eMedicine Specialties > Emergency Medicine > Gastrointestinal

Cholecystitis and Biliary Colic: Follow-up

Author: Rahul Sharma, MD, MBA, FACEP, Assistant Professor, Weill Medical College of Cornell University; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Coauthor(s): Peter A D Steel, MA, MBBS, Staff Physician, Department of Emergency Medicine, Joan and Sanford I Weill Medical College of Cornell and Columbia University College of Physicians and Surgeons, New York Presbyterian Hospitals
Contributor Information and Disclosures

Updated: Jul 28, 2009

Follow-up

Further Inpatient Care

  • Cholecystectomy may be performed after the first 48 hours or after the inflammation has subsided. In approximately 30% of patients with uncomplicated cholecystitis, medical therapy is not sufficient and these patients usually need cholecystectomy within 24-72 hours. Unstable patients may need more urgent intervention with ERCP, percutaneous drainage, or cholecystectomy.
  • Laparoscopic cholecystectomy is very effective and has few complications. Approximately 5% must be converted to an open cholecystectomy. In acute cholecystectomy, the conversion rate can be as high as 50%.
  • Immediate laparoscopic cholecystectomy (within 24 h) is now being increasingly performed by surgeons because it has been shown to be safe, not more difficult than laparoscopic cholecystectomy performed later, and shortens the hospital length of stay.
  • Patients who are not good surgical risks but who are toxic may benefit from percutaneous gallbladder drainage and placement of a T tube if common bile duct stones are suspected. The alternative is ERCP to attempt endoscopic opening of the common bile duct or cystic duct.
  • Delayed surgical intervention can be used for patients who have high-risk medical conditions and are unstable for surgery and in patients in whom the diagnosis in doubt.
  • In patients younger than 60 years, the mortality rate for emergent cholecystectomy is approximately 3%, whereas mortality in early or elective cholecystectomy approaches 0.5%.

Further Outpatient Care

  • For acute cholecystitis, some patients may be treated as outpatients. The patients must meet the following criteria:
    • Afebrile and normal vital signs
    • Minimal amount of pain and tenderness
    • No markedly abnormal labs, normal common bile duct on sonography, and no pericholecystic fluid or biliary air
    • No underlying medical problems (eg, diabetes, cirrhosis, vascular condition, steroids), advanced age, or pregnancy
    • Next day follow-up visit
    • Discharge on oral antibiotics and a small number of pain medications
  • In pregnancy, since symptoms may be recurrent, refer women to their OB/GYN as well as a surgeon. Second trimester cholecystectomy is the safest time period because the risk of premature labor is lower, and the uterus does not push on the gallbladder.
  • Other therapies: For simple gallbladder colic, other therapies rarely are performed because they require long-term therapy (oral dissolution), cause complications (shock wave therapy), and ultimately do not prevent the recurrence of gallstones.
    • Oral dissolution therapy: Bile acid therapy consists of ursodeoxycholic acid sometimes in combination with chenodeoxycholic acid. With this treatment, cholesterol saturation of bile is decreased, and dissolution of small gallstones (<5 mm) is possible with 6-12 months of therapy; however, over one half recur. This treatment has several disadvantages including the time frame of up to 2 years. Fewer than 10% of patients with symptomatic gallstones are candidates for this therapy. The doses are not listed because this treatment option is chosen rarely, and it is not in the purview of the ED.
    • Extracorporeal shock-wave lithotripsy: This is another little-used therapy due to the recurrence of stones. This therapy is not popular because only small, <2 cm, stones can be fragmented and also a recurrence of gallstones occurs in up 30% of patients within 5 years.
    • Dissolution therapy: Percutaneous contact dissolution by injection of methyl tert-butyl ether into the gallbladder to dissolve stones rarely is used.

Deterrence/Prevention

  • Some literature supports dietary modification of decreased fat intake to decrease occurrence of biliary colic.

Complications

  • Cholangitis
  • Sepsis
  • Pancreatitis
  • Gallbladder perforation
    • Gallbladder perforation occurs in 10% of patients with cholecystitis. When perforation is localized, it may be seen as pericholecystic fluid by ultrasound. Abscess formation is common.
    • Free perforation also can occur, releasing bile and inflammatory matter intraperitoneally, causing peritonitis.
  • Gallstone ileus
    • When perforation occurs next to a hollow viscus, a gallbladder enteric fistula can be formed.
    • Fistulas into the duodenum are most common. When gallstones are passed directly through the fistula into the small bowel, if they are greater than 2.5 cm, they can obstruct the ileocecal valve. This causes gallstone ileus.
    • Mortality can be up to 20% because diagnosis is difficult.
    • Treatment includes cholecystectomy, CBC exploration, and closure of the fistulous tract.
  • Hepatitis
  • Choledocholithiasis (10%)

Prognosis

  • Uncomplicated cholecystitis has a low mortality.
  • Emphysematous gallbladder of infection by gas-forming organisms (eg, Clostridium species) is more common in patients with diabetes and men. Mortality is 15%. Perforation of the gallbladder occurs in 3-15% of cholecystitis with up to 60% mortality.
  • Gangrenous or empyema of the gallbladder carries 25% mortality.

Patient Education

  • Advise patients with biliary colic to refrain from eating fatty or spicy foods. They should contact their physician for persistent recurrence of pain or fever.
  • For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center. Also, see eMedicine's patient education article Gallstones.

Miscellaneous

Medicolegal Pitfalls

  • Delay in diagnosis of acute cholecystitis can result in complications, such as gangrene and perforation, and eventually increased morbidity and mortality. ED physicians should consider this in patient populations that may have atypical presentations such as diabetics, elderly, and children. Generally, all patients with a diagnosis of acute cholecystis should be admitted to the hospital for IV antibiotics and scheduled for cholecystectomy within 24-72 hours.

Special Concerns

  • Gallstones are more likely to be symptomatic in pregnancy. For gallbladder colic in pregnancy, since symptoms may be recurrent, women should be referred to their OB/GYN as well as a surgeon. Second trimester cholecystectomy is the safest time period because the risk of premature labor is lower, and the uterus does not push on the gallbladder.
  • Children form gallstones uncommonly; if they do, they are more likely to have congenital anomalies, biliary anomalies, or hemolytic (pigment) stones.
  • Incidence of gallstone increases with age. Elderly patients are more likely to go from asymptomatic gallstones to serious complications of gallstones without gallbladder colic. Delays in diagnosis are common as symptoms may be limited to change in mental status or decreased food intake. Physical examination and laboratory indexes may be normal.9,10
  • Acalculous cholecystitis occurs in critically ill patients and localized pain and tenderness can sometimes not be present. Patients with burns or sepsis and postoperative and trauma patients are all at risk for acalculous cholecystitis.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Sally Santen, MD, to the development and writing of this article.



More on Cholecystitis and Biliary Colic

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Differential Diagnoses & Workup: Cholecystitis and Biliary Colic
Treatment & Medication: Cholecystitis and Biliary Colic
Follow-up: Cholecystitis and Biliary Colic
Multimedia: Cholecystitis and Biliary Colic
References
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Further Reading

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Contributor Information and Disclosures

Author

Rahul Sharma, MD, MBA, FACEP, Assistant Professor, Weill Medical College of Cornell University; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Peter A D Steel, MA, MBBS, Staff Physician, Department of Emergency Medicine, Joan and Sanford I Weill Medical College of Cornell and Columbia University College of Physicians and Surgeons, New York Presbyterian Hospitals
Peter A D Steel, MA, MBBS is a member of the following medical societies: American College of Emergency Physicians, British Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Samuel M Keim, MD, Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine
Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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