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==Background==
==Background==
{{Gallbladder disease types}}
*Inflammation of the gallbladder caused by obstruction of the cystic duct by gallstones
{{Gallbladder background}}
*Most common complication of [[cholelithiasis]]
*10-20% of patients with gallstones will develop cholecystitis
*Risk factors (5 F's — mnemonic):
**Female, Forty, Fertile (multiparity), Fat (obesity), Fair (Northern European descent)
**Additional: rapid weight loss, TPN, medications (estrogen, fibrates, octreotide)
*Pathophysiology: cystic duct obstruction → gallbladder distension → wall inflammation → secondary infection (in ~50%)
*Complications: gangrenous cholecystitis (20%), perforation (2-15%), gallstone ileus, cholecystoenteric fistula, [[emphysematous cholecystitis]]


==Clinical Features==
==Clinical Features==
===Local Signs===
*RUQ pain (constant, >4-6 hours duration — distinguishes from biliary colic which resolves)
*[[RUQ pain]]
*Pain radiates to right scapula or shoulder (phrenic nerve irritation)
*Murphy Sign
*Nausea and vomiting (common)
**Highest positive LR of any clinical finding or lab value
*Fever (low-grade; high fever suggests complications)
===Systemic signs===
*Murphy sign: inspiratory arrest during RUQ palpation (sensitivity ~65%)
*[[Fever]]
**Sonographic Murphy sign (pain with probe pressure over sonographically visualized gallbladder) is more specific
*[[Nausea and vomiting]]
*RUQ guarding, rebound tenderness (suggests peritonitis)
*Jaundice suggests [[choledocholithiasis]] (common bile duct stone) or [[cholangitis]] (Charcot triad/Reynolds pentad)


==Differential Diagnosis==
==Differential Diagnosis==
{{DDX RUQ}}
*[[Biliary colic]] (most important to distinguish — resolves within 4-6h)
*[[Choledocholithiasis]] / [[cholangitis]]
*[[Hepatitis]]
*[[Peptic ulcer disease]]
*[[Pancreatitis]]
*[[Appendicitis]] (especially high-riding appendix)
*[[Pneumonia]] (RLL)
*[[Pyelonephritis]] / [[nephrolithiasis]]
*[[MI]] (inferior — especially in elderly/diabetics)
*[[Fitz-Hugh-Curtis syndrome]] (perihepatitis)
 
{{RUQ pain DDX}}


==Evaluation==
==Evaluation==
===Laboratory Findings===
===Labs===
*Leukocytosis
*WBC: leukocytosis (12,000-15,000); WBC >20,000 suggests gangrenous or emphysematous cholecystitis
*LFT abnormalities (obstructive picture)
*LFTs: mild elevation of AST/ALT; alkaline phosphatase and bilirubin elevated if CBD stone
*Lipase: rule out concurrent [[pancreatitis]] ([[gallstone pancreatitis]])
*Lactate: if septic
*Blood cultures: if febrile or septic
*Pregnancy test in reproductive-age women


===Imaging===
===RUQ Ultrasound (Test of Choice)===
[[File:Gallstones.png|thumb|Gallstone impacted in the neck of the gallbladder with gall bladder wall thickening.]]
*Sensitivity 88%, specificity 80% for acute cholecystitis
[[File:Gallbladder wall thickening.png|thumb|Gallbladder wall thickening]]
*Findings:
[[File:Acute cholecystitis.png|thumb|Acute cholecystitis]]
**Gallstones (echogenic foci with posterior acoustic shadowing)
*[[Biliary ultrasound]]
**Gallbladder wall thickening >3-4 mm (nonspecific — also seen in CHF, ascites, hepatitis)
**Gallstones
***Distinguish by characteristic "shadowing"
***Better seen with patient in left lateral decub
**GB wall thickening (>3mm)
***May also be seen with [[Pancreatitis]], ascites, [[Congestive heart failure]], alcoholic hepatitis
**Pericholecystic fluid
**Pericholecystic fluid
**Sonographic Murphy's Sign (PPV 92%)
**Sonographic Murphy sign (most predictive single finding)
***May be absent in patients with DM, gangrenous cholecystitis
**Gallbladder distension (>10 cm long or >5 cm transverse)
*CT
*Combined findings increase diagnostic accuracy
**Useful when [[ultrasound]] results are equivocal
 
===HIDA Scan===
*Most accurate test for cholecystitis (sensitivity 97%, specificity 90%)
*Non-visualization of gallbladder at 4 hours = positive for cholecystitis (cystic duct obstruction)
*Takes 1-4 hours to complete — not practical for acutely ill ED patients
*Use when US equivocal and diagnosis uncertain
 
===CT===
*Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding
*Useful for identifying complications (perforation, abscess, emphysematous changes)


==Management==
==Management==
===[[Antibiotics]]===
===ED Management===
{{Cholecystitis Antibiotics}}
*NPO
*IV fluid resuscitation
*Pain control:
**Ketorolac 15-30 mg IV (shown to be effective and may reduce gallbladder inflammation)
**'''Opioids''' (morphine or hydromorphone) — traditional concern about sphincter of Oddi spasm is likely overstated
*Antiemetics: ondansetron 4 mg IV
*Antibiotics if complicated (febrile, septic, diabetic, immunocompromised):
**Piperacillin-tazobactam 3.375-4.5g IV OR
**Ceftriaxone 2g IV + metronidazole 500 mg IV
**Coverage: gram-negatives (E. coli, Klebsiella) and anaerobes
*Surgical consultation for cholecystectomy
 
===Definitive Treatment===
*Laparoscopic cholecystectomy (standard of care)
*Early cholecystectomy (<72 hours) preferred — associated with shorter hospital stays and lower complication rates<ref>Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). ''Ann Surg''. 2013;258(3):385-393. PMID 24022431</ref>
*Percutaneous cholecystostomy for patients too unstable for surgery (critically ill, multiple comorbidities)


===Surgical consultation===
===Special Populations===
*Definitive treatment involves surgical removal or decompression
*Acalculous cholecystitis: occurs in critically ill/ICU patients without gallstones (5-10% of cases)
*Emphysematous cholecystitis: gas-forming organisms; higher perforation risk; more common in diabetic men
*Elderly/diabetics: higher risk of complications, may present atypically


==Disposition==
==Disposition==
*Admit
*Admit all patients with acute cholecystitis
 
*ICU if septic, gangrenous, or emphysematous cholecystitis
==Complications==
*Surgical consultation in ED for early cholecystectomy
*Gangrene
**Occurs in 20% if untreated (esp. diabetics, elderly, delay in seeking care)
**Consider if patient presents with sepsis in addition to cholecystitis
*Perforation
**Occurs in 2% after development of gangrene 
**Usually localized, leading to pericholecystic abscess
*Gallstone [[Ileus]]
**Due to cholecystoenteric fistula
*Emphysematous cholecystitis
**Due to secondary infection of GB by gas-forming organisms (C. perfringens)
**Presents like cholecystitis but often progresses to sepsis and gangrene
**IV antibiotic and cholecystectomy are essential
**Ultrasound report may mistake GB wall gas for bowel gas
**Mortality as high as 15% due to gangrene or perforation
*Mirizzi Syndrome
**Partial obstruction of common hepatic duct due to stone impaction / chronic inflammation
**Symptoms of acute cholecystitis + dilated intrahepatic ducts + jaundice
**Inflammation can cause erosive fistula from Hartmann pouch into common hepatic duct
***US and CT can usually delineate the fistula
**Treatment = open cholecystectomy
*Gallstone Ileus
**Bowel obstruction due to impaction of gallstone at terminal ileum
***Gallstone enters small bowel through biliary-duodenal fistula
**Diagnosis suggested by pneumobilia, bowel obstruction, ectopic gallstone


==See Also==
==See Also==
*[[Gallbladder Disease (Main)]]
*[[Biliary colic]]
*[[Biliary ultrasound]]
*[[Choledocholithiasis]]
*[[Cholangitis]]
*[[Gallstone pancreatitis]]
*[[Acalculous cholecystitis]]


==References==
==References==
<references/>
<references/>
*Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. ''J Hepatobiliary Pancreat Sci''. 2018;25(1):41-54. PMID 29032636
*Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. ''World J Emerg Surg''. 2016;11:25. PMID 27307785
*Trowbridge RL, et al. Does this patient have acute cholecystitis? ''JAMA''. 2003;289(1):80-86. PMID 12503981
[[Category:GI]]
[[Category:GI]]
[[Category:ID]]

Revisión actual - 09:29 22 mar 2026

Background

  • Inflammation of the gallbladder caused by obstruction of the cystic duct by gallstones
  • Most common complication of cholelithiasis
  • 10-20% of patients with gallstones will develop cholecystitis
  • Risk factors (5 F's — mnemonic):
    • Female, Forty, Fertile (multiparity), Fat (obesity), Fair (Northern European descent)
    • Additional: rapid weight loss, TPN, medications (estrogen, fibrates, octreotide)
  • Pathophysiology: cystic duct obstruction → gallbladder distension → wall inflammation → secondary infection (in ~50%)
  • Complications: gangrenous cholecystitis (20%), perforation (2-15%), gallstone ileus, cholecystoenteric fistula, emphysematous cholecystitis

Clinical Features

  • RUQ pain (constant, >4-6 hours duration — distinguishes from biliary colic which resolves)
  • Pain radiates to right scapula or shoulder (phrenic nerve irritation)
  • Nausea and vomiting (common)
  • Fever (low-grade; high fever suggests complications)
  • Murphy sign: inspiratory arrest during RUQ palpation (sensitivity ~65%)
    • Sonographic Murphy sign (pain with probe pressure over sonographically visualized gallbladder) is more specific
  • RUQ guarding, rebound tenderness (suggests peritonitis)
  • Jaundice suggests choledocholithiasis (common bile duct stone) or cholangitis (Charcot triad/Reynolds pentad)

Differential Diagnosis

Template:RUQ pain DDX

Evaluation

Labs

  • WBC: leukocytosis (12,000-15,000); WBC >20,000 suggests gangrenous or emphysematous cholecystitis
  • LFTs: mild elevation of AST/ALT; alkaline phosphatase and bilirubin elevated if CBD stone
  • Lipase: rule out concurrent pancreatitis (gallstone pancreatitis)
  • Lactate: if septic
  • Blood cultures: if febrile or septic
  • Pregnancy test in reproductive-age women

RUQ Ultrasound (Test of Choice)

  • Sensitivity 88%, specificity 80% for acute cholecystitis
  • Findings:
    • Gallstones (echogenic foci with posterior acoustic shadowing)
    • Gallbladder wall thickening >3-4 mm (nonspecific — also seen in CHF, ascites, hepatitis)
    • Pericholecystic fluid
    • Sonographic Murphy sign (most predictive single finding)
    • Gallbladder distension (>10 cm long or >5 cm transverse)
  • Combined findings increase diagnostic accuracy

HIDA Scan

  • Most accurate test for cholecystitis (sensitivity 97%, specificity 90%)
  • Non-visualization of gallbladder at 4 hours = positive for cholecystitis (cystic duct obstruction)
  • Takes 1-4 hours to complete — not practical for acutely ill ED patients
  • Use when US equivocal and diagnosis uncertain

CT

  • Not first-line but may show gallbladder distension, wall thickening, pericholecystic stranding
  • Useful for identifying complications (perforation, abscess, emphysematous changes)

Management

ED Management

  • NPO
  • IV fluid resuscitation
  • Pain control:
    • Ketorolac 15-30 mg IV (shown to be effective and may reduce gallbladder inflammation)
    • Opioids (morphine or hydromorphone) — traditional concern about sphincter of Oddi spasm is likely overstated
  • Antiemetics: ondansetron 4 mg IV
  • Antibiotics if complicated (febrile, septic, diabetic, immunocompromised):
    • Piperacillin-tazobactam 3.375-4.5g IV OR
    • Ceftriaxone 2g IV + metronidazole 500 mg IV
    • Coverage: gram-negatives (E. coli, Klebsiella) and anaerobes
  • Surgical consultation for cholecystectomy

Definitive Treatment

  • Laparoscopic cholecystectomy (standard of care)
  • Early cholecystectomy (<72 hours) preferred — associated with shorter hospital stays and lower complication rates[1]
  • Percutaneous cholecystostomy for patients too unstable for surgery (critically ill, multiple comorbidities)

Special Populations

  • Acalculous cholecystitis: occurs in critically ill/ICU patients without gallstones (5-10% of cases)
  • Emphysematous cholecystitis: gas-forming organisms; higher perforation risk; more common in diabetic men
  • Elderly/diabetics: higher risk of complications, may present atypically

Disposition

  • Admit all patients with acute cholecystitis
  • ICU if septic, gangrenous, or emphysematous cholecystitis
  • Surgical consultation in ED for early cholecystectomy

See Also

References

  1. ↑ Gutt CN, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study). Ann Surg. 2013;258(3):385-393. PMID 24022431
  • Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. PMID 29032636
  • Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016;11:25. PMID 27307785
  • Trowbridge RL, et al. Does this patient have acute cholecystitis? JAMA. 2003;289(1):80-86. PMID 12503981
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