resulting in higher rates of gallbladder disease in pregnant females. Acalculous cholecystitis is observed more often in elderly men.

Prevalence of cholecystitis by race and ethnicity

Cholelithiasis, the major risk factor for cholecystitis, has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia.[6, 7] In the United States, white people have a higher prevalence than black people.

Uncomplicated cholecystitis has an excellent prognosis, with very low mortality. Most patients with acute cholecystitis have a complete remission within 1-4 days. However, 25-30% of patients either require surgery or develop some complication.

Once complications such as perforation/gangrene develop, the prognosis becomes less favorable. Perforation occurs in 10-15% of cases. Patients with acalculous cholecystitis have a mortality ranging from 10-50%, which far exceeds the expected 4% mortality observed in patients with calculous cholecystitis. In patients who are critically ill with acalculous cholecystitis and perforation or gangrene, mortality can be as high as 50-60%.

Cholecystitis (ko-luh-sis-TIE-tis) is inflammation of the gallbladder. Your gallbladder is a small, pear-shaped organ on the right side of your abdomen, beneath your liver. The gallbladder holds a digestive fluid that's released into your small intestine (bile).

In most cases, gallstones blocking the tube leading out of your gallbladder cause cholecystitis. This results in a bile buildup that can cause inflammation. Other causes of cholecystitis include bile duct problems and tumors.

If left untreated, cholecystitis can lead to serious, sometimes life-threatening complications, such as a gallbladder rupture. Treatment for cholecystitis often involves gallbladder removal.

Signs and symptoms of cholecystitis may include:

Severe pain in your upper right abdomen

Pain that radiates from to your right shoulder or back

Tenderness over your abdomen when it's touched

Nausea

Vomiting

Fever

Cholecystitis signs and symptoms often occur after a meal, particularly a large or fatty meal.

When to see a doctor

Make an appointment with your doctor if you have worrisome signs or symptoms. For abdominal pain so severe you can't sit still or get comfortable, have someone drive you to the emergency room.

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HYPERLINK "/gallbladder-and-bile-duct/img-20008461"Gallbladder and bile ductCholecystitis occurs when your gallbladder becomes inflamed. Gallbladder inflammation can be caused by:

Gallstones. Most cholecystitis is the result of hard particles that develop in your gallbladder (gallstones) from imbalances in the substances in bile, such as cholesterol and bile salts. Gallstones can block the cystic duct the tube through which bile flows when it leaves the gallbladder causing bile to build up and resulting in inflammation.

Tumor. A tumor may prevent bile from draining out of your gallbladder properly, causing bile buildup that can lead to cholecystitis.

Bile duct blockage. Kinking or scarring of the bile ducts can cause blockages that lead to cholecystitis

Having gallstones is the main risk factor for developing cholecystitis.

Cholecystitis can lead to a number of serious complications, including:

Infection within the gallbladder. If bile builds up within your gallbladder, causing cholecystitis, the bile may become infected.

Death of gallbladder tissue. Untreated cholecystitis can cause tissue in the gallbladder to die, which in turn can lead to a tear in the gallbladder, or it may cause your gallbladder to burst.

Torn gallbladder. A tear in your gallbladder may result from gallbladder enlargement or infection.

Make an appointment with your doctor if you have signs or symptoms that worry you. If your doctor suspects you have cholecystitis, he or she may either refer you to a doctor who specializes in the digestive system (gastroenterologist) or send you to a hospital.

Here's information to help you prepare for your appointment.

What you can do

Be aware of pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.

Write down your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment.

Write down key personal information, including major stresses or recent life changes.

Make a list of all medications, vitamins and supplements you're taking.

Take a family member or friend along, if possible. Someone who accompanies you can help you remember the information you get.

Write down questions to ask your doctor.

For cholecystitis, some basic questions to ask your doctor include:

Is cholecystitis the likely cause of my abdominal pain?

What are other possible causes for my symptoms?

What tests do I need?

Do I need gallbladder removal surgery?

How soon do I need surgery?

What are the risks of surgery?

How long does it take to recover from gallbladder surgery?

Are there other treatment options for cholecystitis?

Should I see a specialist?

Are there brochures or other printed material that I can take with me? What websites do you recommend?

Don't hesitate to ask other questions, as well.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, including:

When did your symptoms begin?

Have you had pain similar to this before?

Have your symptoms been continuous or occasional?

How severe are your symptoms?

What, if anything, seems to improve your symptoms?

What, if anything, appears to worsen your symptoms?

Tests and procedures used to diagnose cholecystitis include:

Blood tests. Your doctor may order blood tests to look for signs of an infection or signs of gallbladder problems.

Imaging tests that show your gallbladder. Imaging tests, such as abdominal ultrasound or a computerized tomography (CT) scan, can be used to create pictures of your gallbladder that may reveal signs of cholecystitis.

A scan that shows the movement of bile through your body. A hepatobiliary iminodiacetic acid (HIDA) scan tracks the production and flow of bile from your liver to your small intestine and shows blockage. A HIDA scan involves injecting a radioactive dye into your body, which binds to the bile-producing cells so that it can be seen as it travels with the bile through the bile ducts.

Treatment for cholecystitis usually involves a hospital stay to stabilize the gallbladder inflammation and possible surgery.

Hospitalization

If you're diagnosed with cholecystitis, you'll likely be hospitalized. Your doctor will work to control your signs and symptoms and to control the inflammation in your gallbladder. Treatments may include:

Fasting. You may not be allowed to eat or drink at first in order to take stress off your inflamed gallbladder. So that you don't become dehydrated, you may receive fluids through a vein in your arm.

Antibiotics to fight infection. If your gallbladder is infected, your doctor likely will recommend antibiotics.

Pain medications. These can help control pain until the inflammation in your gallbladder is relieved.

Your symptoms are likely to subside in a day or two.

Surgery to remove the gallbladder

Because cholecystitis frequently recurs, most people with the condition eventually require gallbladder removal surgery (cholecystectomy). The timing of surgery will depend on the severity of your symptoms and your overall risk of problems during and after surgery. If you're at low surgical risk, you may have surgery within 48 hours or during your hospital stay.

Cholecystectomy is most commonly performed using a tiny video camera mounted at the end of a flexible tube. This allows your surgeon to see inside your abdomen and to use special surgical tools to remove the gallbladder (laparoscopic cholecystectomy). The tools and camera are inserted through four incisions in your abdomen, and the surgeon watches a monitor during surgery to guide the tools. An open procedure, in which a long incision is made in your abdomen, is rarely required.

A less invasive way to remove gallbladders is under study. Known as natural orifice transluminal endoscopic surgery (NOTES), the procedure is intended to lessen scarring and discomfort. While laparaoscopic cholecystectomy remains the standard of care for gallbladder removal, NOTES is being performed in a few centers worldwide and may eventually be an important alternative.

Once your gallbladder is removed, bile flows directly from your liver into your small intestine, rather than being stored in your gallbladder. You don't need your gallbladder to live normally.

You can reduce your risk of cholecystitis by taking the following steps to prevent gallstones:

Lose weight slowly. Rapid weight loss can increase the risk of gallstones. If you need to lose weight, aim to lose 1 or 2 pounds (0.5 to about 1 kilogram) a week.

Maintain a healthy weight. Being overweight increase the risk of gallstones. To achieve a healthy weight, reduce calories and increase the physical activity. Maintain a healthy weight by continuing to eat well and exercise.

Choose a healthy diet. Diets high in fat and low in fiber may increase the risk of gallstones. To reduce your risk of gallstones, choose a diet high in fruits, vegetables and whole grains.