eMedicine Specialties > Emergency Medicine > Gastrointestinal

Cholecystitis and Biliary Colic

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

Introduction

Background

Biliary colic and cholecystitis are in the spectrum of biliary tract disease. This spectrum ranges from asymptomatic gallstones to biliary colic, cholecystitis, choledocholithiasis, and cholangitis. In the United States, autopsies have shown that at least 20% of women and 8% of women older than 40 years have gallstones.

Gallstones can be divided into 2 categories: Cholesterol stones (80%) and pigment stones (20%). Stones may temporarily obstruct the cystic duct or pass through into the common bile duct, developing symptomatic biliary colic. Cholecystitis occurs when obstruction at the cystic duct is prolonged (usually several hours) resulting in inflammation of the gallbladder wall. Choledocholithiasis occurs when the stone become lodged in the common bile duct, with the potential sequelae of cholangitis and ascending infections.

Pathophysiology

Cholecystitis is inflammation of the gallbladder wall, caused by obstruction of the cystic duct. This inflammation may be sterile or bacterial. Gallstones usually (>90%) cause this obstruction (calculous cholecystitis) but may infrequently be acalculous or caused by sludge. This obstruction results in gallbladder distention, gallbladder wall edema, and ischemia. Inflammatory mediators, specifically prostaglandins, are released resulting in increased gallbladder inflammation. The wall of the gallbladder may undergo necrosis and gangrene (gangrenous cholecystitis).

Bacterial superinfection with gas-forming organisms may lead to gas in the wall or lumen of the gallbladder (emphysematous cholecystitis). Bacterial infection is thought to be a consequence, not a cause, of cholecystitis. In the early stages of acute cholecystitis, bile is sterile. Approximately 20-75% of bile cultures are eventually positive with the most common organisms being Escherichia coli, Klebsiella species, Enterococci, and Enterobacter. Common bile duct stones (choledocholithiasis, 10%) are either secondary (from the gallbladder) or primary (formed in bile ducts).

Frequency

United States

Prevalence of cholelithiasis is affected by many factors, including race, ethnicity, gender, age, medical problems, and fertility. Between 10-20% of adults (approximately 20 million people) in the United States have gallstones. Each year, only 1-3% of people with stones develop biliary colic. Acute cholecystitis eventually develops in about 20% of these symptomatic patients if they are left untreated.¹

International

People of Hispanic or northern European countries are more likely to have stones.

Mortality/Morbidity

• Asymptomatic gallstones result in morbidity and mortality when they become symptomatic.
• The incidence of acute cholecystitis is falling, likely due to increased acceptance by patients of laparoscopic cholecystectomy as a treatment for symptomatic gallstones.²
• Mortality can be as high as 15% in immunocompromised patients.
• Complicated cholecystitis has 25% mortality (eg, gangrene, empyema of gallbladder). Perforation of gallbladder occurs in 3-15% of patients with cholecystitis and is associated with 60% mortality.

Race

• Racial or ethnic influences are important in gallbladder disease. Fair people of northern European descent are more likely to have gallstones.
• African Americans are at decreased risk for gallstones unless they have a hematologic reason for stones (eg, sickle cell anemia).
• Asians with stones are more likely than other populations to have pigmented stones. In elderly Pima Indians, incidence of gallstones is approximately 75%. Increased incidence of stones may be observed in people of Hispanic ethnicity.

Sex

• The phrase "fair, female, fat, and fertile" summarizes the major risk factors for development of gallstones. Although gallstones and cholecystitis are more common in women, men with gallstones are more likely to develop cholecystitis than women with gallstones.
• Whether women who are pregnant or have multiple pregnancies are more likely to develop stones or whether they are simply more symptomatic with stones is unknown.
• Some oral contraceptives or estrogen replacement therapy may increase the risk of gallstones.

Age

• Age increases rates of gallstones, cholecystitis, and common bile duct stones. Elderly patients are more likely to go from asymptomatic gallstones to serious complications of gallstones without gallbladder colic.
• Children are more likely than adults to have acalculous gallstones. If stones exist, they are more likely pigmented stones from hemolytic diseases (eg, sickle cell diseases, spherocytosis, G-6-PD deficiency) or chronic diseases (eg, total parenteral nutrition, burns, trauma).
• Teenagers have the same etiologies of gallstones as adults, with a higher incidence in girls and during pregnancy.

Clinical

History

• Typical gallbladder colic is 1-5 hours of constant pain, most commonly in the epigastrium or right upper quadrant. Pain may radiate to the right scapular region or back. Peritoneal irritation by direct contact with the gallbladder localizes the pain to the right upper quadrant. Pain is severe, dull or boring, and constant (not colicky). Patients tend to move around to seek relief from the pain. Onset of pain develops hours after a meal, occurs frequently at night, and awakens the patient from sleep. Associated symptoms include nausea, vomiting, pleuritic pain, and fever.
• Up to 70% of patients with cholecystitis report having experienced similar episodes in the past that spontaneously resolved. Persistence of biliary obstruction leads to cholecystitis and persistent right upper quadrant pain. Character of pain is similar to gallbladder colic except that it is prolonged and lasts hours (usually >6 h) or days. Nausea, vomiting, and low-grade fever are associated more commonly with cholecystitis
• Indigestion, belching, bloating, and fatty food intolerance are thought to be typical symptoms of gallstones; however, these symptoms are just as common in people without gallstones and frequently are not cured by cholecystectomy.
• Most gallstones (60-80%) are asymptomatic at a given time. Smaller stones are more likely to be symptomatic than larger ones. Almost all patients develop symptoms prior to complications.
• Symptoms of cholecystitis are steady pain in the right hypochondrium or epigastrium, nausea, vomiting, and fever. Acute attack often is precipitated by a large or fatty meal.

Physical

• Vital signs parallel the degree of illness. Patients with cholangitis are more likely to have fever, tachycardia, and/or hypotension. Patients with gallbladder colic have relatively normal vital signs. In a retrospective study, only 32% of patients with cholecystitis had fever. Fever may be absent, especially in elderly patients.
• Patients with cholecystitis are usually more ill appearing than simple biliary colic patients, and they usually lie still on the examination table since any movement may aggravate any peritoneal signs.
• Abdominal examination in gallbladder colic and cholecystitis is remarkable for epigastric or right upper quadrant tenderness and abdominal guarding. The Murphy sign (an inspiratory pause on palpation of the right upper quadrant) can be found on abdominal examination. Singer et al found that a positive Murphy sign was extremely sensitive (97%) and predictive (PPV, 93%) for cholecystitis.³ However, in elderly patients, this sensitivity may be decreased.
• When observed, peritoneal signs should be taken seriously. Most uncomplicated cholecystitis does not have peritoneal signs; thus, search for complications (eg, perforation, gangrene) or other sources of pain.
• Gallbladder gangrene can be a complication in up to 20% of cases of cholecystitis and is usually in diabetics, elderly, or immunocompromised persons.
• A palpable fullness in the RUQ may be appreciated in 20% of cases.
• As in all patients with abdominal pain, perform a complete physical examination, including rectal and pelvic examinations in women.
• In elderly patients and those with diabetes, occult cholecystitis or cholangitis may be the source of fever, sepsis, or mental status changes.
• Jaundice is unusual in the early stages of acute cholecystitis and may be found in fewer than 20% of patients. Frank jaundice should raise suspicion of concomitant choledocholithiasis or Mirizzi's syndrome (obstruction of the bile duct as a result of external compression of a stone in the gallbladder or cystic duct).
• A very high bilirubin should prompt the physician to pay special attention to the common bile duct and pancreatic region.

Causes

Risk factors for biliary colic and cholecystitis include pregnancy, elderly population, obesity, certain ethnic groups, and drugs.

Risk factors for acalculous cholecystitis include diabetes, HIV, vascular disease, total parenteral nutrition, prolonged fasting, or being an ICU patient.

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