eMedicine Specialties > Gastroenterology > Biliary

Cholecystitis

Author: Don Gladden, DO, Staff Physician, Department of Emergency Medicine, Seton Medical Center
Coauthor(s): Alexandre F Migala, DO, Staff Physician, Department of Emergency Medicine, Denton Regional Medical Center; Clinton S Beverly, MD, Clinical Assistant Professor, Department of Surgery, Mercer University School of Medicine; Jeffery Wolff, DO, Consulting Staff, Department of Gastroenterology, Brooke Army Medical Center
Contributor Information and Disclosures

Updated: Dec 11, 2009

Introduction

Background

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 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. 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.

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.

Pathophysiology

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. 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.2 Endotoxin also abolished the contractile response to cholecystokinin (CCK), leading to gallbladder stasis.

Although the exact mechanism of acalculous cholecystitis is unclear, a couple of 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 CCK stimulus to empty; thus, the concentrated bile remains stagnant in the lumen.

Frequency

United States

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.

International

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.3,4

Mortality/Morbidity

  • 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.
  • Patients with acalculous cholecystitis have a mortality rate ranging from 10-50%, which far exceeds the expected 4% mortality rate observed in patients with calculous cholecystitis. Emphysematous cholecystitis has a mortality rate approaching 15%.
  • Perforation occurs in 10-15% of cases.

Race

  • Pima Indian and Scandinavian people have the highest prevalence of cholelithiasis and, consequently, cholecystitis.
  • Populations at the lowest risk reside in sub-Saharan Africa and Asia.
  • In the United States, white people have a higher prevalence than black people.

Sex

  • 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.

Age

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.

Clinical

History

  • The most common presenting symptom of acute cholecystitis is upper abdominal pain, often radiating to the tip of the right scapula.
    • Most patients with acute cholecystitis describe a history of biliary pain. Some patients may have documented gallstones. Acalculous biliary colic also occurs, most commonly in young–to–middle-aged females. The presentation is almost identical to calculous biliary colic with the exception of reference range laboratory values and no findings of cholelithiasis on ultrasound.
    • Frequently, the pain begins in the epigastric region and then localizes to the right upper quadrant (RUQ). Although the pain may initially be described as colicky, it becomes constant in virtually all cases.
    • Signs of peritoneal irritation may be present, and, in some patients, the pain may radiate to the right shoulder or scapula.
  • Nausea and vomiting are generally present, and patients may report fever.
  • In elderly patients, pain and fever may be absent, and localized tenderness may be the only presenting sign. Patients with acalculous cholecystitis may present similarly to patients with calculous cholecystitis, but acalculous cholecystitis frequently occurs suddenly in severely ill patients without a prior history of biliary colic. Often, patients with acalculous cholecystitis may present with fever and sepsis alone, without history or physical examination findings consistent with acute cholecystitis.
  • Cholecystitis is differentiated from biliary colic by the persistence of constant severe pain for more than 6 hours.

Physical

  • Physical examination may reveal fever, tachycardia, and tenderness in the RUQ or epigastric region, often with guarding or rebound.
  • A palpable gallbladder or fullness of the RUQ is present in 30-40% of cases.
  • Jaundice may be noted in approximately 15% of patients.
  • The absence of physical findings does not rule out the diagnosis of cholecystitis. Many patients present with diffuse epigastric pain without localization to the RUQ. Patients with chronic cholecystitis frequently do not have a palpable RUQ mass secondary to fibrosis involving the gallbladder.
  • Elderly patients and patients with diabetes frequently have atypical presentations, including absence of fever and localized tenderness with only vague symptoms.
  • Murphy sign, which is specific but not sensitive for cholecystitis, is described as tenderness and an inspiratory pause elicited during palpation of the RUQ.

Causes

  • Risk factors for calculous cholecystitis mirror those for cholelithiasis and include the following:
    • Female sex
    • Certain ethnic groups (see Race)
    • 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 TPN
    • Prolonged fasting
  • Other causes of acalculous cholecystitis include the following:
    • Cardiac events, including myocardial infarction
    • Sickle cell disease
    • Salmonella infections
    • Diabetes mellitus
    • Patients with AIDS with cytomegalovirus, cryptosporidiosis, or microsporidiosis
  • Idiopathic cases exist.

More on Cholecystitis

Overview: Cholecystitis
Differential Diagnoses & Workup: Cholecystitis
Treatment & Medication: Cholecystitis
Follow-up: Cholecystitis
Multimedia: Cholecystitis
References
Further Reading
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References

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  2. Cullen JJ, Maes EB, Aggrawal S, et al. Effect of endotoxin on opossum gallbladder motility: a model of acalculous cholecystitis. Ann Surg. Aug 2000;232(2):202-7. [Medline].

  3. Huang J, Chang CH, Wang JL, Kuo HK, Lin JW, Shau WY, et al. Nationwide epidemiological study of severe gallstone disease in Taiwan. BMC Gastroenterol. Aug 22 2009;9:63. [Medline].

  4. Lee SW, Yang SS, Chang CS, Yeh HJ. Impact of the Tokyo guidelines on the management of patients with acute calculous cholecystitis. J Gastroenterol Hepatol. Aug 3 2009;[Medline].

  5. Singer AJ, McCracken G, Henry MC, et al. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. Sep 1996;28(3):267-72. [Medline].

  6. Towfigh S, McFadden DW, Cortina GR, et al. Porcelain gallbladder is not associated with gallbladder carcinoma. Am Surg. Jan 2001;67(1):7-10. [Medline].

  7. Kim YK, Kwak HS, Kim CS, Han YM, Jeong TO, Kim IH, et al. CT findings of mild forms or early manifestations of acute cholecystitis. Clin Imaging. Jul-Aug 2009;33(4):274-80. [Medline].

  8. Sahai AV, Mauldin PD, Marsi V, et al. Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP. Gastrointest Endosc. Mar 1999;49(3 Pt 1):334-43. [Medline].

  9. Lee SS, Park do H, Hwang CY, et al. EUS-guided transmural cholecystostomy as rescue management for acute cholecystitis in elderly or high-risk patients: a prospective feasibility study. Gastrointest Endosc. Nov 2007;66(5):1008-12. [Medline].

  10. Mutignani M, Iacopini F, Perri V, et al. Endoscopic gallbladder drainage for acute cholecystitis: technical and clinical results. Endoscopy. Jun 2009;41(6):539-46. [Medline].

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  12. Binenbaum SJ, Teixeira JA, Forrester GJ, Harvey EJ, Afthinos J, Kim GJ, et al. Single-incision laparoscopic cholecystectomy using a flexible endoscope. Arch Surg. Aug 2009;144(8):734-8. [Medline].

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Keywords

cholecystitis, cholelithiasis, gallstones, gallbladder stones, gallbladder inflammation, cystic duct obstruction, cystic duct stones, acute cholecystitis, chronic cholecystitis, emphysematous cholecystitis, acalculous cholecystitis, calculous cholecystitis, biliary pain, acalculous biliary colic, calculous biliary colic, biliary stasis, cholecystectomy

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Contributor Information and Disclosures

Author

Don Gladden, DO, Staff Physician, Department of Emergency Medicine, Seton Medical Center
Don Gladden, DO is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Alexandre F Migala, DO, Staff Physician, Department of Emergency Medicine, Denton Regional Medical Center
Alexandre F Migala, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic Association, Association of Military Osteopathic Physicians and Surgeons, and Texas Medical Association
Disclosure: Nothing to disclose.

Clinton S Beverly, MD, Clinical Assistant Professor, Department of Surgery, Mercer University School of Medicine
Clinton S Beverly, MD is a member of the following medical societies: American College of Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Jeffery Wolff, DO, Consulting Staff, Department of Gastroenterology, Brooke Army Medical Center
Jeffery Wolff, DO is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Anil Minocha, MD, FACP, FACG, Clinical Professor, School of Pharmacy, Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center
Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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