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Potentially life-threatening emergency
Cholecystitis
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Potentially life-threatening emergency

Cholecystitis

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Contributors: Arnel Magno MD, Charu Ramchandani MD, Kaartik Soota MD, Nayef El-Daher MD, PhD, Zaw Min MD, FACP
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Synopsis

Acute cholecystitis and cholangitis are 2 of the 3 main emergencies of the biliary tract and can be life-threatening if appropriate treatment is not initiated promptly. Both present with abdominal pain and are frequently seen in clinical practice. The primary focus of this summary is cholecystitis. Cholangitis is discussed in further detail separately.

Acute cholecystitis is a clinical syndrome that is associated with gallbladder wall inflammation and characterized by right-upper-quadrant (RUQ) abdominal pain, fever, and leukocytosis. There are 2 main types of acute cholecystitis: calculous and acalculous.

Acute calculous cholecystitis:
Constitutes 90%-95% of all cases. Stones can be of the following types:
  • Cholesterol stones – Approximately 75% of all gallstones in the United States.
  • Pigment stones – 25% are pigment stones and are made of calcium bilirubinate and calcified bilirubin. This type of gallstone can be either black or brown. Black stones comprise 20% of all gallstones and are found in patients with chronic hemolytic anemia, Gilbert's syndrome, liver cirrhosis, or cystic fibrosis. Brown stones are more common in the Asian population, and they develop in the setting of chronic biliary tract infection such as parasite infection.
  • Mixed stones – Mixture of cholesterol and pigment stones.
Acute acalculous cholecystitis:
Constitutes 5%-10% of cholecystitis. Associated with critical illnesses such as trauma, burns, severe sepsis and diabetes, immunosuppression, HIV infection, recent non-biliary surgery, parenteral nutrition, or childbirth. There is a 25%-40% mortality rate, higher than for calculous cholecystitis.

Pathophysiology of acute cholecystitis:
About 10% of the population has gallstones, most of which are asymptomatic. Biliary colic develops in 1%-4% of patients annually, and acute cholecystitis eventually develops in about 20% of symptomatic patients if left untreated. Thus the presence of gallstones does not mean that a patient will develop symptoms.

The initial event in acute calculous cholecystitis is the obstruction to gallbladder drainage. This, by itself, causes biliary colic if it is brief; over many hours, it can cause inflammation, resulting in wall-thickening and subsequent development of pericholecystic fluid. Inflammation is sterile in early cases, but secondary infection develops in most patients. Common organisms are Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp.), Enterococcus spp., and anaerobes (Bacteroides spp., Clostridium spp., Fusobacterium spp.).

Demographics and risk factors of acute cholecystitis:
Sex – Women are more likely to develop gallstones because of higher estrogen levels. For the same reason, pregnancy and hormone replacement therapy increase the risk of gallstones. Approximately 25% of women older than 60 have gallstones. Cholecystitis develops in women more frequently from the relative prevalence of gallstones.

Age – Gallstones are unusual in children. In cases when they occur, they are commonly pigment stones. The following conditions put children at a higher risk of having gallstones:
  • Spinal injury
  • History of abdominal surgery
  • Sickle cell disease
  • Impaired immunity
  • Intravenous nutrition
Ethnicity / geography – Gallstones are related to diet, particularly fat and cholesterol; hence, their incidence varies in different populations and parts of the world. Hispanics, Europeans, and Americans have a higher risk of gallstones than people of Asian or African descent. Those of Asian or African descent who do develop gallstones have a higher risk of developing brown pigment stones.

Obesity and weight changes – In obesity, the liver overproduces cholesterol, which increases the risk of gallstone formation. Rapid weight loss is also a risk factor for the development of cholesterol gallstones.

Pregnancy – Increase in cholesterol saturation of bile and impaired gallbladder contraction during pregnancy predispose to formation of cholesterol stones or biliary sludge.

Genetics – Having a family member with gallstones increases one's risk. Mutation of gene ABCG8 increases the risk of gallstone formation.

AIDS – Biliary disease occurs via 2 mechanisms in patients with AIDS:
  • Acute acalculous cholecystitis
  • AIDS cholangiopathy (commonly due to Cryptosporidium or cytomegalovirus)
Drugs – Many drugs increase the formation of gallstones and hence the incidence of cholecystitis. Examples include fibrates, oral contraceptive pills, thiazides, ceftriaxone, and octreotide.
 
Ascariasis – This is a geographical risk factor in regions such as China and Southeast Asia. It can cause cholecystitis, cholangitis or hepatic abscess, or even pancreatitis.

Clinical manifestations of cholecystitis:
Symptoms include fever and RUQ pain.

RUQ pain:
  • Biliary colic is the main symptom of uncomplicated cholelithiasis – Episodic, severe, and located in the epigastrium or RUQ.
  • Following fatty food ingestion.
  • Often at night.
  • Radiates to the back or right shoulder.
  • Prolonged or recurrent biliary colic can result in acute calculous cholecystitis. It presents with pain that is steady and severe, as opposed to episodic pain of biliary colic. This pain is often accompanied by nausea and vomiting.
Signs include tenderness and guarding in the RUQ and Murphy's sign.
 
Murphy's sign:
  • Arrest in inspiration while palpating the gallbladder during a deep breath.
  • Sensitivity of 50%-60% and a high specificity of up to 79%-96%.

Codes

ICD10CM:
K81.9 – Cholecystitis, unspecified

SNOMEDCT:
76581006 – Cholecystitis

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Updated: 04/13/2016
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Potentially life-threatening emergency
Cholecystitis
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Cholecystitis : Fever, Nausea/vomiting, Epigastric pain, RUQ pain, WBC elevated, Right shoulder pain
Imaging Studies image of Cholecystitis
CT scan of the abdomen demonstrating distended gallbladder with wall thickening and inflammatory changes in the surrounding fat.

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