Cholecystitis Clinical Presentation

Updated: Mar 12, 2019
  • Author: Alan A Bloom, MD; Chief Editor: BS Anand, MD  more...
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Presentation

History

The most common presenting symptom of acute cholecystitis is upper abdominal pain. Signs of peritoneal irritation may be present, and in some patients, the pain may radiate to the right shoulder or scapula. 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. Nausea and vomiting are generally present, and patients may report fever.

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. Cholecystitis is differentiated from biliary colic by the persistence of constant severe pain for more than 6 hours.

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 a history or physical examination findings consistent with acute cholecystitis.

Cholecystitis in elderly persons

Elderly patients (especially patients with diabetes) may present with vague symptoms and without many key historical and physical findings. Pain and fever may be absent, and localized tenderness may be the only presenting sign. Elderly patients may also progress to complicated cholecystitis rapidly and without warning.

Cholecystitis in children

The pediatric population may also present without many of the classic findings. Children who are at a higher risk for developing cholecystitis include patients with sickle cell disease, seriously ill children, those on prolonged TPN, those with hemolytic conditions, and those with congenital and biliary anomalies. [9] For more information, see the Medscape Drugs & Diseases article Pediatric Cholecystitis.

Complications

Bacterial proliferation within the obstructed gallbladder results in empyema of the organ. Patients with empyema may have a toxic reaction and may have more marked fever and leukocytosis. [10, 11] The presence of empyema frequently requires conversion from laparoscopic to open cholecystectomy. [12]

In rare instances, a large gallstone may erode through the gallbladder wall into an adjacent viscus, usually the duodenum. Subsequently, the stone may become impacted in the terminal ileum or, less frequently, in the duodenal bulb and/or pylorus, causing gallstone ileus.

Emphysematous cholecystitis occurs in approximately 1% of cases and is noted by the presence of gas in the gallbladder wall from the invasion of gas-producing organisms, such as Escherichia coli, Clostridia perfringens, and Klebsiella species. This complication is more common in patients with diabetes, has a male predominance, and is acalculous in 28% of cases. Because of a high incidence of gangrene and perforation, emergency cholecystectomy is recommended. Perforation occurs in up to 15% of patients. [11, 13] For more information, see the Medscape Drugs & Diseases article Emphysematous Cholecystitis.

Other complications include sepsis and pancreatitis. [14]

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Physical Examination

The physical examination may reveal fever, tachycardia, and tenderness in the RUQ or the epigastric region, often with guarding or rebound. The Murphy sign, which is specific but not sensitive for cholecystitis, is described as tenderness and an inspiratory pause elicited during palpation of the RUQ. 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 the absence of fever and localized tenderness with only vague symptoms.

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